At enrolment in this postnatal cohort, only 30% of women had a cervical screening test reported as part of HIV care, a third of whom had been screened more than a year previously. Women diagnosed with HIV prior to rather than during their most recent pregnancy, and therefore with more opportunity to receive HIV care, were more likely to have a cervical screening test reported at enrolment, as were those with more previous pregnancies. A fifth of those screened had a finding of LSIL or HSIL.
In this study, we could only assess the coverage of cervical screening carried out as part of HIV care; women may have accessed screening through contraceptive, sexual health or other services. Screening is recommended six-monthly for the general population, but it is unclear whether this policy is followed in practice - in the 2003 World Health Survey 66% of 1361 women reported being screened in the last three years 
, but there were no data on screening frequency, or laboratory or clinical data, with which to validate self-reports. In addition to more regular screening, HIV-positive women may also benefit from more intensive follow-up following a mild abnormal smear, a lower threshold for referral to colposcopy (especially if severely immunosuppressed) and more intensive surveillance immediately following HIV diagnosis compared with the standard of care 
. However, this can only be offered if the healthcare provider is aware of the woman’s HIV status. Of those diagnosed as HIV-positive during their most recent pregnancy, only a quarter had been screened as part of HIV care by enrolment despite most having returned to the HIV/AIDS Centre at >12 weeks postpartum. As there is no policy for referral of newly diagnosed women to other services, it is likely that many did not receive any cervical screening in the year following HIV diagnosis. Even among the fifth of women with follow-up, coverage of cervical screening among those with no test reported at enrolment was only 39%.
The 30% of women with screening test results available in this study were a selected group whose characteristics (e.g. higher prevalence of BV) may mean findings are not generalisable to the cohort as a whole. Nevertheless, the 21% prevalence of abnormal findings on cytologic screening was comparable to the 23% prevalence of LSIL/HISL among 285 HIV-positive women recruited from a patient programme in Brooklyn from 1990–93 
, and 27% prevalence of abnormalities reported among 1134 HIV-positive women enrolled at the European sites of a multi-site cohort study 
. A study of 200 HIV-positive women attending mother-child health clinics in Zimbabwe, a country with postnatal opportunistic testing but no national screening policy, found a prevalence of cervical dyskaryosis of 30% 
. In another study, prevalence of LSIL/HSIL among 400 HIV-positive women in South Africa was found to be 48% 
. In the Women’s Interagency HIV Study, a large representative US study of HIV-positive women, the prevalence of LSIL/HSIL was lower at 15%, possibly because all women participated in six-monthly screening 
. The role of ART in prevention of HPV-related cervical lesions or promotion of their regression is unclear 
. With further roll-out of ART (currently available to only around half of adults with advanced HIV disease in Ukraine 
) and decline in deaths due to other AIDS-defining diseases, the proportion of deaths attributable to cervical cancer may increase 
, particularly as the HIV-positive population ages.
There was a high prevalence of a number of co-factors implicated in the aetiology of cervical cancer in this cohort, including smoking, chlamydia and HSV-2 infections 
. In adjusted analyses, HSV-2 seropositivity was associated with an 80% increased risk of LSIL/HSIL and BV with over a three-fold increased risk. These associations could have been due to selective screening of women at high risk for both HPV infection and infection with HSV-2 or BV (e.g. women with multiple sexual partners). However, co-infections to HPV may increase the risk of cervical cancer due to the effect of reactive oxidative metabolites generated by inflammatory processes local to the cervix 
, or by acting as cofactors 
. A pooled analysis of seven studies found an increased risk of invasive cervical cancer associated with HSV-2 seropositivity independent of HPV infection and sexual risk behaviours 
. Evidence of an association between BV and HPV acquisition/persistence or cervical abnormalities is less well established 
, but a recent meta-analysis of twelve studies (only three of which independently showed an association between BV and cervical HPV infection) demonstrated a significantly increased risk of cervical HPV infection among women with BV (combined OR 1.43, 95% CI 1.11–1.84) 
. Two studies including HIV-positive women (one of which was included in the meta-analysis) showed an association between BV and both incident and prevalent cervical HPV infection, independent of sexual risk factors 
. Given the prevalence of BV in this cohort (17%), and the associated risk of other adverse effects (including preterm delivery 
and STI acquisition 
), regular screening for BV with prompt treatment where indicated should be a priority.
Women in poorer socioeconomic groups are less likely to be screened for cervical abnormalities in the US 
, and in Ukraine, where World Household Survey data showed coverage with three-yearly screening of 87% in the top and 68% in the bottom wealth quintiles 
. HIV-positive women may be socially disadvantaged due to their poor health, discriminatory employment practices and coexisting behaviours (e.g. IDU). In our study, a fifth reported being unable to afford contraception and a third had not disclosed their HIV status to a parent, family member or friend, indicating both economic and social marginalisation. Among those diagnosed prior to conception, women with fewest years of education were least likely to have been screened. An organised screening programme could improve awareness and uptake among the most marginalised women. At an HIV clinic in the United Kingdom, a higher uptake of cervical screening was found among women on HAART compared with those not yet on treatment, probably due to their on-going engagement with HIV care 
. Regular invitations to attend the HIV/AIDS Centre for screening could help prevent postpartum loss to follow-up among HIV-positive women not on ART. As national policy, organised screening programmes delivered as part of HIV care could also lessen the regional disparities in screening coverage.
In Eastern Europe 70% of cervical cancer cases are attributed to vaccine-preventable HPV types 16 and 18 
, but HPV vaccination programmes have yet to be introduced in Ukraine 
. The safety and efficacy of HPV vaccination in immune-compromised populations have not yet been established 
. Although an important future intervention, HPV vaccination will not obviate the need for an organised cervical screening programme in Ukraine.
Lack of data on cervical HPV infection or sexual risk behaviours precluded more detailed exploration of the association between BV and LSIL/HSIL. False positives or negatives cannot be ruled out, particularly as a quarter of the samples were taken in pregnancy, 10% at <12 weeks postpartum and 38% on the same day as a positive sample for a genital infection 
. We are not able to comment on sensitivity and specificity of cytologic screening in this population, as colposcopy and histology takes place at referral hospitals and data are not routinely shared with the HIV/AIDS Centre. Because women with a screening test had a higher prevalence of BV than those without, the observed prevalence of cervical abnormalities in this study could be an overestimate. Furthermore, since cervical screening test results were only available for 30% of women, selection bias in the association between BV and cervical abnormalities (e.g. due to sexual risk-taking behaviour) cannot be ruled out. Local differences exist in provision of cervical screening services both within and outside of HIV care, and our results may therefore not be generalizable to other areas in Ukraine. Finally, coverage of cervical screening as part of HIV care may be higher in this cohort than in the wider population of HIV-positive women in Ukraine, as all women in the cohort were in contact with HIV healthcare services.
In conclusion, cervical screening coverage of this high risk population as part of HIV care is low. An organised programme where women are invited to attend the HIV/AIDS Centre for cervical screening could increase coverage, particularly among marginalised women. BV testing and treatment could potentially reduce vulnerability to cervical abnormalities.