Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus

Howard D. Strickler, Marla J. Keller, Nancy A. Hessol, Isam Eldin Eltoum, Mark H. Einstein, Philip E. Castle, L. Stewart Massad, Lisa Flowers, Lisa Rahangdale, Jessica M. Atrio, Catalina Ramirez, Howard Minkoff, Adaora A. Adimora, Igho Ofotokun, Christine Colie, Megan J. Huchko, Margaret Fischl, Rodney Wright, Gypsyamber D'Souza, Jason LeiderOlga Diaz, Lorraine Sanchez-Keeland, Sadeep Shrestha, Xianhong Xie, Xiaonan Xue, Kathryn Anastos, Joel M. Palefsky, Robert D. Burk

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background: Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH). Methods: We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry. Results: Mean age was 46 years, median CD4 was 592 cells/μL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing"had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing"(Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy. Conclusions: PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.

Original languageEnglish (US)
Pages (from-to)1529-1537
Number of pages9
JournalClinical Infectious Diseases
Issue number9
StatePublished - May 1 2021


  • HIV
  • cervical cancer screening
  • human papillomavirus (HPV)
  • p16/Ki-67
  • primary HPV screening

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases


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