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  • Canadian study finds cervical cancer screening delayed in 30% of women with HIV
  • Pap tests are recommended on an annual basis for HIV-positive women in Canada
  • Women with male healthcare providers were less likely to have been screened

Human papilloma virus (HPV) is a common sexually transmitted infection. Some strains of HPV can cause ano-genital warts. Other strains can cause the development of abnormal cells and, in some cases, their transformation into cancers, such as cervical cancer. In 1993 the U.S. Centers for Disease Control and Prevention (CDC) added invasive cervical cancer to the list of AIDS-defining cancers.

HIV treatment

Adherence to HIV treatment (ART) helps improve and maintain the health of the immune system. The impact of ART is so profound that scientists increasingly expect that many ART users will have a near-normal life span. However, ART does not eliminate the risk of abnormal changes to cervical cells caused by HPV infection. Therefore, cervical cancer screening should be a regular part of health maintenance. Guidelines in Canada recommend yearly Pap tests for HIV-positive women.

Focus on cervical cancer screening

Researchers with the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS) have been collecting and analysing health-related information from more than 1,400 HIV-positive women. CHIWOS has produced useful reports for improving the care and health of HIV-positive women. A recent analysis from CHIWOS focused on cervical cancer screening. CHIWOS researchers found that there were moderate to long delays in cervical cancer screening in nearly 30% of HIV-positive women. The researchers stated that “additional efforts are needed to improve women’s and health care providers’ awareness of cervical cancer screening recommendations, particularly among women who are sexually inactive, who are immunosuppressed and who have male HIV care providers.”

Study details

Although CHIWOS has enrolled 1,422 HIV-positive women, for the present analysis researchers focused on data collected from 1,189 women. Their average profile upon entering the study was as follows:

  • age – 42 years
  • major ethno-racial groups: white – 40%; African, Caribbean or Black – 31%; Indigenous –22%
  • distribution of people by province: British Columbia – 291 women; Ontario – 604 women; Quebec – 294 women
  • currently on ART – 83%
  • having a viral load less than 50 copies/mL – 73%

Researchers focused on issues related to Pap tests. Participants were interviewed several years ago when they first entered CHIWOS.


After HIV-positive women entered CHIWOS, researchers found the following:

  • 69% had received a Pap test less than one year earlier
  • 18% had received a Pap test between one and three years earlier
  • 14% had received a Pap test at least three years earlier or not at all

(Note: Numbers do not add up to 100% due to rounding.)

Delays in cervical cancer screening

Researchers found that a “moderate delay” (between one and three years after a previous Pap test) was likely to occur in women with the following circumstances:

  • they lived in Ontario
  • their care provider was a man

Researchers found that a “long delay” (three or more years) was likely to occur in women with the following circumstances:

  • they lived in Ontario or Quebec
  • they were sexually inactive
  • they had CD4+ cell counts that were classed as “unknown or less than 200 cells/mm3
  • their care provider was a man

Reasons for delay

Researchers asked the women if “a doctor or nurse had ever discussed with them the need for a regular Pap smear.” Overall, 306 women (26%) said no.

Among women whose last Pap smear was at least three years ago, 57% answered no.

Among women who never had a Pap smear, 73% said no.

Common reasons for not having a Pap smear in the past year were as follows:

  • not getting around to it – 47%
  • not thinking it was necessary – 38%
  • disliking having the procedure done – 20%
  • my healthcare provider never mentioned it – 19%
  • fear – 14%

This last reason included fear of the following issues:

  • pain
  • embarrassment
  • HIV disclosure
  • finding something wrong

Communication as an issue

The researchers made the following statement: “As previously reported in the general population, providers have a crucial role to play in the adherence to cervical cancer screening recommendations and our results underline the importance of better communicating the need for cervical cancer screening to women with HIV.”

Gender and the care provider

In explaining the reasons that having a male care provider could result in delayed cervical cancer screening, the researchers advanced the following possibilities:

  • male care providers might prioritize different issues
  • women may feel “uncomfortable having a gynecological examination done by a man”


The researchers added: “In circumstances where performing a Pap smear is problematic for either the provider or patient, potential solutions may include” the following:

  • office/schedule organization
  • systematic reminders
  • collaboration with a nurse, female colleague, family physician or gynecologist to provide cervical cancer screening or offering HPV self-sampling

Education remains important

As mentioned earlier, researchers found that women who were sexually inactive were more likely to have delays in cervical cancer screening. The researchers stated that when educating women about cervical cancer risk, care providers “need to specify that the risk remains even if a woman is no longer sexually active, because decades can pass between an initial HPV infection and the development of cervical cancer.”

Bear in mind

The present study was done with data collected from each woman at one point in time. This kind of study is cross-sectional in design and is good at finding statistical associations. However, such associations need to be examined in studies of a different design, such as longitudinal studies. Despite having a cross-sectional design, the CHIWOS data are unique and important for HIV-positive women and provide a great foundation for future research.


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—Sean R. Hosein


de Pokomandy A, Burchell AN, Salters K, et al. Cervical cancer screening among women living with HIV: a cross-sectional study using the baseline questionnaire data from the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study (CHIWOS). CMAJ Open. 2019 Apr 12;7(2):E217-E226.