HAB Performance Measures Group 2 -
Cervical Cancer Screening

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Percentage of women with HIV infection who have a Pap screening in the measurement year.

Number of HIV-infected female clients who had Pap screen results documented in the measurement year

Number of HIV-infected female clients who:

• were ≥ 18 years old [ 1 ] in the measurement year or reported having a history of sexual activity, and
• had a medical visit with a provider with prescribing privileges [ 2 ] at least once in the measurement year

1. Patients who were < 18 years old and denied history of sexual activity
2. Patients who have had a hysterectomy for non-dysplasia/non-malignant indications

1. Is the client HIV-infected? (Y/N)
   1. If yes, is the client female? (Y/N)
      1. If yes, is she ≥ 18 years or reports having a history of sexual activity? (Y/N)
         1. If yes, was the pap screening completed during the measurement year?

• Ryan White Program Data Report, Section 5, Items 42 and 52 may provide data useful in establishing a baseline for this performance measure
• Electronic Medical Record/Electronic Health Record
• CAREWare, Lab Tracker, or other electronic data base
• HIVQUAL reports on this measure for grantee under review
• Medical record data abstraction by grantee of a sample of records

IHI Goal: 90% [ 3 ]

*from HAB data base

• Incidence of cervical cancer in the female HIV-infected clinic population

Human Papillomavirus (HPV) is a common infection in the general population. Current evidence suggests that over 50% of sexually active adults have been infected with one or more HPV types. According to population-based prospective studies, HPV precedes the development of cervical cancer. [ 5 ]

Cervical cancer may be the most common AIDS-related malignancy in women. Although not a common diagnosis in women in the general population, according to New York City AIDS Surveillance data from 1990 to 1995, the observed cervical cancer cases in HIV-positive women were two to three times higher than the expected number of cases. [ 6, 7 ] Findings such as these resulted in the inclusion of cervical cancer in the Centers for Disease Control and Prevention (CDC) expanded definition of AIDS. [ 8 ]

When compared with HIV-negative women, HIV-positive women with invasive cervical cancer present at more advanced stages and with cancer metastasizing to unusual locations. HIV- positive women have poorer responses to standard therapy and have higher recurrences and death rates, as well as shorter intervals to recurrence or death. [ 9, 10 ]

The CDC currently recommends that HIV-positive women have a complete gynecologic evaluation, including a Pap smear, as part of their initial HIV evaluations, or upon entry to prenatal care, and another Pap smear six months later. If both smears are negative, annual screening is recommended thereafter in asymptomatic women. The CDC further recommends more frequent screenings (every six months) for women with symptomatic HIV infection, prior abnormal Pap smears, or signs of HPV infection. [ 11, 12 ]

Cervical cancer can often be prevented or detected in its earliest stages through effective screening with a Pap smear and avoidance of known risk factors. This accentuates the importance of routine gynecological care, which includes Pap smears for HIV-infected women. [ 13 ]

Measure reflects important aspect of care that impacts HIV-related morbidity and focuses on treatment decisions that affect a sizable population. Measure has a strong evidence base supporting the use.

"In accordance with the recommendation of the Agency for Health Care Policy and Research, the Pap smear should be obtained twice during the first year after diagnosis of HIV infection and, if the results are normal, annually thereafter" [ 14 ] (6/14/02).

[1] Onset of sexual activity is not reliably reported or recorded. The age bracket of 18 years is selected for performance measurement purposes only and should not be interpreted as a recommendation about the age at which screening should begin to occur.

[2] A "provider with prescribing privileges" is a health care professional who is certified in their jurisdiction to prescribe ARV therapy.

[3] IHI Measure reads, "Percent of Female Patients/Clients with an Annual Papanicolaou (Pap) Test"
( http://www.ihi.org/IHI/Topics/HIVAIDS/HIVDiseaseGeneral/Measures/PercentofPatientswithPAPSmearinLastSix
Months.htm )

[4] National HIVQUAL data looks at the percent of clients who have an annual pelvic exam.
( http://www.hivguidelines.org/admin/files/qoc/hivqual/proj%20info/HQNatlAggScrs3Yrs.pdf )
( http://www.hivguidelines.org/admin/files/qoc/hivqual/proj%20info/HQNatlAggScrs3Yrs.pdf )

[5] Davis, AT. Cervical dysplasia in women infected with the human immunodeficiency virus (HIV): A correlation with HIV viral load and CD4 count. Gynecologic Oncology. 2001; 80(3):350-354.

[6] Approximately 16,000 new cases of cervical cancer are diagnosed each year, and about 4,800 women die from this disease annually. Clinical Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. Chapter 9.

[7] Chiasson, MA. Declining AIDS mortality in New York City . New York City Department of Health. Bull NY Acad. Med. 1997; 74:151-152.

[8] Centers for Disease Control and Prevention (CDC). 1993. Revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. MMWR. 1992; 41(RR-17).
( http://www.cdc.gov/mmwr/preview/mmwrhtml/00018871.htm )

[9] Ibid.

[10] U.S. Department of Health and Human Services. Anderson, JA, editor. Guide to the Clinical Care of Women with HIV; 2005.

[11] http://www.niaid.nih.gov/factsheets/womenhiv.htm

[12] The interval for each patient should be recommended by the physician based on risk factors, i.e., early onset of sexual history, a history of multiple sex partners, low socioeconomic status, and, for women infected with HIV, more frequent screening, according to the established guidelines.

[13] Kjaer, S. Type specific persistence of high risk human papillomavirus (HPV) as indicator of high grade cervical squamous intraepithelial lesions in young women: population based prospective follow-up study, Brit Med J. 2002; 325: 572-578.

[14] Centers for Disease Control and Prevention. Guidelines for Preventing Opportunistic Infections Among HIV-Infected Persons - 2002 Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America . MMWR 2002;51(No. RR-8) ( http://www.cdc.gov/mmwr/PDF/rr/rr5108.pdf or http://aidsinfo.nih.gov/ContentFiles/OIpreventionGL.pdf )