Identification of potential missed opportunities for human papillomavirus (HPV) vaccination in women referred to an academic colposcopy clinic for evaluation of abnormal cervical cytology.

OBJECTIVE: To identify possible predictors of missed opportunities for human papillomavirus (HPV) counseling and vaccination prior to presentation at an academic colposcopy clinic. MATERIALS AND METHODS: We examined the characteristics of 638 vaccinated and 1,024 unvaccinated age-eligible patients using data from a patient registry of women presenting for colposcopic evaluation between 2/26/2007 and 3/10/2014 who were aged 26 or less at presentation. Demographics, smoking history, pregnancy history, sexually transmitted infections (STIs), sexual history, contraception use, immunosuppression, and medical problems were compared between HPV vaccinated and unvaccinated women. Multivariable logistic regression models included age, race, language, marital status, insurance type, lifetime number of sexual partners, other medical illnesses, number of pregnancies, contraception use, history of STIs, and smoking history to determine predictors of HPV vaccination. RESULTS: In multivariable analysis, race, marital status, and language were not significantly associated with HPV vaccination. Women with fewer pregnancies were more likely to be vaccinated (p-trend <0 .0001). Vaccinated women were more likely to have other medical illnesses (OR=1.44, 95% CI=1.13-1.83) and be aware of their HPV status (OR=1.75, 95% CI= 1.40-2.18). CONCLUSIONS: In this study, greater number of pregnancies was associated with lower vaccination rates as compared to women who had never been pregnant. Reproductive health visits, such as postpartum and family planning visits, represent an ideal opportunity to educate women about HPV and the importance of vaccination, and should be an area of focus to improve current HPV vaccination rates.

Comparing Cervical Cytology and Histology Among Human Papillomavirus-Vaccinated and -Unvaccinated Women in an Academic Colposcopy Clinic.

OBJECTIVE: To analyze differences in cytology and histology results between patients previously vaccinated against human papillomavirus (HPV) compared with unvaccinated patients who presented to an academic colposcopy clinic for evaluation of abnormal cervical cytology. METHODS: Using data from a patient registry from 2007 to 2014, we examined 1,662 patients aged 26 years or younger at the time of presentation. Demographics, HPV vaccination status, smoking, pregnancy history, sexually transmitted infections, number of sexual partners, contraception, immunosuppression, and other relevant medical issues were reviewed. Cytology and histology results were compared between previously HPV-vaccinated and unvaccinated women to determine if there was a difference in the severity of subsequent cytologic or pathologic specimens. RESULTS: In multivariable analyses, women who previously received at least one dose of the HPV vaccine had 53% (adjusted odds ratio [OR] 0.47, 95% confidence interval [CI] 0.34-0.66; P<.001) lower odds of presenting with high-grade cytology (adenocarcinoma in situ, atypical glandular cells, atypical squamous cells cannot rule out high grade, and high-grade squamous intraepithelial lesion) and 36% (adjusted OR 0.64, 95% CI 0.48-0.85; P=.002) lower odds of presenting with cervical intraepithelial neoplasia 2 or 3 or worse histology compared with unvaccinated women. CONCLUSION: Patients presenting for colposcopic evaluation of abnormal cytology who had previously received the HPV vaccine had fewer high-grade lesions on both cytology and histology when compared with HPV-unvaccinated women. LEVEL OF EVIDENCE: II.

Optimal time on HAART for prevention of mother-to-child transmission of HIV.

OBJECTIVES: To determine the impact of time between initiating highly active antiretroviral therapy (HAART) and delivery-duration of antenatal HAART-on perinatal HIV infection. DESIGN: We conducted a retrospective cohort analysis of pregnant HIV-infected women in Lusaka, Zambia. Women in our cohort were receiving HAART and had an infant HIV polymerase chain reaction test between 3 and 12 weeks of life. METHODS: We examined factors associated with infant HIV infection and performed a locally weighted regression analysis to examine the effect of duration of antenatal HAART on perinatal HIV infection. RESULTS: : From January 2007 to March 2010, 1813 HIV-infected pregnant women met inclusion criteria. Mean gestational age at first antenatal visit was 21 weeks (SD ± 6), median CD4+ cell count was 231 cells per microliter (interquartile range: 164-329), and median duration of antenatal HAART was 13 weeks (interquartile range 8-19). Fifty-nine (3.3%) infants were HIV infected. Duration of antenatal HAART was the most important predictor of perinatal HIV transmission. Compared with women initiating HAART at least 13 weeks before delivery, women on HAART for ≤4 weeks had a 5.5-fold increased odds of HIV transmission (95% confidence interval: 2.6 to 11.7). Locally weighted regression analysis suggested limited additional prophylactic benefit beyond 13 weeks on antenatal HAART. CONCLUSIONS: Low rates of mother-to-child HIV transmission can be achieved within programmatic settings in Africa. Maximal effectiveness of prevention of mother-to-child transmission programs is achieved by initiating HAART at least 13 weeks before delivery.