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HPV testing should be added to cervical cancer screening of HIV-positive women

Women who have HIV infection are at greater risk for being infected with the human papillomavirus (HPV) and precursor lesions of cervical cancer than women without HIV. In fact, persistent HPV infection (with high-risk types of HPV) has been strongly linked to development of both cervical precancerous lesions and cervical cancer.

The currently recommended cervical cancer screening policy in HIV-infected women could be made more efficient by adding an HPV test to the first two Pap smears for HIV-infected women within the year after HIV diagnosis and modifying subsequent screening intervals based on HPV test results. This targeted screening strategy would be effective and cost effective and is a simple modification to existing guidelines, according to a study supported in part by the Agency for Healthcare Research and Quality (HS07317).

The researchers estimate that in HIV-infected women on antiretroviral therapy, cervical cytology screening via Pap smears every 6 months for women with detectable HPV DNA and annual screening for all others would cost $10,000 to $14,000 per quality-adjusted life year gained, compared with no screening. This targeted screening strategy capitalizes on the high negative predictive value of a negative HPV test, allowing those women who are at lower risk of cancer to be stratified to less aggressive strategies.

A universal screening strategy consisting of annual Pap smears for all women (with no HPV testing) was 15 percent less effective and had a less attractive cost-effectiveness ratio. Targeted screening may be most beneficial for those HIV-infected women at particularly high risk for loss to followup, since efforts and resources to improve adherence to more frequent preventive and gynecologic care could be targeted to those at greatest risk for high-grade lesions and cancer (i.e., detectable HPV), explains Sue J. Goldie, M.D., M.P.H., of the Harvard School of Public Health.

Dr. Goldie and her colleagues developed a theoretical model to simulate the natural history of cervical cancer precursor lesions in HIV-infected women. The model incorporated data from prospective cohort studies, national databases, and published literature and was used to calculate quality-adjusted life expectancy, life expectancy, lifetime costs, and cost-effectiveness of targeted screening and universal screening. Probabilities of progression and regression of cervical lesions were conditional on transient or persistent infections with HPV, as well as stage of HIV and effectiveness of antiretroviral therapy.

See "Cost effectiveness of human papillomavirus testing to augment cervical cancer screening in women infected with the human immunodeficiency virus," by Dr. Goldie, Kenneth A. Freedberg, M.D., M.Sc., Milton C. Weinstein, Ph.D., and others, in the August 1, 2001 American Journal of Medicine 111, pp. 140-149.

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