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Difficulty: HardPreventive Care and Screening

Seeking to establish care after recently relocating, a 68-year-old woman presents to a new primary care provider for a wellness visit. Her past medical history is notable for human immunodeficiency virus (HIV) infection, diagnosed two decades ago, which remains well-controlled on a daily antiretroviral regimen. Her most recent CD4 T-lymphocyte count is 680 cells/mm³, and her viral load is undetectable. She smoked one pack of cigarettes daily from age 20 to age 38, completely abstaining since then.

A review of her previous medical records reveals the following preventive care history:
- A screening colonoscopy at age 60 demonstrated no polyps or masses.
- A screening mammogram performed 11 months ago was interpreted as Breast Imaging Reporting and Data System (BI-RADS) category 1.
- A dual-energy x-ray absorptiometry scan at age 65 showed a T-score of -0.8 at the lumbar spine and femoral neck.
- Cervical cancer screening via cytology and high-risk human papillomavirus (hrHPV) co-testing was performed at ages 59, 62, and 65; all results were negative for intraepithelial lesion or malignancy and negative for hrHPV.

The patient currently takes no medications other than her antiretroviral therapy. She is up to date on her recombinant zoster vaccine, pneumococcal vaccination series, and the seasonal influenza vaccine.

Based on current evidence-based guidelines, which of the following screening tests is indicated for this patient today?

  1. Cervical cytology and high-risk human papillomavirus co-testingAnswer
  2. B
    Low-dose computed tomography of the chest
  3. C
    Screening colonoscopy
  4. D
    Dual-energy x-ray absorptiometry scan
  5. E
    Ultrasonography of the abdominal aorta

Answer

Cervical cytology and high-risk human papillomavirus co-testing
The correct answer is to perform cervical cytology and high-risk human papillomavirus co-testing. In the general population, cervical cancer screening can be discontinued at age 65 if the patient has had adequate prior negative screening (e.g., three consecutive negative cytology results or two consecutive negative co-tests within the past 10 years). However, there are critical exceptions to this rule. Women who are infected with HIV, have a history of in utero diethylstilbestrol (DES) exposure, or have a history of cervical cancer or high-grade cervical dysplasia (CIN 2/3) must continue cervical cancer screening throughout their lifetime. For women with HIV who have had three consecutive normal annual cytology tests, the recommended screening interval becomes every 3 years. Because this patient's last co-test was at age 65, she is exactly due for her next screening at age 68.

Step-by-Step Solution

1
Evaluate the patient's demographic and clinical risk profile.
The patient is a 68-year-old female with HIV and an 18 pack-year smoking history (quit 30 years ago).
Age, biological sex, smoking history, and immune status directly dictate preventive screening eligibility.
2
Assess eligibility for lung, colon, breast, and bone density screening based on recent test dates.
Lung: ineligible (quit >15 years ago, <20 pack-years). Colon: due at 70. Breast: due next year (biennial). Bone: normal at 65, no repeat needed yet.
Avoids premature or contraindicated testing.
3
Apply cervical cancer screening guidelines for special populations.
While average-risk women stop screening at 65 after adequate negative results, HIV-positive women require lifelong screening.
HIV-associated immunodeficiency alters the natural history of HPV infection, maintaining a lifelong risk for cervical dysplasia.
4
Determine the appropriate interval for the indicated test.
The patient's last negative co-test was at age 65 (3 years ago), making her due for her next 3-year interval screening today.
Routine interval for HIV-positive women over age 30 with at least 3 consecutive normal annual Paps is every 3 years.

Key Concept

Cervical cancer screening exceptions (Lifelong screening in HIV)
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Topics

Preventive Care and Screening

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