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HCSUS studies examine Pap screening followup for HIV-positive women and lifestyle changes following HIV diagnosis

Two recent studies from the HIV Cost and Services Utilization Study (HCSUS) address issues in preventive screening and health-promoting behavior among people with HIV infection. Individuals who have HIV infection need to be concerned about detection of possible comorbid conditions. In addition, developing a more healthy lifestyle can have clinical benefits.

One HCSUS report found that 81 percent of HIV-positive women had a Pap test in the prior year, and 95 percent of those with initially abnormal Pap test results had scheduled followup Pap testing or colposcopy (insertion of a magnifying lens into the vagina to examine the tissues of the cervix and vagina). A second HCSUS study concluded that most people diagnosed with HIV make healthy changes in their lifestyle following diagnosis.

HCSUS is led by Samuel A Bozzette, M.D., Ph.D., of the University of California, San Diego, and RAND, and Martin F. Shapiro, M.D., Ph.D., of RAND and the University of California, Los Angeles. The studies, which are summarized here, were supported in part by the Agency for Healthcare Research and Quality (HS08578).

Stein, M.D., Cunningham, W.E., Nakazono, T., and others. (2001, August). "Screening for cervical cancer in HIV-infected women receiving care in the United States." Journal of Acquired Immune Deficiency Syndromes 27, pp. 463-466.

Invasive cervical cancer is a serious gynecologic manifestation of HIV infection, and it occurs in HIV-infected women three times as often as in uninfected women. Regular Pap tests with appropriate followup when results are abnormal could prevent nearly all deaths from cervical cancer. Current opportunistic infection guidelines recommend annual Pap smears after two initial smears, 6 months apart, are normal. However, the benefit of Pap testing depends on access of HIV-infected women to this screening.

The investigators examined sociodemographic, clinical, and provider factors associated with screening for cervical cancer among 624 women being treated for HIV infection, part of the nationally representative HCSUS cohort. Women were asked if they had received a Pap test in the past year and whether, if the results were abnormal, they were scheduled for another Pap test or colposcopy within 3 months. Of these HIV-positive women, 81 percent had received a Pap test in the past year. Women who had a gynecologist and primary care physician at the same clinical site were almost twice as likely as other women to report Pap testing. Among the women who reported abnormal Pap test results and who did not have vaginal infections, 95 percent were scheduled for a repeat Pap test or colposcopy, and 85 percent had received a repeat Pap test or colposcopy within 3 months.

Earlier studies associated lower socioeconomic status and lack of health insurance with lower screening rates, but this study did not replicate these findings. The high rates of Pap testing and referral for followup of abnormal results were encouraging. Organizing care so that gynecologic and general HIV services are provided at the same site appears to be one promising strategy to improve these rates further.

Collins, R.L., Kanouse, D.E., Gifford, A.L., and others. (2001). "Changes in health-promoting behavior following diagnosis with HIV: Prevalence and correlates in a national probability sample." Health Psychology 20(5), pp. 351-360.

Certain behaviors may have especially harmful effects among people with HIV infection. Cigarette smoking has been linked to greater risk of infections among HIV-positive people and also to maternal-fetal transmission of HIV. Alcohol use is related to poor immune functioning in HIV disease. Perhaps the most important effect of improving diet and exercise is to reduce cardiovascular risk, which may be high in the HIV-positive population in part due to possible vascular complications of antiretroviral therapy.

Most of the nationally representative HCSUS sample of 2,864 people receiving HIV care had made healthy changes in their lifestyle since HIV diagnosis. Nearly half (43 percent) increased their physical activity, and over half (59 percent) improved their diet. Also, nearly half (49 percent) of smokers and 80 percent of alcohol and drug users either quit or cut down.

People with more education were most likely to improve their diets, and those with higher emotional well-being and lower propensity to deny their HIV illness were more likely to reduce substance use. People who were younger, functioned well physically, did not have wasting syndrome, and had high self-rated health were more likely to increase their physical exercise. People diagnosed with Pneumocystis carinii pneumonia were more likely to reduce smoking than those who had not contracted this opportunistic infection.

These healthy behavior changes apparently reflected an effort to cope with and control a potentially devastating disease. Individuals who made these positive changes tended to want more information about HIV and its treatment, wanted to be more involved in their own medical care, and tried to cope in positive ways with HIV infection. Most individuals had made healthy changes since HIV diagnosis, but the time elapsed since testing HIV positive was not related to change. This suggests that the change toward healthier behaviors may have taken place very soon after an individual learned of his or her infection. If so, this may be a critical time for counseling, skills training, and education designed to encourage lifestyle changes and healthy behaviors.

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