Letter to the Editor Knowledge and use of Papanicolaou test among HIV-positive women Diego Serraino 1 * , Catia Pavia 1 , Assunta Navarra 1 , Pierluca Piselli 1 , Giuseppe Pisani 2 , Massimiliano Scuderi 1 , Simona Barzoni Secchia 1 , Maria Capobianchi 3 , and Giuseppe Ippolito 1 for the Immunosuppression and Cancer Study Group 1 Department of Epidemiology, Istituto Nazionale per le Malattie Infettive L. Spallanzani, IRCCS, Rome, Italy 2 Gynaecological Department, San Camillo Hospital, Rome, Italy 3 Virology Unit, Istituto Nazionale per le Malattie Infettive L. Spallanzani, IRCCS, Rome, Italy Dear Sir, It is well known that women who are infected with the human immunodeficiency virus (HIV) have higher rates of infection with human Papillomaviruses (HPV) 1,2 and that these women present an approximately 10-fold higher risk for invasive cervical cancer (ICC) than age-matched women in the general population. 3 In addition to the high frequency of HPV infection, the increased ICC risk in HIV- positive women could be explained by the immunosuppressive effect of HIV, which may accelerate HPV-related oncogenesis. 4,5 More- over, because of life-styles often associated with HIV infection (e.g., use of intravenous drugs and prostitution), HIV-positive women may be less likely to receive appropriate cervical screening through Papanicolaou (Pap)-smear than HIV-negative women. In this epidemiological research, we investigated I) the extent to which HIV-infected women were aware that Pap-smear could pre- vent cervical cancer, ii) factors eventually associated with lack of awareness of Pap-smear, and iii) whether lack of awareness affected the use of Pap-smear screening. A cross-sectional study was conducted between January 2003 and June 2004 at the HIV Outpatient Gynaecological Clinic of the National Institute for Infectious Disease L. Spallanzani, Rome. During this period, 534 HIV-positive women were referred by infectious disease specialists for gynaecological examination, including Pap-smear and, when appropriate, colposcopy. Of these 534 HIV-positive women, 147 were not timely traced. According to a protocol approved by the Ethical Committee of the National Institute for Infectious Disease L. Spallanzani, Rome, 387 women (72.5%) were thus invited to take part in the study. Three hundred eighty-one of them accepted participation and signed the informed consent. Following the aim of this analysis, 44 out of the 381 HIV-positive women who accepted participation were excluded because of missing information on the study endpoint: the remain- ing 337 HIV-positive women constitute the study group. Relevant information was collected through a questionnaire-based interview that was conducted, before the gynaecological examina- tion, by 2 gynaecologists (CP and GP). To assess awareness of the Pap-smear, study participants were first asked if they were ever told about Pap-smear and, second, if they knew that Pap-smear was a cancer preventive tool. Following the aims of this analysis, women who knew that a Pap-test was used to prevent cervical cancer (or cancer of the uterus) were considered aware of Pap-smear. Other collected data included sociodemographic factors (e.g., age, educa- tion and country of origin), smoking and reproductive history, sexual habits (e.g., age at first intercourse, number of partners and contra- ceptive methods) and history of HIV infection (e.g., date of first seropositive test and mode of HIV acquisition). History of Pap- smear was investigated in detail to assess lifetime testing, age at first smear, number of smears done in the 5 years and in the last year pre- ceding the interview, and a self-reported history of abnormal smears. The association between awareness of Pap-smear and the above- mentioned characteristics was investigated through odds ratios (ORs) and 95% confidence intervals (CIs). Multiple logistic regression (MLR) equations were fitted to account for the effect of potential con- founders that were identified through a stepwise forward procedure. 6 The 337 HIV-positive women included in our study had a median age of 38 years (interquartile range, IQR: 33–43) and a median time of HIV-seropositivity of 8 years (IQR: 4–13 years). Intravenous drug use was reported from 30.0% of them. Table I illustrates the distribution of these women according to Pap-test knowledge and selected characteristics. Overall, 186 (55.2%, 95% CI: 49.9–60.5%) out of the 337 HIV- positive women were not aware that Pap-smear could prevent cer- vical cancer. Area of birth and education turned out to be strongly associated with lack of Pap-smear awareness (Table I). In addi- tion, a moderate increase in the risk of being unaware of Pap- smear was associated with younger ages, whereas other factors including marital status, parity, age at first sexual intercourse, number of lifetime sexual partners, use of oral contraceptives in the last 3 years and history of intravenous use of drugs were not associated with knowledge of the Pap-smear. Women who never had a Pap-smear in their lifetime had a 4.5-fold significantly higher risk of being unaware of Pap-smear (Table I). Although the association was of borderline statistical signifi- cance, HIV-positive women who did not have a Pap-smear in the last 5 years and those who never had an abnormal Pap-smear were more likely to be unaware of Pap-smear (Table II). Forty-six per- cent of HIV-positive women had not had a Pap-smear in the 12 months preceding the interview [the median time between last Pap-smear and interview was 267 days for women who reported a history of abnormal Pap-smear, and 393 days for those who did not (data not shown in tables)]: no association emerged between knowledge of Pap-smear and screening in the last year. Current guidelines recommend that all women infected with HIV undergo regular cervical screening 2 times in the first year after HIV diagnosis and, if the results are normal, annually there- after. 7 However, in HIV-infected women, few studies have inves- tigated use of Pap-smear screening and none has investigated knowledge. In the United States, 19% of a population-based sam- ple of HIV-infected women had not had a Pap-test in the last 12 months, 8 while lack of lifetime Pap-smear was reported in 12% of another group of HIV-infected women. 9 In Italy, Zanetta and colleagues 10 observed that only 1 out of 6 HIV-infected women with ICC received a Pap-smear in the last 24 months and none in the last 12 months. In women of the general population, knowl- edge about Pap test was shown to be associated with increased use of screening, 11 whereas a low educational level was identified as a risk factor for lack of Pap-test knowledge. 12 Grant sponsor: Ricerca Finalizzata 2000; Grant sponsor: Ricerca Cor- rente IRCCS Spallanzani; Grant sponsor: Programma Nazionale AIDS, Istituto Superiore di Sanita `, Rome, Italy; Grant number: 20D.13. *Correspondence to: Department of Epidemiology, INMI L. Spallan- zani, IRCCS, Via Portuense 292, 00149 Rome, Italy. Fax: þ39-06-5582-825: E-mail: serraino@inmi.it Received 1 December 2004; Accepted after revision 17 December 2004 DOI 10.1002/ijc.20956 Published online 4 March 2005 in Wiley InterScience (www.interscience. wiley.com). Int. J. Cancer: 115, 1009–1010 (2005) ' 2005 Wiley-Liss, Inc. Publication of the International Union Against Cancer