This study was the first attempt to provide estimates of self-reported Pap-smear history in HIV-positive women attending infectivology units of a large Italian region. We found that 91% of women had had at least one Pap-smear in their lifetime, and 61% reported a Pap-smear in the last year. These proportions are similar to the ones reported by the general population of the same age and geographical area (95% and 47%, respectively) (Carrozzi and Bertozzi, personal communication), and substantially higher than those reported (43%) in 2001 by a physician-based Italian survey . Increase in the number of Pap-smears performed, however, is difficult to evaluate, given the different study designs of previous studies conducted in Italy [13, 14]. The proportion of women who had a Pap-smear in the last year, however, remains suboptimal with respect to current guidelines regarding HIV-positive women (annual Pap-smear recommended to all patients), and is lower than the estimates (approximately 80%) reported in the USA [8, 9].
Factors associated with lack of recent Pap-smear were young age (<35 years), recent HIV diagnosis (≤2 years), and more advanced diseases (CD4 count at last visit <200 cells/μL). Conversely, receiving screening advice from a gynecologist significantly improved the adherence to Pap-smear. We found less influence of education level or country of birth than a previous cross-sectional study conducted in Rome . As expected, study women reported a high proportion of previous abnormal Pap-smears (34%), in agreement with previous reports among HIV-positive women in Italy  and the United States [8, 9].
Overall, our study highlights the difficulties in following the recommended protocol of combining routine follow-up of HIV infection with gynecological examination, which is generally not performed in infectivology units [5, 10]. In addition, patient compliance needs to be improved  and health professionals (e.g., infectious disease specialists and gynecologists) should thoroughly inform HIV-positive women (particularly the disadvantaged ones) of the importance of Pap-smear to their health.
The present study has strengths and weaknesses. Strengths included the high participation among unselected women attending infectivology units. Approximately 1,500 HIV-positive women are estimated to live in the Emilia-Romagna Region [15, 16] and all women attending HIV follow-up (recommended every 6 months) were contacted in a 1-year period. A previous study in Northern Italy  showed that patients infected with HIV through injecting drug use, patients without AIDS diagnosis, or patients with higher CD4 counts are more likely to miss medical appointments and discontinue their follow-up. It is unlikely that HIV-positive women in the region received their follow-up visits elsewhere, given the high standard of medical care provided (free of charge) in Emilia-Romagna in comparison with other Italian areas. However, the possibility of some socio-demographic bias in women who did not attend regularly follow-up cannot be totally ruled out.
The number of self-reported Pap-smears among HIV-positive women in our study may be an overestimate as women tend to over-report their participation in cervical cancer screening in a given timeframe . Confidentiality prevented us from linking women's reports with gynecological and cytological records, thus leaving substantial uncertainty about the actual additional tests and treatments performed. To validate self-reported Pap-smear use and to follow-up the treatment of HIV-positive women diagnosed with gynaecological lesions, a new study is being planned, which will adopt broader confidentiality rules and obtain a written consent to follow-up. The most important limitation of our survey, however, is the restriction to HIV-positive women followed by public clinics in one of the best organized regions of Italy, in terms of participation and quality of cervical cancer screening [21, 22].