Care of vaginal symptoms among HIV-infected women

OBJECTIVE: Gynecologic disease is common in HIV-infected women. We examine the sociodemographic, clinical, and provider factors associated with the care of women with vaginal symptoms. METHODS: Women enrolled in the HIV Cost and Services Utilization Study (HCSUS), a nationally representative probability sample of HIV-infected adults, were interviewed between January 1996 and April 1997. Women with vaginal symptoms who sought medical attention were asked, "Did your health care provider examine your vaginal area?" Women were also asked if they received medication for their symptoms. RESULTS: Among 154 women with vaginal symptoms, 127 sought care for their symptoms. Of those who sought care, 48% saw a gynecologist and 52% sought care from nongynecologists, most often their usual HIV care provider. Women who saw a gynecologist for their symptoms were more likely to have received a pelvic examination (92% versus 76%; p =.06) and vaginal fluid collection (98% versus 88%; p =.06) than those who saw their regular HIV provider. Fifteen percent of women received medication for their symptoms without having a pelvic examination; gynecologists were less likely to prescribe without an examination (8% versus 21%; p =.12). CONCLUSION: Gynecologists are more likely to provide adequate care of vaginal symptoms among HIV-infected women than nongynecologists who were HIV care providers. This specialty difference is consistent with quality of care studies for other medical conditions, but the potential gynecologic complications of inadequate evaluation and treatment warrants further investigation.     

Human papillomavirus absence predicts normal cervical histopathologic findings with abnormal papanicolaou smears: a study of a university-based inner city population

INTRODUCTION: We studied the role of human papillomavirus (HPV) typing in predicting cervical dysplasia in women with abnormal Papanicolaou (Pap) test results. STUDY DESIGN/METHODS: A university colposcopy clinic-based consecutive sample of 179 women completed a questionnaire and underwent colposcopy, HPV typing (Hybrid Capture System HPV DNA Assay II; Digene Diagnostics, Gaithersburg, MD, USA), and biopsy (if indicated). RESULTS: No severe dysplasia was observed in women with low-risk HPV or in women with negative HPV test results who had a low-grade abnormality on the Pap test. High-risk (HR) HPV was present in every case of severe dysplasia on biopsy. The cumulative odds risk for cervical dysplasia was 1.11 in HIV(+) women with low-grade squamous intraepithelial lesion on the Pap test who were older than 21 years of age and HPV-HR(+). CONCLUSIONS: In the population studied, HPV typing is a valuable adjunct to a low-grade abnormality on the Pap test in predicting the absence of cervical dysplasia on biopsy. Larger prospective population-based studies are needed to study the role of HPV as a negative predictor of disease in cervical dysplasia.     

Adherence to colposcopy among women with HIV infection

In the general population, nonadherence to the recommendation to have colposcopy in women with abnormal cytologic smears is estimated at 30% to 80%, but studies have failed to identify consistent risk factors for nonadherence. The purpose of this analysis is to assess adherence to colposcopy in a subset of participants in the Women's Interagency HIV Study (WIHS), an ongoing multisite longitudinal study of HIV infection in women in the United States and determine factors associated with nonadherence. Identification of such predictors would be useful in designing strategies to improve adherence in this group. METHODS: Adherence to colposcopy was examined in a cohort of 462 women with, or at risk for, HIV infection with abnormal cervical cytology on entry into WIHS. Adherence was defined as having colposcopy done within 6 months of an abnormal cytology result. RESULTS: Overall adherence to colposcopy was 65% (302 of 462). A multivariate logistic regression model revealed that the odds of adherence were significantly lower for the women who were HIV-infected (p = .011), current crack/cocaine users (p = .040), ever too ill to get medical care (p = .033), not recruited by WIHS study staff (p = .004), and less concerned about the care of their children (p = .037). Among HIV-seropositive women, low CD4 counts, high viral loads, and presence of AIDS-defining illness were not predictive of nonadherence. DISCUSSION: Adherence to colposcopy among WIHS participants was at the upper limit of the reported range in the United States. Chemical dependency and domestic violence may negatively impact on colposcopy adherence whereas supportive study personnel, having health insurance, and concerns about raising one's children appear to be motivators for adherence to colposcopy in this study. HIV infection was a risk factor for nonadherence, but markers of advanced disease were not predictive of nonadherence.     

HPV testing is an efficient management choice for women with inadequate liquid-based cytology in cervical cancer screening

This study compares colposcopy referrals of 2 management strategies: oncogenic human papillomavirus (HPV)-DNA testing (Hybrid Capture 2 assay, Qiagen, Germantown, MD) and repeat cytology. In the New Technology in Cervical Cancer Trial, 22,708 subjects were randomly assigned to undergo both HPV and liquid-based cytologic testing. Women aged 35 to 60 years old with unsatisfactory cytologic findings were directly referred for colposcopy if the HPV test result was positive, and were referred for repeat cytologic examination if the HPV test result was negative; women aged 25 to 35 years old were referred for repeat cytologic examination independent of HPV test results. A positive or a second unsatisfactory cytologic examination referred women for colposcopy. Five hundred sixty women had unsatisfactory cytologic findings. Colposcopy referral was not significant and slightly higher with HPV testing than repeat cytologic test (9.8% vs 6.8%, P = .11). When cytologic testing was repeated 36.8% were unavailable for follow-up and most of the colposcopies were performed in HPV-negative women. For unsatisfactory cytologic findings, HPV triage is a more logical and efficient management strategy than a repeat cytologic test.     

The prevalence of abnormal cervical cytology in women with infertility

The aim of this study was to compare the frequency of abnormal cervical cytology in women with infertility problems with that of fertile women by using ThinPrep® liquid‐based Pap Tests™. A retrospective case–control study for over 2 years was conducted. The cases included all women with infertility problems who had Pap tests during their infertility treatment period. The cases were further subdivided into primary and secondary infertility groups. The control group included all women without infertility problems who had routine Pap tests in the same period. The age and demographic features were adjusted and matched for both groups. Statistical analysis included chi‐square test and Fischer exact test. The infertility group (n = 490) showed significantly (P < 0.05) more abnormal cervical squamous epithelial abnormalities (48 positive cases, 9.8%) than the controls (n = 7,150, 216 positive cases, 3%). Women with secondary infertility had more epithelial abnormalities and more high‐grade lesions than women with primary infertility. Women with infertility had statistically significant higher frequency of squamous intraepithelial lesions than women without infertility problems of similar age and demographic background. The data suggest that women with infertility might benefit from more frequent cervical cytology screening. Diagn. Cytopathol. 2010;38:791–794. © 2009 Wiley‐Liss, Inc.     

A cost-effectiveness analysis of four management strategies in the determination and follow-up of atypical squamous cells of undetermined significance

Atypical squamous cells of undetermined significance (ASC-US) are the most common abnormal cytological result on Papanicolaou (Pap) smear. We analyzed four management strategies in a hypothetical cohort of women divided by age group: (1) immediate colposcopy, (2) repeat cytology after an ASC-US Pap smear result, (3) conventional Pap with reflex human papillomavirus (HPV) testing, and (4) liquid-based cytology with reflex HPV testing. Parameter variables were collected from previously published data. Strategies that included reflex HPV testing had the lowest overall costs for all age groups combined. Repeat Pap smears had the highest number of true positive results throughout all stages but also had the uppermost number of missed cancers and highest costs. Immediate colposcopy had the second highest overall costs and detected fewer true positive results than liquid-based cytology. Younger women (aged 18-24 yr) consistently had higher total costs for all strategies investigated. Using the incremental cost-effectiveness (CE) ratio, the immediate colposcopy strategy was more costly and less effective than liquid-based cytology and, therefore, was dominated. The incremental CE ratio was lowest for liquid-based cytology compared with conventional cytology and liquid-based cytology with reflex HPV testing was the most cost-effective strategy.     

Predictors of adherence to follow-up recommendations after an abnormal Pap smear among underserved inner-city women

ObjectivesThis study aimed to identify cognitive-affective predictors of adherence to initial diagnostic colposcopy and 6-month follow-up recommendations among underserved women.MethodsA secondary data analysis was completed of a randomized clinical trial assessing tailored telephone counseling for colposcopy adherence after an abnormal screening Pap smear among 210 underserved inner-city women.ResultsAdherence to initial diagnostic colposcopy was significantly associated with greater self-efficacy (OR = 1.504, 95% CI 1.021–2.216). Women with lower monitoring attentional style had significantly greater adherence to 6-month follow-up recommendations compared to women with higher monitoring scores (OR = 0.785, 95% CI 0.659–0.935).ConclusionIncreasing cervical cancer-related self-efficacy and tailoring cervical cancer risk communication to monitoring attentional style may help improve adherence to follow-up recommendations after an abnormal Pap smear test result.Practice implicationsFuture research is needed to develop and implement psychosocial approaches to improving adherence to diagnostic colposcopy and follow-up recommendations adherence among underserved women.     

Frequency of gynecologic follow-up and cervical cancer screening in the Swiss HIV cohort study

BACKGROUND: According to current recommendations, HIV-infected women should have at least 1 gynecologic examination per year. OBJECTIVES: To analyze factors associated with frequency of gynecologic follow-up and cervical cancer screening among HIV-infected women followed in the Swiss HIV Cohort Study (SHCS). METHODS: Half-yearly questionnaires between April 2001 and December 2004. At every follow-up visit, the women were asked if they had had a gynecologic examination and a cervical smear since their last visit. Longitudinal models were fitted with these variables as outcomes. RESULTS: A total of 2186 women were included in the analysis. Of the 1146 women with complete follow-up in the SHCS, 35.3% had a gynecologic examination in each time period, whereas 7.4% had never gone to a gynecologist. Factors associated with a poor gynecologic follow-up were older age, nonwhite ethnicity, less education, underweight, obesity, being sexually inactive, intravenous drug use, smoking, having a private infectious disease specialist as a care provider, HIV viral load <400 copies/mL, and no previous cervical dysplasia. No association was seen for living alone, CD4 cell count, and positive serology for syphilis. CONCLUSIONS: Gynecologic care among well-followed HIV-positive women is poor and needs to be improved.     

Review of screening guidelines for non-AIDS-defining malignancies: evolving issues in the era of highly active antiretroviral therapy

HIV-associated morbidity and mortality have declined dramatically in the era of HAART. Through direct and indirect benefits of HAART, people with HIV/AIDS are living longer, developing less AIDS-defining cancers and more cancers commonly seen in the seronegative population. Herein, we review cancer screening strategies for people living with HIV and compare and contrast them with those of the general population. The most noticeable differences occur in anal and cervical cancer screening. Although anal cancer is uncommon in the general population, it is more prevalent in men who have sex with men and people at high risk for human papillomavirus infection, especially those infected with HIV. To address this, we recommend that a digital rectal exam and a visual inspection be performed annually. In addition, an anal Pap test should be performed soon after the diagnosis of HIV infection, with follow-up testing every six months until two normal tests. Abnormal cytological results are then investigated with high-resolution anoscopy and biopsy of suspicious lesions. In screening for cervical cancer, a Pap test should be performed during the anogenital exam after initial HIV diagnosis, with a second Pap six months later, then annually if the results are normal. A colposcopy should follow an abnormal result. Human papillomavirus testing as a screening method for cervical cancer in women with HIV can also be efficacious. In lung cancer screening, preliminary data suggest that low-dose computerized tomography may play an important role, but further research is needed. Screening for breast and colon cancer should follow guidelines for the general population. Early screening for prostate cancer based on a diagnosis of HIV lacks clear benefit.     

Detection of high-grade cervical dysplasia: Impact of age and Bethesda System terminology

Pap smear, colposcopy, and biopsy results were collected from 1988–1993 at a group of family planning clinics. Positive predictive values and likelihood ratios were calculated for diagnosis of high-grade lesions based on age and Pap smear results. One thousand and forty-seven colposcopies were logged; 771 had a biopsy or endocervical curettage. Seventy-nine (10%) were high-grade lesions. If only human papillomavirus (HPV) was reported on the Pap smear, the likelihood of a high-grade biopsy was lowest (positive predictive value, 4.5%; likelihood ratio, 0.4). Women under age 25 were less likely to have high-grade biopsies (positive predictive value, 7.3%; likelihood ratio 0.7). Repeat Pap smears for atypical cells of undetermined significance (ASCUS) and low grade squamous intra-epithelial lesion (LGSIL) showing only HPV in women under age 30 would have reduced the immediate colposcopy rate by 60% and delayed diagnosis of 23% of high-grade lesions. Consideration of patient age and whether HPV is the only Pap smear finding may reduce referral for immediate colposcopy. Diagn. Cytopathol. 1997;17:321–325. © 1997 Wiley-Liss, Inc.     

Liqui‐PREP® versus conventional papanicolaou smear to detect cervical cells abnormality by split‐sample technique: A randomized double‐blind controlled trial

To assess the diagnostic performances of LiquiPrep® (LP) to detect cervical cellular abnormality in comparison to Papanicolaou (Pap) smear in 194 women with abnormal cervical cytology who were scheduled for colposcopy at the institution between January 2008 and November 2008. The women were randomized to undergo a repeated cervical cytologic evaluation by Pap smear followed by LP, or the two methods in alternating order. The pathologist was blinded to previous cytologic diagnosis and the pair of slides assigned for each woman. Cytologic results from each method were compared to subsequent histopathology. Mean screening time for each LP and Pap slides were 4.3 ± 1.2 minutes and 5.4 ± 1.1 minutes, respectively (P < 0.001). From 194 cases, ASC or AGC were diagnosed in 72 cases (37.1%) from LP and 68 cases (35.1%) from Pap smear. After excluding the ASC/AGC group, the overall cytologic diagnostic agreement between the two tests were 69 of 87 cases (73.6%) while the agreements with histologic diagnoses were 39/87 cases from LP (44.8%) and 41 (47.1%) from Pap smear (P = 0.824). The accuracy of LP was not significantly different from Pap test, 43.4% (95% confidence interval [CI]: 34.8–52.1%) compared to 44.4% (95% CI: 35.7–53.1%). LP did not have superior performance over Pap test to detect high‐grade lesions (≥cervical intraepithelial neoplasia II) using ASC/AGC as the threshold with the sensitivity of 70.5% (95% CI: 64.0–76.9%) versus 77.3% (95% CI: 71.4–83.2%), respectively. Diagn. Cytopathol. 2011;39:22–27. © 2010 Wiley‐Liss, Inc.     

The year-long effect of HIV-positive test results on pregnancy intentions, contraceptive use, and pregnancy incidence among Malawian women

OBJECTIVES: To estimate the effect of receiving HIV-positive test results on intentions to have future children and on contraceptive use and to assess the association between pregnancy intentions and pregnancy incidence among HIV-positive women in Malawi. METHODS: Women of unknown HIV status completed a questionnaire about pregnancy intentions and contraceptive use and then received HIV voluntary counseling and testing (VCT). Women who were HIV-positive and not pregnant were enrolled and followed for 1 year while receiving HIV care and access to family planning (FP) services. RESULTS: Before receiving their HIV test results, 33% of women reported a desire to have future children; this declined to 15% 1 week later (P < 0.0001) and remained constant throughout follow-up. Contraceptive use increased from 38% before HIV testing to 52% 1 week later (P < 0.0001) and then decreased to 46% by 12 months. The pregnancy incidence among women not reporting a desire to have future children after VCT was less than half of the incidence among women reporting this desire. CONCLUSIONS: With knowledge of their HIV-positive status, women were less likely to desire future pregnancies. Pregnancy incidence was lower among women not desiring future children. Integration of VCT, FP, and HIV care could prevent mother-to-child HIV transmission.     

The prevalence of abnormal cervical cytology in women with systemic lupus erythematosus

To compare the frequency of abnormal cervical cytology in women with systemic lupus erythematosus (SLE) with that of healthy women without connective tissue diseases by using ThinPrep® liquid based Pap Tests^TM. A retrospective case‐control study over 2 years was conducted. The cases included all women with SLE who had Pap tests during their treatment period. The control group included all women without SLE or other connective tissue diseases (CTDs) that had routine Pap tests in the same period. The age and demographic features were adjusted and matched for both groups. Statistical analysis included Chi‐Square test and Fischer exact test. The SLE group (n= 55) showed significantly (P < 0.05) more abnormal cervical squamous epithelial abnormalities [14 positive cases (25.4%) than the controls (n = 8,175, with 285 positive cases (3.5%)]. Women with SLE had statistically significant higher frequency and prevalence of squamous intraepithelial lesions than women without SLE of similar age and demographic background. The data suggested that women with SLE might benefit from more frequent cervical cytology screening. Diagn. Cytopathol. 2010. © 2010 Wiley‐Liss, Inc.     

Disclosure of HIV status: the role of ethnicity among people living with HIV in London

OBJECTIVE: To examine HIV disclosure among people living with HIV in London. METHODS: Between June 2004 and June 2005, 1687 people living with HIV (73% response) receiving medical care in National Health Service (NHS) clinics in northeast London completed a confidential, self-administered questionnaire. Respondents were asked whether they had told anyone else that they had HIV, and if so, whom. RESULTS: The analysis included 1407 people: 667 black African heterosexual respondents (453 women, 214 men) and 740 gay men (633 white, 107 ethnic minority). The majority of respondents (88.0%) had told at least 1 other person about their HIV infection, but this varied between groups: white gay men, 95.0%; ethnic minority gay men, 93.5%; black African heterosexual women, 84.8%; black African heterosexual men, 76.6% (P < 0.001). Black African heterosexual men (65.3%) and women (60.4%) were less likely to have told their current partner about their HIV infection than white (86.2%) or ethnic minority gay men (85.2%): black African men, adjusted odds ratio (AOR) 0.25, 95% confidence interval (CI) 0.14, 0.44, P < 0.001; black African women, AOR 0.24, 95% CI 0.15, 0.39, P < 0.001 (reference group, white gay men). Only 1 in 5 respondents (21.6%) had disclosed their HIV status to their employer (white gay men, 30.5%; ethnic minority gay men, 15.8%; black African heterosexual women, 10.5%; black African heterosexual men, 8.8%; P < 0.001). CONCLUSIONS: In this London study there were striking differences, by ethnicity, in the extent to which people with HIV disclosed their infection. This has important implications in light of the 2005 Disability Discrimination Act and recent prosecutions in the UK for the reckless transmission of HIV.     

Cervical squamous intra-epithelial changes and human papillomavirus infection in women infected with human immunodeficiency virus in Pune, India

In view of the dual burden of HIV infection and cervical cancers in India, this study was undertaken to estimate the prevalence of Pap smear abnormalities and human papillomavirus infection among HIV-infected women. Consecutive HIV-infected women attending voluntary counseling testing clinics were enrolled. Written informed consent, demographic information, Pap smears, cervical swabs for HPV typing and a blood sample for CD4+ cell count were collected. Treatment for opportunistic and sexually transmitted infections and reproductive tract infections was provided. Women with Pap smear abnormality were referred for further intervention. Between January 2003 and May 2004, 287 HIV-infected women were enrolled. Pap smear abnormalities were seen in 6.3% women and were more common among women aged 30 and above (P=0.042) and those who had suffered from opportunistic infections (P=0.004). In multivariate analysis, Pap smear abnormalities were associated independently with opportunistic infections (P=0.02, AOR 3.8, 95% CI 1.2--11.5). Of the 100 random cervical specimens screened for HPV 16 and 18 genotypes, 33% (95 CI 23.9--43.1) were positive for HPV 16/18. Of the 122 patients who returned for a follow-up visit, 5 patients (4.1%) who did not have Pap smear abnormality at baseline, had developed Pap smear abnormality. The incidence of Pap smear abnormalities was 5.5 per 100 person year of follow-up. In order to prevent thousands of deaths due to cervical cancer in India, there is a need for strengthening the Pap smear screening program and HPV vaccine development.     

High-risk HPV testing in women with borderline and mild dyskaryosis: long-term follow-up data and clinical relevance.

In The Netherlands and most other European countries, women with two serial cervical smears with borderline or mild dyskaryosis (BMD) within 6 months are referred for colposcopy-directed biopsies. Only about 10% of these women have high-grade cervical intraepithelial neoplasia (CIN). This study therefore investigated whether human papillomavirus (HPV) testing could identify which women with smears read as BMD are most likely to have high-grade CIN, either at referral or during follow-up and the relationship was determined between clearance of high-risk HPV and regression of abnormal cytology. Women with smears read as BMD (n=278) were referred to the gynaecologist for colposcopy. They were subdivided into two groups; group A comprised women with a single smear (n=172) and group B women with two sequential smears (n=106) read as BMD before referral. High-risk HPV detection with Hybrid Capture II (HC II) was performed on a cervical scrape taken at the first visit before colposcopy (i.e. baseline smear) and during follow-up. Biopsies were taken when lesions suspected for CIN were seen at colposcopy. High-risk HPV DNA was present in the baseline smears of 126 (45.0%) women; 26 (20.6%) of them had histologically confirmed CIN 2/3 at the first visit and another 14 (11.1%) during follow-up. Only one of the 152 women (0.7%) with a negative high-risk HPV test had a CIN 2 lesion at the first visit and no CIN lesions were detected during follow-up of these women. After exclusion of women who were treated for prevalent high-grade CIN, the median follow-up times were 1.3 years (range 0.0-4.3 years) and 1.6 years (range 0.0-4.5 years) for women with HPV-negative and HPV-positive baseline smears, respectively. The sensitivity of a positive high-risk HPV test for CIN 2/3 at the first visit was 96.3%, the specificity 60.2%, the positive predictive value 20.6%, and the negative predictive value 99.3%. These values did not change markedly when stratified for group A or group B. Thus, a high-risk HPV positive test was strongly associated with the presence at the first visit and the development of CIN 2/3 lesions during follow-up. Moreover, regression of abnormal cytology in women with a positive high-risk HPV test at baseline was strongly associated with viral clearance and occurred 0.3 years (range -1.2 to 1.7 years) later than HPV clearance. This study establishes the value of a high-risk HPV positive test for women at risk of high-grade CIN, with virtually no risk for missing CIN 2/3. Addition of a test on high-risk HPV in women with BMD could prevent 55% of the referrals and/or repeat smears.     

Usefulness of concurrent Papanicolaou smear at time of cervical biopsy

The reliability and cost-effectiveness of a repeat Papanicolaou (Pap) smear performed at the time of colposcopic biopsy is uncertain. To evaluate the usefulness of this practice, Pap smear and biopsy results of 718 patients were reviewed and compared: 619 patients had Pap smears performed prior to colposcopy with a 1.1% false-negative rate, 97.5% sensitivity, and 83.6% positive predictive value. Ninety-nine patients had Pap smears performed at the time of colposcopy with a 19.1% false-negative rate, 56.8% sensitivity, and 92.6% positive predictive value. Repeat Pap smear at the time of colposcopy resulted in significant changes in the management of only 2 patients (2%) and more careful follow-up in one (1%). Pap smears performed at colposcopic biopsy are less sensitive than those done prior to biopsy (P < 0.001). The clinical benefit of this practice is marginal, considering the added costs and potential detrimental effects to the colposcopic examination, provided patients receive adequate follow-up.     

Predictors of repeat pregnancy among HIV-1-infected women

BACKGROUND: In the Women and Infants Transmission Study (WITS), a prospective cohort study of HIV-infected pregnant women at six US mainland and Puerto Rican sites, changes in the HIV-1 epidemic have included higher income, better education, and better-controlled HIV disease among more recently enrolled women. Because these changes may alter the reproductive patterns of these women an awareness of these women's current reproductive behaviors is essential. We examined predictors of repeat pregnancy among HIV-1-infected women enrolled in the Women and Infants Transmission Study (WITS). METHODS: Women enrolled in WITS without a history of sterilization were included. Using bivariate and multivariate analyses, predictors of a repeat pregnancy were modeled. Changes in risk factors for repeat pregnancy over time were examined and important predictors of repeat pregnancy were determined. RESULTS: Of 2246 eligible women, 22% had more than one WITS-enrolled pregnancy. In bivariate analyses, risk of repeat pregnancy was associated with younger age, lower educational status, higher CD4%, and lower viral loads. There was little change in risk factors for repeat pregnancy over time. CONCLUSIONS: HIV-1-infected women who are younger and healthier are more likely to have more than one pregnancy. Factors associated with repeat pregnancy among HIV-1-infected women have remained stable over time. Awareness of these factors will better equip healthcare providers to address the reproductive needs of HIV-1-infected women.     

Inadequate follow-up for abnormal Pap smears in an urban population

PURPOSE: To determine the factors associated with inadequate follow-up for abnormal Pap smears among a cohort of Boston women from urban academic clinics. METHODS: Subjects were women > 18 years with abnormal cervical cytology between February 1999 and April 2000. Inadequate follow-up was defined as lack of subsequent cervical cytology or pathology specimen within four months of the initial abnormal specimen for high-grade lesions or within 7 months for low-grade lesions. RESULTS: Of the 423 subjects, the mean age was 33 years. Sixty percent were black, 23% Hispanic, 15% white, 2% Asian. The population was largely uninsured or publically insured. The overall inadequate follow-up rate was 38%. In bivariate analysis, age was a significant risk factor; 46% of women ages 18-29 had inadequate follow-up (p < 0.01). In multivariate analysis, women aged 18-29 years were more likely than women 50 years and older to have inadequate follow-up (OR 2.7, 95% CI 1.1-6.4), as were women with Medicaid insurance compared with private insurance (OR 1.9, 95% CI 1.01-3.5). After 12 months, 26% of women with abnormal Pap smears still had not received follow-up. CONCLUSIONS: In a predominantly urban minority population, the overall rate of inadequate follow-up for abnormal Pap smears was high at 38%. Programs to address follow-up of abnormal cervical cytology should focus on minority populations, especially younger and all low-income women.     

Educational level and cervical cancer screening programs in a Venezuelan urban area

The purpose of this study was to investigate, in a group of Venezuelan women, the knowledge and understanding of the purpose of the Pap smear and the correlation of this knowledge with their educational level. Women were recruited for a cervical cancer screening program and answered a questionnaire concerning what a Pap smear is used for. Three hundred one women were included in the study. Two hundred eighty six women (95%) answered that they knew about Pap smear. Two hundred sixty eight patients (89%) knew that the Pap smear is used for cervical cancer screening. One hundred sixteen women (38.5%) had a low educational level. One hundred and four of them (89.7%) knew that Pap smear is used to screen cervical cancer. Ninety two percent of women who did not complete elementary school had the knowledge of the purpose of vaginal cytology. Two hundred eighty one patients (93%) mentioned that they had at least one Pap smear. One hundred sixty four patients (58.3%) reported to have > or = 4 Pap smears in their life time. Two hundred fifty seven women (91.5%) remembered when the first Pap smear was taken. Twenty one patients (7%) had a Pap smear for the first time. The conclusions are: 1) low educational level in an urban area is not a limitation for knowing about and having a cervical cytology test taken; 2) high percentage of Venezuelan women in an urban area know what the Pap smear is used for.