Increasing cervical cytology uptake in Glasgow HIV cohort

INTRODUCTION

HIV has been shown to hasten the progression of precancerous cervical lesions and increase the risk of cervical cancer. ¹ In 1993, the Centers for Disease Control and Prevention included invasive cervical cancer in its list of AIDS-defining diagnoses ² and in 2007 BASHH/BHIVA/FFP (British Association for Sexual Health and HIV/British HIV Association/Faculty of Family Planning) jointly produced guidelines for ‘Sexual and Reproductive Healthcare of People Living with HIV’, which recommend offering annual cervical cytology. ¹

In Scotland, smears are offered to all women over the age of 20 years. All results can be accessed online with a woman's CHI number on the Scottish Cervical Smear Call-Recall System (SCCRS). ³ For a patient to receive annual recall the smear taker must identify the patient as requiring it every time a smear is performed; if not they return to standard three-yearly recall and miss annual reminders. All patients seeking HIV care in Greater Glasgow and Clyde are seen by either the infectious diseases or genitourinary (GU) medicine teams in the Brownlee Centre, Gartnavel General Hospital. Currently, we have a cohort of 342 women who are advised to have annual smears which can be performed in the Brownlee by members of the GU medicine team or department's sexual health advisers (SHAs).

In 2004 an audit was performed looking at smear uptake in the GU medicine cohort and found in 2002 that eight out of 22 women (36%) had a smear in the last year, increasing to 17 out of 32 (53%) women in 2003.

We re-audited our department's smear uptake, looking at how many smears were done in our department and if patients were correctly identified as needing annual cytology.

METHODS

Demographic information for our female patients was taken from our HIV database of current HIV-positive attendees and their latest smear results recorded from SCCRS. Data collection occurred from August to November 2009.

RESULTS

HIV information was available for all 342 women; four had no SCCRS record, SCCRS data were found in 338. One had a previous total hysterectomy and two had been incorrectly coded by SCCRS as male and not invited for smears. Average age was 37 years (range 18–69). Ethnicities – 243 Black African (71%), 92 Caucasian (27%), four Chinese (1%), two Thai (0.6%), one Caribbean (0.3%). In all, 257/342 (75%) women had smears or cervical biopsies performed in the 12 months before data capture commenced in August to November 2009.

Seventy-nine out of 257 (31%) investigations were performed in the Brownlee Centre (see Tables 1–3).

DISCUSSION

Smear uptake in our cohort is favourable compared with rates for the general population in Greater Glasgow (75% versus 68.7% in 2009)³ and has increased greatly from 2004. It is also higher than the uptake of 73% seen in a BASHH UK audit in 2007. ⁴ However, this is significantly lower than the 95% target set by BASHH. ¹ Due to the methodology of this audit, we are unable to comment on the reasons why a smear has not been performed in the last year. One reason may be that women were unaware it was needed. It is important that women are correctly identified as requiring annual smears on the SCCRS so they can receive annual smear reminders.

Over a third of all smears were performed by staff in the HIV clinic. The smears are offered on an opportunistic basis and have been able to screen women who have been reluctant or not able to access screening through other services such as their GP. In addition, women were least likely to be incorrectly coded as requiring three-yearly follow-up when tested at the Brownlee. A possible contributor to the high rates of patients receiving three-yearly requests could be women not telling the smear taker of their HIV status. All patients are advised to tell their GP about their diagnosis but this is not mandatory.

Four women have no record on the SCCRS. This may be due to patients using different names when accessing HIV care, using different spellings of their name or receiving smears in England and Wales. In addition, two patients were incorrectly identified as male and so not invited for smears, these patient's details have now been amended.

All women attending our HIV service are able to have smears in our department so lack of service access should not be a reason for non-uptake of smears. The details of the women who have not had an annual smear have been given to our SHAs and the women will be further reminded of their need for a smear. If they have declined a smear, the SHAs will investigate reasons for this.

Women with HIV are advised to have annual smears due to the potential increase in progression of precancerous lesions and risk of cervical cancer. However, from our results there is only a small increase in borderline and mild dyskaryosis results compared with general population of Glasgow and no cases of invasive cancer. This may be due to our HIV-positive women having lower rates of other risk factors for cervical cancer compared with the general population.

From the results of this audit we aim to remind other services such as local sexual health clinics, gynaecology services and patient's GPs that HIV-positive women need to be identified as such on the SCCRS so they can receive annual reminders.

The advent of the computerized SCCRS and increased awareness from previous audits has led to increases in cytology uptake in spite of a large rise in HIV-positive women attending our service. One weakness in the SCCRS system however is the inability to request lifelong annual recall.