Cervical cancer screening
16. Screening in immune-deficient women
GUIDELINE UPDATES - This guideline was last updated 7/1/2022
This section refers to women with acquired immune deficiency because of viral infection (e.g. human immunodeficiency virus (HIV)) or treatment with immunosuppressant drugs to prevent transplant rejection or to control an autoimmune disease (e.g. rheumatoid arthritis), as well as inherited primary immunodeficiency disorders (e.g. common variable immunodeficiency). Research on immune deficiency and cervical cancer has mostly focused on women with HIV and renal transplant recipients.
Cervical prevalence of oncogenic human papillomavirus (HPV) in HIV-positive women without cytological abnormalities is higher than their counterparts from the general population. Shared behavioural risk factors for HIV and HPV potentially play some role in these observed differences. While HPV16 remains the most common type, in infected women with cytological abnormalities there appears to be a shift in the prevalence of HPV oncogenic types from HPV16 to other high risk types and a higher risk of multiple HPV infections with increasing severity of cervical disease; in a meta-analysis of 20 studies, HIV-positive women with a cytological prediction of high-grade squamous intraepithelial lesion (HSIL) were significantly more likely to have a positive oncogenic HPV (not 16/18) test result and to have multiple HPV infections, compared with HIV-negative women with HSIL. In renal transplant recipients, prevalence estimates of oncogenic HPV types vary, with some studies finding estimates similar to the general population and others reporting higher estimates. Shared behavioural risk factors for HIV and HPV potentially play some role in these observed differences.
HIV infection has been consistently associated with HPV infection and pre-cancerous cervical lesions, and a significantly higher rate of cervical cancer in women with HIV/acquired immune deficiency syndrome (AIDS) was reported in a meta-analysis of six population-based studies (incidence ratio: 5.8). High incidence rates of cervical cancer have been reported by some subsequent studies, although others have found incidence to be the same as in the general population. Antiretroviral therapy (ART) and highly active antiretroviral therapy (HAART) do not appear to have reduced cervical cancer incidence in women with HIV/AIDS and a systematic review by Cobucci (2015) found that the risk of invasive cervical cancer has increased since the introduction of HAART (RR=1.46, 95%CI: 1.09–1.94). In the past, ART/HAART was only prescribed to people with a low CD4 count, and this is likely to have influenced results of previous studies. Since 2015, however, HAART has been recommended for anyone living with HIV, irrespective of CD4 count.
In solid organ transplant recipients, the majority of population-based studies have reported a higher incidence of cervical cancer than in their immunocompetent counterparts (standardised incidence ratios between 2–3). In contrast, a large US cohort study, using linked data from national and local registries, found the same incidence in transplant recipients as in the general population. There is also some evidence of a higher incidence of cervical intraepithelial neoplasia (CIN) in organ transplant recipients, although more research in this area is needed.
Screening appears to play an important role in whether or not risk is increased compared to the general population, with studies in screened populations suggesting no difference in risk in contrast to other studies that have identified higher risks of cervical cancer.
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The literature searches were performed to identify data for HIV-positive women and transplant recipients, because these groups were identified as being immune-deficient in the pre-renewal National Cervical Screening Program (NCSP) guidelines and are the predominant focus of research activities.
Systematic review evidence
Two systematic reviews were performed to identify studies that evaluated the safety and effectiveness of screening HIV-positive women and organ transplant recipient women using a modified recommended screening strategy (starting at an age less than 25 years and/or screening at intervals less than 5 years and/or referring all women with a positive oncogenic HPV test result to colposcopy irrespective of reflex liquid based cytology (LBC) result), compared with the recommended screening strategy for the general population. The search strategies and inclusion and exclusion criteria used are described in detail in the Technical report.
No randomised or pseudo-randomised controlled trials were found that evaluated the safety and effectiveness of screening immune-deficient women using strategies other than those recommended for the general population, compared with screening strategies used for the general population.
General literature review evidence
In the absence of any direct evidence from the systematic review, a general review of the literature was performed investigating cervical screening and the risk of progression among HIV-positive women and transplant recipients.
In the Women’s Interagency HIV Study, the risks of CIN2+ and CIN3+ were assessed among women with normal cervical cytology, according to HIV status and oncogenic HPV status at baseline. HPV status was ascertained from cervicovaginal lavage samples: 
- In women in whom oncogenic HPV was not detected, the 5-year cumulative risk of CIN2+ and CIN3+ was the same, regardless of HIV status and CD4 count, and was less than 1% in both HIV-negative women and HIV-positive women, including in each CD4 count stratum (< 350, 350–500, and >500).
- In women with a positive oncogenic HPV test result, the 5-year cumulative risk for CIN2+ was 16% (95% CI:9–23%) in HIV-positive women versus 10% (95% CI:0–21%) in HIV-negative women.
- In multivariate analyses, there was no clear gradient in increasing risk for CIN2+ or CIN3+ with decreasing CD4 counts.
- Among HIV-positive women who were positive for HPV16, the 5-year cumulative risks for CIN2+ and CIN3+ were 29% (95%CI:6-46) and 10% (95%CI:0-23) respectively.
Other studies have reported that clearance of oncogenic HPV types other than 16/18 appeared to differ in immune-deficient women, compared with other women, however clearance of HPV16 infections did not. In HIV-positive women, progression from low-grade cytological abnormalities to a higher-grade abnormality (either cytological or histological) appears to increase and regression to negative cytology appears to decrease with lower CD4 counts.
In regard to the performance of HPV testing (Hybrid Capture 2) for detecting high-grade CIN in women with HIV, sensitivity was reported to be somewhat greater in HIV-positive women (96.4% for CIN3; 99.2% for CIN2+) than in HIV-negative women (90.9% for CIN3; 85.5% for CIN2+), and the negative predictive value was high in both HIV-positive and HIV-negative women (99.8% and 99.5% respectively for less than CIN2). Specificity was lower in HIV-positive women. However, the positive predictive value of HPV testing in detecting CIN2 or CIN3 was equally as high in HIV-positive as in HIV-negative women.
It has been hypothesised that the difference in incidence of cervical cancer in immune-deficient women observed between studies may be due to the extent to which the women included in the different studies have been screened. Low participation in cervical screening by HIV-positive women and transplant recipients has been reported in some studies. The influence of screening on risk is also indirectly supported by findings from studies reporting that risk in immune-deficient women is much more elevated for non-cervical HPV-related cancers (e.g. anal, vaginal, vulval, for which effective screening is not available) than for cervical cancer, even though the HPV attributable fraction for these cancers is lower than for cervical cancer.
A review of international guidelines was also performed. The review focused on guidelines for HPV-based screening for immune-deficient women, as these guidelines are the most relevant for the renewed NCSP. Two recent guidelines now include recommendations for HPV-based screening, and both guidelines recommend a three-year interval for HIV-positive women:
- The World Health Organization (WHO 2013) recommends that sexually active HIV-positive women should be screened as soon as the woman has tested HIV positive and those who are HPV-negative to be rescreened within 3 years.
- Recent US guidelines recommend 3-yearly co-testing with HPV and cytology for HIV-positive women aged 30 years or older.
The evidence regarding screening and treatment to prevent cervical cancer in immune-deficient women is of lower quality than that in the general population, due to the absence of long-term randomised controlled trials comparing screening strategies in these women. Given that the evidence is unclear about the safety of lengthening the screening interval to 5 years for immune-deficient women, and that two international guidelines recommend a 3-year interval in the context of HPV testing in this population, it is considered safer to retain a 3-yearly interval in the renewed NCSP until further evidence about the negative predictive value of HPV testing in this population is better understood.
The US guidelines recommend 3-yearly co-testing but the review of the evidence carried out in Australia for the Medical Services Advisory Committee (MSAC) suggests that co-testing offers little additional benefit, compared with HPV testing alone. This is in line with other international recommendations and, therefore, co-testing is not recommended in this population or the wider program, as oncogenic HPV testing alone offers very similar benefits to co-testing. Therefore, the 3-year interval recommendation in this guideline is in accordance with WHO guidelines and supported by US guidelines for screening and treatment of precancerous lesions for cervical cancer prevention in HIV-positive women.
The following recommendations apply to the following groups:
- women with HIV
- solid organ transplant recipients.
These groups have been defined as sufficiently immune-deficient to warrant more frequent screening and a lower threshold for colposcopy referral than the general female population, based on current literature and pre-renewal NCSP guidelines. Note that this list is not exhaustive and does not include all patients with auto-immune conditions.
Flowchart 16.1. Management of screen detected abnormalities in immune-deficient women
Screening interval recommendations
|REC16.1: Immune-deficient women in whom oncogenic HPV is not detected |
Immune-deficient women who have a HPV test in which oncogenic HPV types are not detected should be screened every 3 years with a HPV test.
Management of abnormalities
|REC16.2: Colposcopy referral: positive oncogenic HPV test result (any type) in immune-deficient women |
Women who are immune-deficient and have HPV (any type) detected should be referred for colposcopic assessment. If the screening sample was collected by a healthcare provider, then reflex LBC will be performed by the laboratory. If the screening sample was self-collected, then LBC should be undertaken at colposcopy.
|REC16.3: Colposcopy assessment and treatment in immune-deficient women |
Assessment and treatment of immune-deficient women with screen-detected abnormalities should be by an experienced colposcopist or in a tertiary centre.
|REC16.4: Colposcopy of whole lower genital tract in immune-deficient women|
The entire lower anogenital tract should be assessed, as the same risk factors apply for cervical, vaginal, vulval, perianal and anal lesions.
|REC16.5: Treatment in immune-deficient women|
When treatment of the cervix is considered necessary in immune-deficient women, it should be by excisional methods.
|REC16.6: Histological abnormalities of the cervix in immune-deficient women |
Women with histologically confirmed abnormalities should be managed according to the same guidelines as women who are not immune-deficient.
|REC16.7: Test of Cure for treated immune-deficient women|
Women who are immune-deficient and treated for HSIL (CIN2/3) should have follow-up with Test of Cure as recommended in these guidelines. Women who complete Test of Cure should return to routine 3-yearly screening with a HPV test.
|REC16.8: Screening before solid organ transplantation|
Women aged between 25 and 74 years should have a review of cervical screening history when they are added to the organ transplant waiting list and while they remain on the waiting list, to confirm they are up to date with recommended screening for the general population. Women who are overdue for screening, or become due while on the waiting list ,should be screened with a HPV test so that any abnormalities can be investigated or treated as necessary prior to transplantation and commencement of immunosuppressive therapy.
|REC16.9: Screening women with a new diagnosis of HIV|
Women aged between 25 and 74 years who have a new diagnosis of HIV should have a review of their cervical screening history to ensure they are up to date with screening in line with the recommended 3-yearly interval for this group.
REC16.10: Other groups that may require special consideration
|REC16.11: Regular screening for immune-deficient women |
Women who are immune deficient should be educated regarding the increased risk from HPV infection and encouraged to attend for regular screening every 3 years.
REC16.12: Young women with long term immune deficiency
* Note amendments to relevant Medicare Benefits Schedule items to support testing on a self-collected sample for this specific use will be effective from 1 November 2022
|REC16.13: Guidance for immune-deficient women and their healthcare professionals |
It is important that immune-deficient women and their healthcare professionals are guided by a clinical immunology specialist when using these guidelines.
- Management of low-grade squamous abnormalities
- Management of high-grade squamous abnormalities
- Management of glandular abnormalities
Benefits and harms
There is evidence of an increased risk of CIN in immune-deficient women, but evidence is also suggestive that screening plays an important role in reducing or removing excess risk of cervical cancer. The current recommendations will ensure the prompt treatment of any precancerous lesions before progression to cervical cancer. Diagnostic assessments and potential treatment required in these women, currently under increased surveillance for their underlying disease, may cause additional anxiety and distress.
However, it is generally considered that the benefits outweigh the harms for immune-deficient women.
Health system implications of these recommendations
Recommendations regarding the management of immune-deficient women are consistent with present clinical practice.
No additional costs are anticipated.
Barriers to implementation
Some immune-deficient women may choose not to attend for cervical screening as frequently as recommended. Less frequent screening has been reported in both women with HIV and organ transplant recipients.
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There is some evidence to support increased progression of cervical abnormalities in HIV-positive women compared with HIV-negative women. Although HAART has been in use for two decades, there is only limited evidence of an increased likelihood of lesion regression and a higher clearance rate of oncogenic HPV positive SIL in adherent users. Overall, there is insufficient direct evidence to support a change from the screening recommendations in pre-renewal NCSP guidelines, which recommended colposcopy referral for any screen-detected abnormality.
When CIN is diagnosed in HIV-positive women, excisional therapy is recommended. However, failure rates are high, necessitating frequent post-treatment surveillance. Massad et al reported that most lesions detected after therapy in HIV-positive women were low grade which may be indicative of new HPV infections that are less likely to progress.
The burden of HPV-related cancers can be expected to increase in HIV-positive women given successful prolongation of life with ART and potentially longer duration of HPV persistence.
There is insufficient evidence available to determine the optimal cervical screening strategy in immune-deficient women. Current recommendations reflect a cautious approach until further data become available. The effect of ART on progression of cervical disease is still unclear.
These guidelines have not investigated the need for special consideration in other groups of women who may be immune deficient either due to a disease, immunosuppressive drugs or both. This group is heterogeneous due to by varying degrees of disease severity, duration, types and length of treatments.
Future research priorities
Long-term randomised controlled trials, comparing screening strategies in immune-deficient women, are needed to inform future guidelines. It is anticipated that the renewed NCSP and the National Cancer Screening Register will facilitate the collection of data on immune-deficient women to support future recommendations. Modelled analysis may help in determining whether routine 5-yearly screening could be suitable for this group of women.
- Dr Vivienne Milch – Co-author
- A/Professor Lyndal Anderson – Co-author
- Dr Marsali Newman – Co-author
- A/Professor Alison Brand — Contributor
- Professor Ian Hammond — Contributor
- A/Professor Selvan Pather — Contributor
- Dr Lara Roeske — Contributor
- Mr. C. David H. Wrede — Contributor
- Cancer Council Australia Cervical Cancer Screening Guidelines Working Party — Co-author
We acknowledge and thank Professor Claire Vajdic (Head, Cancer Epidemiology Research Unit, Centre for Big Data Research in Health, University of New South Wales) and Andrew Grulich (Head, HIV Epidemiology and Prevention Program, The Kirby Institute, University of New South Wales) for their contributions to this section.
- Clifford GM, Gonçalves MA, Franceschi S, HPV and HIV Study Group. Human papillomavirus types among women infected with HIV: a meta-analysis. AIDS 2006 Nov 28;20(18):2337-44 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17117020.
- de Sanjosé S, Diaz M, Castellsagué X, Clifford G, Bruni L, Muñoz N, et al. Worldwide prevalence and genotype distribution of cervical human papillomavirus DNA in women with normal cytology: a meta-analysis. Lancet Infect Dis 2007 Jul;7(7):453-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17597569.
- Aggarwal C, Li L, Borghaei H, Mehra R, Somaiah N, Turaka A, et al. Multidisciplinary Therapy of Stage IIIA Non-Small-Cell Lung Cancer: Long-term Outcome of Chemoradiation With or Without Surgery. Cancer Control 2014 Jan;21(1):57-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24357742.
- Pietrzak B, Mazanowska N, Ekiel AM, Durlik M, Martirosian G, Wielgos M, et al. Prevalence of high-risk human papillomavirus cervical infection in female kidney graft recipients: an observational study. Virol J 2012 Jun 18;9:117 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22709394.
- Origoni M, Stefani C, Dell’Antonio G, et al. Cervical human papillomavirus in transplanted Italian women: a long-term prospective follow-up study. J Clin Virol 2011;51:250–4.
- Veroux M, Corona D, Scalia G, Garozzo V, Gagliano M, Giuffrida G, et al. Surveillance of human papilloma virus infection and cervical cancer in kidney transplant recipients: preliminary data. Transplant Proc 2009 May;41(4):1191-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19460514.
- Strickler HD, Burk RD, Fazzari M, Anastos K, Minkoff H, Massad LS, et al. Natural history and possible reactivation of human papillomavirus in human immunodeficiency virus-positive women. J Natl Cancer Inst 2005 Apr 20;97(8):577-86 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15840880.
- Moscicki AB, Shiboski S, Hills NK, Powell KJ, Jay N, Hanson EN, et al. Regression of low-grade squamous intra-epithelial lesions in young women. Lancet 2004 Nov;364(9446):1678-83 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15530628.
- Schuman P, Ohmit SE, Klein RS, Duerr A, Cu-Uvin S, Jamieson DJ, et al. Longitudinal study of cervical squamous intraepithelial lesions in human immunodeficiency virus (HIV)-seropositive and at-risk HIV-seronegative women. J Infect Dis 2003 Jul 1;188(1):128-36 Available from: http://www.ncbi.nlm.nih.gov/pubmed/12825181.
- Grulich AE, van Leeuwen MT, Falster MO, Vajdic CM. Incidence of cancers in people with HIV/AIDS compared with immunosuppressed transplant recipients: a meta-analysis. Lancet 2007 Jul 7;370(9581):59-67 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17617273.
- Dal Maso L, Polesel J, Serraino D, Lise M, Piselli P, Falcini F, et al. Pattern of cancer risk in persons with AIDS in Italy in the HAART era. Br J Cancer 2009 Mar 10;100(5):840-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19223894.
- Simard EP, Engels EA. Cancer as a cause of death among people with AIDS in the United States. Clin Infect Dis 2010 Oct 15;51(8):957-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20825305.
- Massad LS, Seaberg EC, Watts DH, Minkoff H, Levine AM, Henry D, et al. Long-term incidence of cervical cancer in women with human immunodeficiency virus. Cancer 2009 Feb 1;115(3):524-30 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19127538.
- Simard EP, Pfeiffer RM, Engels EA. Cumulative incidence of cancer among individuals with acquired immunodeficiency syndrome in the United States. Cancer 2011 Mar 1;117(5):1089-96 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20960504.
- Engels EA, Biggar RJ, Hall HI, Cross H, Crutchfield A, Finch JL, et al. Cancer risk in people infected with human immunodeficiency virus in the United States. Int J Cancer 2008 Jul 1;123(1):187-94 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18435450.
- Adler DH. The impact of HAART on HPV-related cervical disease. Curr HIV Res 2010 Oct;8(7):493-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20946095.
- Cobucci RN, Lima PH, de Souza PC, Costa VV, Cornetta Mda C, Fernandes JV, et al. Assessing the impact of HAART on the incidence of defining and non-defining AIDS cancers among patients with HIV/AIDS: a systematic review. J Infect Public Health 2015 Jan;8(1):1-10 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25294086.
- Collett D, Mumford L, Banner NR, Neuberger J, Watson C. Comparison of the incidence of malignancy in recipients of different types of organ: a UK Registry audit. Am J Transplant 2010 Aug;10(8):1889-96 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20659094.
- Vajdic CM, McDonald SP, McCredie MR, van Leeuwen MT, Stewart JH, Law M, et al. Cancer incidence before and after kidney transplantation. JAMA 2006 Dec 20;296(23):2823-31 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17179459.
- Madeleine MM, Finch JL, Lynch CF, Goodman MT, Engels EA. HPV-related cancers after solid organ transplantation in the United States. Am J Transplant 2013 Dec;13(12):3202-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24119294.
- Marschalek J, Helmy S, Schmidt A, Polterauer S, Sobulska M, Gyoeri GP, et al. Prevalence of genital dysplasia after kidney transplantation--a retrospective, non-interventional study from two centers. Acta Obstet Gynecol Scand 2015 Aug;94(8):891-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25912178.
- Engels EA, Pfeiffer RM, Fraumeni JF Jr, Kasiske BL, Israni AK, Snyder JJ, et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2;306(17):1891-901 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22045767.
- Adami J, Gäbel H, Lindelöf B, Ekström K, Rydh B, Glimelius B, et al. Cancer risk following organ transplantation: a nationwide cohort study in Sweden. Br J Cancer 2003 Oct 6;89(7):1221-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/14520450.
- National Health and Medical Research Council. Screening to prevent cervical cancer: guidelines for the management of asymptomatic women with screen detected abnormalities. Canberra: NHMRC; 2005.
- Keller MJ, Burk RD, Massad LS, Eltoum IE, Hessol NA, Castle PE, et al. Cervical Precancer Risk in HIV-Infected Women Who Test Positive for Oncogenic Human Papillomavirus Despite a Normal Pap Test. Clin Infect Dis 2015 Nov 15;61(10):1573-81 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26187020.
- Keller MJ, Burk RD, Xie X, Anastos K, Massad LS, Minkoff H, et al. Risk of cervical precancer and cancer among HIV-infected women with normal cervical cytology and no evidence of oncogenic HPV infection. JAMA 2012 Jul 25;308(4):362-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22820789.
- Blitz S, Baxter J, Raboud J, Walmsley S, Rachlis A, Smaill F, et al. Evaluation of HIV and highly active antiretroviral therapy on the natural history of human papillomavirus infection and cervical cytopathologic findings in HIV-positive and high-risk HIV-negative women. J Infect Dis 2013 Aug 1;208(3):454-62 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624362.
- Aggarwal R, Suri V, Awasthi S, Naru J, Nijhawan R, Minz M, et al. Prevalence and genotypes of HPV in female renal transplant recipients in North India. Int J Gynecol Pathol 2014 Sep;33(5):537-42 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25083973.
- Nguyen ML, Flowers L. Cervical cancer screening in immunocompromised women. Obstet Gynecol Clin North Am 2013 Jun;40(2):339-57 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23732035.
- Denslow SA, Rositch AF, Firnhaber C, Ting J, Smith JS. Incidence and progression of cervical lesions in women with HIV: a systematic global review. Int J STD AIDS 2014 Mar;25(3):163-77 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24216030.
- McDonald AC, Tergas AI, Kuhn L, Denny L, Wright TC Jr. Distribution of Human Papillomavirus Genotypes among HIV-Positive and HIV-Negative Women in Cape Town, South Africa. Front Oncol 2014;4:48 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24672770.
- Massad LS, Seaberg EC, Watts DH, Hessol NA, Melnick S, Bitterman P, et al. Low incidence of invasive cervical cancer among HIV-infected US women in a prevention program. AIDS 2004 Jan 2;18(1):109-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15090836.
- Meeuwis KA, Melchers WJ, Bouten H, van de Kerkhof PC, Hinten F, Quint WG, et al. Anogenital malignancies in women after renal transplantation over 40 years in a single center. Transplantation 2012 May 15;93(9):914-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22377788.
- Dal Maso L, Franceschi S, Lise M, De' Bianchi PS, Polesel J, Ghinelli F, et al. Self-reported history of Pap-smear in HIV-positive women in Northern Italy: a cross-sectional study. BMC Cancer 2010 Jun 21;10:310 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20565935.
- ↑ Jump up to: 35.0 35.1 Courtney AE, Leonard N, O'Neill CJ, McNamee PT, Maxwell AP. The uptake of cervical cancer screening by renal transplant recipients. Nephrol Dial Transplant 2009 Feb;24(2):647-52 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18952575.
- Skov Dalgaard L, Fassel U, Østergaard LJ, Jespersen B, Schmeltz Søgaard O, Jensen-Fangel S. Risk of human papillomavirus-related cancers among kidney transplant recipients and patients receiving chronic dialysis--an observational cohort study. BMC Nephrol 2013 Jul 8;14:137 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23834996.
- World Health Organisation. WHO guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Geneva: WHO; 2013 Available from: http://apps.who.int/iris/bitstream/10665/94830/1/9789241548694_eng.pdf.
- Centers for Disease Control and Prevention (CDC); National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America. Guidelines for prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2015;Online with regular updates; last update Dec 17 2015.
- Minkoff H, Zhong Y, Burk RD, Palefsky JM, Xue X, Watts DH, et al. Influence of adherent and effective antiretroviral therapy use on human papillomavirus infection and squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Infect Dis 2010 Mar;201(5):681-90 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20105077.
- Ahdieh-Grant L, Li R, Levine AM, Massad LS, Strickler HD, Minkoff H, et al. Highly active antiretroviral therapy and cervical squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Natl Cancer Inst 2004 Jul 21;96(14):1070-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15265968.
- Massad LS, Fazzari MJ, Anastos K, Klein RS, Minkoff H, Jamieson DJ, et al. Outcomes after treatment of cervical intraepithelial neoplasia among women with HIV. J Low Genit Tract Dis 2007 Apr;11(2):90-7 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17415113.
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