During the study period we found 341 (0.7%) Pap results showing a glandular abnormality among 48,362 collected during 24, 948 person-years of observation. These occurred in 244 (6%, 95% CI, 5.7%–7.3) of 3,766 women. Of the 341 glandular Pap abnormalities studied, 271 were from 198 HIV seropositive women and 70 were from 46 seronegative women. One woman had a hysterectomy prior to her index glandular abnormality and was excluded from further analysis.
Glandular abnormalities were found in 341 (0.7%, 95% CI, 0.6%–0.8%) smears from 244 (6%) women, including 264 (0.8%, 95% CI, 0.6%–0.9%) of 35057 smears from HIV seropositive women and 70 (0.6% (95% CI, 0.4%–0.8%) of 11,769 smears from seronegative women (P = 0.12 after adjustment for age, ethnicity, smoking, and sexual activity in the prior six months). The demographic characteristics of women with glandular abnormalities on Pap are presented in . The median age was 37 years among 198 HIV seropositive women and 39 years among 46 HIV seronegative women (P = 0.9). Compared to HIV seronegative women, seropositive women with glandular abnormalities were marginally less likely to be smokers and less likely to have multiple recent sexual partners.
Demographic and medical characteristics at the time of first diagnosis among 244 women with glandular abnormalities on Pap tests.
Stratification by CD4 lymphocyte count showed the impact of immunosuppression on risk for glandular cytologic abnormality: glandular abnormalities were found in 93 (1.0%; 95% CI, 0.8%–1.3) of 9564 Pap tests among HIV-seropositive women with CD4 lymphocyte counts <250/cmm, 103 (0.8%; 95% CI, 0.6% –1.0%) of 13023 Paps among those with counts 250–500/cmm, 68 (0.6%; 95% CI, 0.4%–0.8%) of 12470 Paps among women with counts >500/cmm, and 70 (0.6%; 95% CI, 0.4%–0.8 of 11769 Paps among HIV-seronegative women (P for trend = 0.006). Seven women with glandular abnormalities did not have CD4 counts at the corresponding visit.
Despite a study-wide protocol recommending referral for colposcopy and despite intensive infrastructure at each site to promote compliance, colposcopy was documented to have been done within six months for only 148 (61%) of 244 index Pap tests with glandular abnormalities, 119 (60%) of 198 HIV seropositive and 29 (63%) of 46 HIV seronegative women. Endocervical curettings were obtained after 106 (43%) women with index abnormal Paps, including 81 (41%) HIV seropositive women and 25 (54%) seronegative women. Cervical punch biopsies were done for 76 (38%) index Paps, 60 (30%) in HIV seropositive women and 16 (35%) in seronegative women. Endometrial biopsies were done in only 19 (8%) index Pap cases, 13 in HIV seropositive and 6 in seronegative women. Excisional biopsies, including knife conization and loop excision, were done in 14 women. Overall, histologic findings were available for 119 (49%) of the 244 women within six months of an index Pap showing glandular abnormalities. Compliance improved as women were followed, as 212 (87%) of women with index glandular abnormalities had colposcopy and 192 (79%) had at least one biopsy at some subsequent point during the study.
Histology results from these 94 HIV seropositive women and 25 seronegative women with available histologic results after index glandular Pap abnormalities are shown in and . Overall, the severity of results did not differ significantly by HIV serostatus (P = 0.16). For both HIV infected and uninfected women, most abnormalities were squamous. Approximately 40% of biopsies in both groups were negative, and the risk of CIN or cancer was greater than 50%. However, high grade disease, including high grade squamous lesions, glandular atypia, or cancer, was found in 20/94 (21%) of HIV seropositive women and 9/25 (36%) of HIV seronegative women (P = 0.12). Although glandular abnormalities on Pap raise concern for adenocarcinoma, only one HIV seropositive woman and none of the HIV seronegative women had adenocarcinoma, while none of the HIV seropositive women and one of the seronegative women had glandular atypia.
Histologic findings among women with index glandular abnormalities on Pap tests from HIV seropositive women.
Histologic findings among women with index glandular abnormalities on Pap tests from HIV seronegative women.