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Saasa-Modise ML, Musonda JM, Sikwese-Musonda J, Maseko NJ, Hlophe L, Kubeka G. Cervical cancer screening in women living with HIV attending primary care clinics in a health district, South Africa: a descriptive cross-sectional study. Pan Afr Med J 2022; 43:32. [PMID: 36505015 PMCID: PMC9716964 DOI: 10.11604/pamj.2022.43.32.33180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction globally, cervical cancer remains a public health problem. It is ranked the fourth most common cause of women's cancer. In South Africa, it was the second most common cancer diagnosed in 2012. The disease progresses rapidly in women living with Human Immunodeficiency Virus (HIV), due to immune suppression. The purpose was to evaluate cervical cancer screening in HIV-positive women attending primary health care (PHC) clinics in Ekurhuleni Health District (EHD), South Africa. Aim and Objectives: the study aim was to evaluate cervical cancer screening in HIV-positive women attending PHC clinics for routine care in Ekurhuleni Health District, Gauteng Province, South Africa. Objectives were to describe the cervical cancer screening uptake of HIV-positive women on antiretroviral therapy (ART) who remained in care and were screened, determine the length of time or period from starting ART to the first cervical cancer screening, and describe associations among screening, age, and the period from starting ART. Methods this was a retrospective descriptive cross-sectional study design. A review of clinic records was conducted on women living with HIV and on antiretroviral therapy for at least four years. The study period was from March to September 2020. After a clustered randomization of clinics, 550 records were systematically selected. Stata version 16.1 was used for analysis. Results the median age was 34, ranged 23-68, with the interquartile range (IQR) of 29-42 years. Nearly a third (32.9%, n= 181) had cervical cancer screening documented. Those with both an ART start date and first screening were 83% (n= 151). The median for ART duration was 5 years and ranged from 4-8 years. The median time to first screening was 43 weeks with an IQR of 16-67 weeks. Women aged 35-44 years or above 45 were more likely to be screened (AOR 3.2, CI: 1.0-9.8, p= 0.05) and (AOR 5.3, CI: 1.7-16.9, p= 0.01), respectively. Conclusion there was suboptimal uptake and delay in initiating screening in women living with HIV. Nevertheless, the older women were, more likely to be screened. This study suggests poor adherence to policy and highlights the need for accelerated staff training on cervical cancer policy.
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Affiliation(s)
- Mmipe Lillian Saasa-Modise
- Department of Family Medicine and Primary Health Care, University of Witwatersrand, Johannesburg, South Africa,,Corresponding author: Mmipe Lillian Saasa-Modise, Department of Family Medicine and Primary Health Care, University of Witwatersrand, Johannesburg, South Africa.
| | - John Mukuka Musonda
- Department of Family Medicine and Primary Health Care, University of Witwatersrand, Johannesburg, South Africa
| | - Joyce Sikwese-Musonda
- Department of Family Medicine and Primary Health Care, University of Pretoria, Pretoria, South Africa
| | | | - Lineo Hlophe
- District Clinical Specialist Team, Ekurhuleni Health District, Germiston, South Africa
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Gupta R, Mariano LC, Singh S, Gupta S. Highly active antiretroviral therapy (HAART) and outcome of cervical lesions and high-risk HPV in women living with HIV (WLHIV): a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 278:153-158. [DOI: 10.1016/j.ejogrb.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/04/2022]
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The Catastrophic HPV/HIV Dual Viral Oncogenomics in Concert with Dysregulated Alternative Splicing in Cervical Cancer. Int J Mol Sci 2021; 22:ijms221810115. [PMID: 34576278 PMCID: PMC8472041 DOI: 10.3390/ijms221810115] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/04/2021] [Accepted: 09/06/2021] [Indexed: 11/16/2022] Open
Abstract
Cervical cancer is a public health problem and has devastating effects in low-to-middle-income countries (LTMICs) such as the sub-Saharan African (SSA) countries. Infection by the human papillomavirus (HPV) is the main cause of cervical cancer. HIV positive women have higher HPV prevalence and cervical cancer incidence than their HIV negative counterparts do. Concurrent HPV/HIV infection is catastrophic, particularly to African women due to the high prevalence of HIV infections. Although various studies show a relationship between HPV, HIV and cervical cancer, there is still a gap in the knowledge concerning the precise nature of this tripartite association. Firstly, most studies show the relationship between HPV and cervical cancer at genomic and epigenetic levels, while the transcriptomic landscape of this relationship remains to be elucidated. Even though many studies have shown HPV/HIV dual viral pathogenesis, the dual molecular oncoviral effects on the development of cervical cancer remains largely uncertain. Furthermore, the effect of highly active antiretroviral therapy (HAART) on the cellular splicing machinery is unclear. Emerging evidence indicates the vital role played by host splicing events in both HPV and HIV infection in the development and progression to cervical cancer. Therefore, decoding the transcriptome landscape of this tripartite relationship holds promising therapeutic potential. This review will focus on the link between cellular splicing machinery, HPV, HIV infection and the aberrant alternative splicing events that take place in HIV/HPV-associated cervical cancer. Finally, we will investigate how these aberrant splicing events can be targeted for the development of new therapeutic strategies against HPV/HIV-associated cervical cancer.
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Njagi SK, Ngure K, Mwaniki L, Kiptoo M, Mugo NR. Prevalence and correlates of cervical squamous intraepithelial lesions among HIV-infected and uninfected women in Central Kenya. Pan Afr Med J 2021; 39:44. [PMID: 34422167 PMCID: PMC8356940 DOI: 10.11604/pamj.2021.39.44.27182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 04/27/2021] [Indexed: 12/24/2022] Open
Abstract
Introduction cervical intraepithelial neoplasia the precursor of cervical cancer occurs with increased frequency in women infected with human immunodeficiency virus (HIV). This study aimed at determining the prevalence and correlates of abnormal cervical cytology among HIV-infected women and compare to the uninfected women. Methods a cross-sectional study conducted among HIV-infected and uninfected women enrolled in a HIV study in Central Kenya. All women had baseline Pap smear examination assessed using Bethesda system. Bivariate and multivariate logistic regression methods were employed to assess the correlates of cervical squamous epithelial lesions (CSIL). Results a total 480 women had an acceptable baseline smear, 373 (78%) were HIV-infected. Median age was 30.2 years [IQR 25.4-35.5]. Overall prevalence of CSIL was 37% (176/480) with the prevalence of low grade squamous intraepithelial lesion (LSIL), atypical squamous cells undetermined significance (ASCUS), high grade squamous intraepithelial lesions (HSIL) and atypical glandular cells (AGC) were 17%, 14%, 4% and 2% respectively. HIV-infected women had a higher prevalence of CSIL at 42% as compared to HIV-uninfected women at 19%. HIV infection was the predictor associated with development of CSIL at multivariate analysis and specifically, HIV-infected women were 3 times (AOR 3.1, 95% CI: 1.8 - 5.4, p<0.005) more likely to have CSIL than HIV-uninfected women. The age 35 - 44 years was protective to developing CSIL (AOR 0.45, 95% CI: 0.24 - 0.87, p=0.018). Conclusion cervical squamous epithelial lesions is a major problem among Kenyan women. HIV infection confers a higher risk to development of CSIL. Cervical cancer screening should be an established practice in HIV programs.
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Affiliation(s)
- Stella Kawira Njagi
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya.,Partners in Health, Research and Development, Thika Section 9, Nairobi, Kenya
| | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Juja, Kenya
| | - Lawrence Mwaniki
- Partners in Health, Research and Development, Thika Section 9, Nairobi, Kenya
| | - Michael Kiptoo
- Institute for Tropical Medicine and HIV and AIDS Laboratory, Kenya Medical Research Institute, Nairobi, Kenya
| | - Nelly Rwamba Mugo
- Sexual Reproduction and Adolescent Child Health Research Program, Kenya Medical Research Institute, Nairobi, Kenya
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5
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Rahatgaonkar VG, Deshpande AA, Oka GA. Screening for cervical cancer in HIV-infected women: A review of literature. Indian J Cancer 2021; 58:317-325. [PMID: 34380862 DOI: 10.4103/ijc.ijc_888_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Globally, the cervical cancer burden is huge, more so in low-resource countries. Human immunodeficiency virus (HIV) infection increases a woman's risk of human papillomavirus (HPV) infection and cervical cancer. There is a lack of opportunistic, as well as, organized cervical cancer screening structure for HIV-positive women. A large proportion of women have invasive cervical cancer as their initial acquired immune deficiency syndrome (AIDS)-defining illness. There is an especially high-incidence in countries where there are no organized cervical cancer prevention programs. Additionally, there are cultural, social, psychological, and system barriers that women living with HIV have to overcome when accessing healthcare services. We believe that educating women and healthcare providers regarding the need for screening, early detection, and treatment is as important as bringing about a systematic change in healthcare services to improve participation of HIV-positive women in screening for cervical cancer.
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Affiliation(s)
- Veena G Rahatgaonkar
- Department of Obstetrics and Gynecology, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Aditi A Deshpande
- Department of Research, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
| | - Gauri A Oka
- Department of Research, Deenanath Mangeshkar Hospital and Research Center, Pune, Maharashtra, India
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Association Between CD4 Count and Chemoradiation Therapy Outcomes Among Cervical Cancer Patients With HIV. J Acquir Immune Defic Syndr 2021; 85:201-208. [PMID: 32568769 DOI: 10.1097/qai.0000000000002420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In Botswana, nearly two-thirds of cervical cancer patients are HIV-positive. This study examined the relationship between CD4 count and chemoradiation therapy outcomes among cervical cancer patients with HIV. SETTING A prospective cohort study of 231 HIV-positive women with locally invasive cervical cancer was conducted in Gaborone, Botswana from January 2015 to February 2018. METHODS Primary outcome was survival, defined as time from scheduled end of chemoradiation therapy to death or last contact with patient. Nadir CD4 count was defined as lowest CD4 available before cancer diagnosis. Delta CD4 count was defined as improvement from nadir CD4 to CD4 at cancer diagnosis. Hazard ratio (HR) analyses were adjusted for presenting variables (age, baseline hemoglobin, cancer stage, and performance status) and treatment variables (chemotherapy cycles and radiation dose). RESULTS Two hundred thirty-one patients were included in nadir CD4 analysis; 139 were included in delta CD4 analysis. Higher delta CD4 was significantly associated with reduced mortality after adjusting for presenting and treatment variables (CD4 100-249: HR 0.45, 95% CI: 0.21 to 0.95; CD4 ≥250: HR 0.45, 95% CI: 0.20 to 1.02). Higher nadir CD4 showed a trend toward reduced mortality after adjusting for presenting and treatment variables (HR 0.94, 95% CI: 0.84 to 1.06). CONCLUSIONS Higher delta CD4 (greater improvement from nadir CD4 to CD4 at cervical cancer diagnosis) is significantly associated with lower mortality. Although not statistically significant, data suggest that higher nadir CD4 may reduce mortality. These results reinforce the importance of early HIV diagnosis and antiretroviral therapy initiation, as their effects influence cervical cancer outcomes years later.
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Okoye JO, Ngokere AA, Onyenekwe CC, Omotuyi O, Dada DI. Epstein-Barr virus, human papillomavirus and herpes simplex virus 2 co-presence severely dysregulates miRNA expression. Afr J Lab Med 2021; 10:975. [PMID: 33824853 PMCID: PMC8008003 DOI: 10.4102/ajlm.v10i1.975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 10/20/2020] [Indexed: 11/01/2022] Open
Abstract
This cross-sectional study evaluated the expression of miR-let-7b, miR-21, miR-125b, miR-143, miR-145, miR-155, miR-182, miR-200c, p53 gene, Ki67, SCCA1 and CD4+ T-cell counts among 319 women, to Epstein-Barr virus, human papillomavirus and herpes simplex virus 2 mono-infections and co-infections, using enzyme-linked immunosorbent assay and reverse transcriptase-polymerase chain reaction methods. This study suggests that malignancies associated with viral co-infection could be diagnosed early by monitoring cluster of differentiation 4+ T-cell counts and serum expression of miR-145 and miR-182.
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Affiliation(s)
- Jude O Okoye
- Department of Medical Laboratory Science, School of Public and Allied Health, Babcock University, Ilishan-Remo, Ogun State, Nigeria.,Department of Medical Laboratory Science, Faculty of Health Sciences and Technology, College of Medicine, Nnamdi Azikiwe University, Nnewi campus, Anambra, Nigeria
| | - Anthony A Ngokere
- Department of Medical Laboratory Science, Faculty of Health Sciences and Technology, College of Medicine, Nnamdi Azikiwe University, Nnewi campus, Anambra, Nigeria
| | - Charles C Onyenekwe
- Department of Medical Laboratory Science, Faculty of Health Sciences and Technology, College of Medicine, Nnamdi Azikiwe University, Nnewi campus, Anambra, Nigeria
| | - Olaposi Omotuyi
- Department of Biochemistry, Centre for Biotechnology, Adekunle Ajasin University, Akungba-Akoko, Ondo, Nigeria
| | - Deborah I Dada
- Department of Medical Laboratory Science, School of Public and Allied Health, Babcock University, Ilishan-Remo, Ogun State, Nigeria
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8
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Ahn S, Kim GJ, Do SI, Kim K, Lee H, Do IG, Kim DH, Chae SW, Ryu S, Sohn JH. High-sensitivity C-reactive Protein and Regression of Low-grade Squamous Intraepithelial Lesion: The Role of Low-grade Inflammation in Cervical Carcinogenesis. J Epidemiol 2021; 31:615-620. [PMID: 33536377 PMCID: PMC8593578 DOI: 10.2188/jea.je20200142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
Background Inflammation is emerging as a potential mechanism of cervical carcinogenesis. However, few studies have investigated the association between host inflammatory status and the natural course of cervical precursor lesion. The aim of this study was to assess the probability of LSIL regression, associated with an inflammatory biomarker, high-sensitivity C-reactive protein (hs-CRP). Methods In a longitudinal cohort study, female participants were examined annually or biannually using cervical cytology between 2006 and 2015. Incident LSIL cases were included in the analysis, with regression defined as at least one consecutive normal cytologic result. A total of 520 women aged 22–64 years were followed up for LSIL regression. The multivariable-adjusted hazard ratios (HRs) for LSIL regression were estimated using a parametric proportional hazards model. Results During 827.5 person-years of follow-up, 486 out of 520 subjects (93.5%) showed LSIL regression. After adjusting several important potential confounders, a higher quartile of hs-CRP levels was significantly associated with a lower rate of regression (for quartile 4 vs quartile 1, inverse HR 1.33; 95% CI, 1.04–1.69; P for trend = 0.028). Conclusions The low rate of spontaneous regression recorded in women with higher hs-CRP lends support to the role of the perturbated host inflammatory status in cervical carcinogenesis, and suggests that hs-CRP level could help monitor LSIL.
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Affiliation(s)
- Sangjeong Ahn
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Gi Jeong Kim
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Sung-Im Do
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Kyungeun Kim
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Hyunjoo Lee
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - In-Gu Do
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Dong-Hoon Kim
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Seoung Wan Chae
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
| | - Seungho Ryu
- Department of Occupational and Environmental Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine.,Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine.,Department of Clinical Research Design & Evaluation, SAIHST, Sungkyunkwan University
| | - Jin Hee Sohn
- Department of Pathology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine
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CD4 + and CD8 + cell populations in HIV-positive women with cervical squamous intra-epithelial lesions and squamous cell carcinoma. Int J Infect Dis 2020; 103:370-377. [PMID: 33157285 DOI: 10.1016/j.ijid.2020.10.083] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/23/2020] [Accepted: 10/24/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION This study aimed to analyse cervical lymphocytic populations in HIV+ and HIV- patients and correlate different cervical lesions with HIV viral load and presence of high-risk HPV types. MATERIAL AND METHODS A total of 132 histological specimens from 40 HIV+ and 72 HIV- patients were evaluated for CD4+ and CD8+ T cell distribution, presence of high-risk HPV types, peripheral blood HIV viral load and CD4+/CD8+ ratio. RESULTS High-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinoma (SCC) from HIV+ patients had lower CD4+ T cell scores compared with HIV- patients. In all lesion groups, HIV+ patients presented higher epithelial and stromal CD8+ T cell scores. HIV viral load was more often detectable in patients with SCC than in those with low-grade squamous intraepithelial lesion (LSIL) (p = 0.0409). HSIL HIV+ patients had lower circulating CD4+ T cell counts (p = 0.0434) and CD4+/CD8+ ratio (p = 0.0378) compared with LSIL HIV+ patients. High-risk HPV types other than 16 and 18/45 were more prevalent in the HIV+ group. DISCUSSION These results support an imbalance between cervical CD4+ and CD8+ T lymphocytes of HIV+ patients with SIL and SCC, with increased CD8+ infiltrate density with lesion severity, even in patients with immune system recovery under cART.
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10
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Okoye JO, Ngokere AA, Erinle C, Mbamalu C. Co-existence of Herpes simplex virus type 2 and two other oncoviruses is associated with cervical lesions in women living with HIV in South-Western Nigeria. Afr Health Sci 2020; 20:1015-1023. [PMID: 33402947 PMCID: PMC7751508 DOI: 10.4314/ahs.v20i3.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background The prevalence of Herpes simplex virus type 2 (HSV-2) in cervical lesions is under-reported, especially in Human immunodeficiency virus (HIV), Epstein-Barr virus (EBV) and Human Papillomavirus (HPV) infected persons. Objectives This study determined the prevalence of viral mono-infections, co-infections and squamous cell intraepithelial lesions (SIL) in HIV seropositive (HIV+) and HIV seronegative (HIV-) women. Methods This study included HIV+ and HIV- women (105 each). Cervical smears and viral antibodies were evaluated by Papanicolaou's technique and ELISA method, respectively. Results The prevalence of HSV-2, HPV and EBV infections, and SIL were higher in HIV+ women (75.2, 41.9, 41 and 32.4%) than in HIV- women (45.7, 26.7, 26.7 and 13.3%) at p< 0.0001, p= 0.029, 0.041 and 0.002, respectively. Higher prevalence of viral mono-infection and tri-infection was observed in HIV+ women (43.8 and 24.8%) than in HIV- women (27.6 and 8.6%) at p= 0.021, and 0.003, respectively. The prevalence of SIL was also higher in HIV+ women with viral mono-infection, bi-infection and tri-infection (15.2, 42.9, and 53.8%) than in HIV- women (6.9, 12.5, and 44.4%) at p= 0.468, 0.041, and 0.711, respectively. Conclusion This study suggests that the high prevalence of SIL in HIV+ women could be associated with viral co-infections.
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Affiliation(s)
- Jude Ogechukwu Okoye
- Nnamdi Azikiwe University, Medical Laboratory Science; Babcock University, Medical Laboratory Science
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11
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Vasnik GK, Jain G, Husainy FA, Bansal V. Correlation of Cervical Squamous Intraepithelial Lesions with Human Papillomavirus in Women Infected with the Human Immunodeficiency Virus. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2019. [DOI: 10.1007/s40944-018-0251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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12
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Shin SS, Carpenter CL, Ekstrand ML, Wang Q, Grover S, Zetola NM, Yadav K, Sinha S, Nyamathi AM. Cervical cancer awareness and presence of abnormal cytology among HIV-infected women on antiretroviral therapy in rural Andhra Pradesh, India. Int J STD AIDS 2019; 30:586-595. [PMID: 30813859 DOI: 10.1177/0956462419825950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cervical cancer is a leading cause of death among women in low- and middle-income countries, and women living with HIV are at high risk for cervical cancer. The objective of this study was to estimate the prevalence and correlates of cervical cancer and pre-cancer lesions and to examine cervical cancer knowledge among women living with HIV receiving antiretroviral therapy in rural Andhra Pradesh, India. We conducted cytology-based screening and administered a standardized questionnaire among 598 HIV-infected women. We found 5 (0.8%), 39 (6.5%), 29 (4.9%), and 4 (0.7%) had atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), and squamous cervical carcinoma (SCC), respectively. In multivariable logistic regression analysis, ASCUS/LSIL was independently associated with age >16 years old at first sexual encounter and smokeless tobacco use. We found no factors associated with HSIL/SCC. In total, 101 women (16.9%) had heard of cervical cancer and 28 (27.7%) of them correctly identified HIV infection as a risk factor. In light of the high prevalence of pre-cancer lesions and low level of cervical cancer knowledge in our study population, focused interventions are needed to improve cervical cancer literacy and prevention among rural women living with HIV.
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Affiliation(s)
- Sanghyuk S Shin
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | | | - Maria L Ekstrand
- 3 Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA
| | - Qiao Wang
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | - Surbhi Grover
- 4 Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,5 Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Nicola M Zetola
- 4 Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,5 Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Kartik Yadav
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
| | - Sanjeev Sinha
- 6 Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Adeline M Nyamathi
- 1 Sue & Bill Gross School of Nursing, University of California, Irvine, CA, USA
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Davies G, Firnhaber C, Pantanowitz L, Michelow P. The relationship between menopausal women infected with the human immunodeficiency virus and cervical atrophy: A cytologic study. Diagn Cytopathol 2018; 47:302-306. [PMID: 30588777 DOI: 10.1002/dc.24092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 07/18/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the advent of combined antiretroviral therapy (cART), HIV positive women are expected to live longer. The effect of chronic HIV infection and cART on cervical epithelial maturation has not been well studied in postmenopausal woman. The objective of this study was to determine whether HIV positive postmenopausal women on cART show expected atrophic changes in cervical Pap tests. METHODS The maturation index (MI) was performed on routine cervical smears from HIV-infected, postmenopausal women attending an HIV clinic in a tertiary hospital in Johannesburg, over a 4-year period from January 2009 to December 2012. RESULTS In Pap smears of 111 patients on cART, 58 (52%) showed an unexpected predominantly mature squamous epithelial pattern whereas 53 (48%) were predominantly immature or atrophic (P = .0001). There was no significant statistical difference in maturation according to cART use. CONCLUSION HIV-infected, postmenopausal women in this study had reduced rates of cervical atrophy than expected, irrespective of cART use and CD4 count. Initiation of cART before menopause was associated with greater cervical epithelium maturation than those women who started cART after menopause. Additional, larger studies are required to confirm this novel finding and to investigate the reason for this phenomenon.
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Affiliation(s)
- Gillian Davies
- National Health Laboratory Services and Department of Anatomical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Department of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pamela Michelow
- National Health Laboratory Services and Department of Anatomical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Barillari G, Monini P, Sgadari C, Ensoli B. The Impact of Human Papilloma Viruses, Matrix Metallo-Proteinases and HIV Protease Inhibitors on the Onset and Progression of Uterine Cervix Epithelial Tumors: A Review of Preclinical and Clinical Studies. Int J Mol Sci 2018; 19:E1418. [PMID: 29747434 PMCID: PMC5983696 DOI: 10.3390/ijms19051418] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/03/2018] [Accepted: 05/04/2018] [Indexed: 12/15/2022] Open
Abstract
Infection of uterine cervix epithelial cells by the Human Papilloma Viruses (HPV) is associated with the development of dysplastic/hyperplastic lesions, termed cervical intraepithelial neoplasia (CIN). CIN lesions may regress, persist or progress to invasive cervical carcinoma (CC), a leading cause of death worldwide. CIN is particularly frequent and aggressive in women infected by both HPV and the Human Immunodeficiency Virus (HIV), as compared to the general female population. In these individuals, however, therapeutic regimens employing HIV protease inhibitors (HIV-PI) have reduced CIN incidence and/or clinical progression, shedding light on the mechanism(s) of its development. This article reviews published work concerning: (i) the role of HPV proteins (including HPV-E5, E6 and E7) and of matrix-metalloproteinases (MMPs) in CIN evolution into invasive CC; and (ii) the effect of HIV-PI on events leading to CIN progression such as basement membrane and extracellular matrix invasion by HPV-positive CIN cells and the formation of new blood vessels. Results from the reviewed literature indicate that CIN clinical progression can be monitored by evaluating the expression of MMPs and HPV proteins and they suggest the use of HIV-PI or their derivatives for the block of CIN evolution into CC in both HIV-infected and uninfected women.
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Affiliation(s)
- Giovanni Barillari
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 1 via Montpellier, 00133 Rome, Italy.
| | - Paolo Monini
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 299 viale Regina Elena, 00161 Rome, Italy.
| | - Cecilia Sgadari
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 299 viale Regina Elena, 00161 Rome, Italy.
| | - Barbara Ensoli
- National HIV/AIDS Research Center, Istituto Superiore di Sanità, 299 viale Regina Elena, 00161 Rome, Italy.
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15
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Manamela PK, Kgomo KA, van Gelderen CJ, Lekha AR, Michelow P, van den Berg EJ, Adam Y. Low-grade squamous intraepithelial lesions among women with HIV. Int J Gynaecol Obstet 2018; 142:78-83. [PMID: 29637559 DOI: 10.1002/ijgo.12505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/23/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To assess whether women with HIV who had low-grade squamous intraepithelial lesions (LSIL) on cytology had cervical disease. METHODS The present retrospective cross-sectional study included data from women with LSIL who attended a tertiary hospital in South Africa between April 1, 2003, and December 31, 2013. Patient information was extracted from a colposcopy database. RESULTS The study included 652 patients. The median age was 36 years (interquartile range [IQR] 31-42 years; range 18-66 years) and the median parity was three (IQR 2-5; range 0-10). In all, 266 (40.8%) women had a histology result of HPV or cervical intraepithelial neoplasia 1 (CIN1); 386 (59.2%) had a histology result of CIN2 or higher. The median cluster of differentiation 4 (CD4) count was 275.00 cells/mm3 (IQR 173.50-434.00 cells/mm3 ; range 2-1211 cells/mm3 ). A total of 312 (47.9%) women were using antiretroviral therapy. Use of antiretroviral therapy (unadjusted odds ratio 0.57; P=0.001) and a CD4 count of at least 200 cells/mm3 (unadjusted odds ratio 0.81; P=0.002) were associated with a histology result of HPV or CIN1. CONCLUSION Most of the women with a cytology report of LSIL had CIN2 or higher, suggesting that the practice of referral for colposcopy should continue.
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Affiliation(s)
- Portia K Manamela
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Koena A Kgomo
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Cyril J van Gelderen
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Anushka R Lekha
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Pamela Michelow
- School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Anatomical Pathology, Faculty of Health Science, National Health Laboratory Service, Johannesburg, South Africa
| | - Eunice J van den Berg
- School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.,Department of Anatomical Pathology, Faculty of Health Science, National Health Laboratory Service, Johannesburg, South Africa
| | - Yasmin Adam
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.,School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
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16
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HIV-positive women have higher risk of human papilloma virus infection, precancerous lesions, and cervical cancer. AIDS 2018; 32:795-808. [PMID: 29369827 DOI: 10.1097/qad.0000000000001765] [Citation(s) in RCA: 217] [Impact Index Per Article: 36.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE HIV-positive women have higher human papillomavirus (HPV) prevalence and cervical cancer incidence than HIV-negative women, partly because of HIV's modifying effect on HPV pathogenesis. We synthesized the literature on the impact of HIV on HPV natural history. DESIGN Systematic review and meta-analysis. METHODS We searched the literature for studies evaluating HPV acquisition and persistence or precancer progression by HIV status. Data on HPV natural history by HIV status, CD4 cell counts, viral load, and antiretroviral therapy (ART) were summarized using fixed effect models. RESULTS Overall, 38 of 1845 abstracts identified met inclusion criteria. HIV-positive women had higher HPV acquisition [relative risk (RRpooled) 2.64, 95% confidence interval (CI) 2.04-3.42] and lower HPV clearance (hazard ratiopooled 0.72, 95% CI 0.62-0.84) than HIV-negative women. HPV acquisition was higher with declining CD4 cell count and was lower in those virally suppressed on ART. HIV was associated with higher incidence of low-grade squamous intraepithelial lesions (LSIL; RRpooled 3.73, 95% CI 2.62-5.32) and high-grade squamous intraepithelial lesions (HSIL; hazard ratiopooled 1.32, 95% CI 1.10-1.58), largely because of increased HPV persistence. ART lowered progression from normal cytology to LSIL (hazard ratiopooled 0.65, 95% CI 0.52-0.82), but not HSIL. Cervical cancer incidence was associated with HIV positivity (RR 4.1, 95% CI 2.3-6.6), but not with ART. CONCLUSION HIV-positive women have higher risk of acquiring HPV, with risk inversely associated with CD4 cell count. ART lowered HPV acquisition, increased clearance, and reduced precancer progression, likely via immune reconstitution. Although some of our results are limited by small number of studies, our study can inform screening guidelines and mathematical modeling for cervical cancer prevention.
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17
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Kelly H, Weiss HA, Benavente Y, de Sanjose S, Mayaud P. Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis. Lancet HIV 2017; 5:e45-e58. [PMID: 29107561 PMCID: PMC5757426 DOI: 10.1016/s2352-3018(17)30149-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 07/15/2017] [Accepted: 08/02/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND The interactions between antiretroviral therapy (ART) and high-risk human papillomavirus (HPV) and cervical lesions in women living with HIV are poorly understood. We reviewed the association of ART with these outcomes. METHODS We did a systematic review and meta-analysis by searching MEDLINE and Embase databases for cross-sectional or cohort studies published in English between Jan 1, 1996, and May 6, 2017, which reported the association of ART with prevalence of high-risk HPV or prevalence, incidence, progression, or regression of histological or cytological cervical abnormalities, or incidence of invasive cervcal cancer. Studies were eligible if they reported the association of combination ART or highly active ART use with the following outcomes: high-risk HPV prevalence; squamous intraepithelial lesion (SIL) or cervical intraepithelial neoplasia (CIN) prevalence, incidence, progression, or regression; and invasive cervical cancer incidence among women living with HIV. We did random-effects meta-analyses to estimate summary statistics. We examined heterogeneity with the I2 statistic. This review is registered on the PROSPERO database at the Centre of Reviews and Dissemination, University of York, York, UK (registration number CRD42016039546). FINDINGS We identified 31 studies of the association of ART with prevalence of high-risk HPV (6537 women living with HIV) and high grade cervical lesions (HSIL-CIN2+; 9288 women living with HIV). Women living with HIV on ART had lower prevalence of high-risk HPV than did those not on ART (adjusted odds ratio [aOR] 0·83, 95% CI 0·70-0·99; I2=51%, adjusted for CD4 cell count and ART duration), and there was some evidence of association with HSIL-CIN2+ (0·65, 0·40-1·06; I2=30%). 17 studies reported the association of ART with longitudinal cervical lesion outcomes. ART was associated with a decreased risk of HSIL-CIN2+ incidence among 1830 women living with HIV (0·59, 0·40-0·87; I2=0%), SIL progression among 6212 women living with HIV (adjusted hazard ratio [aHR] 0·64, 95% CI 0·54-0·75; I2=18%), and increased likelihood of SIL or CIN regression among 5261 women living with HIV (1·54, 1·30-1·82; I2=0%). In three studies among 15 846 women living with HIV, ART was associated with a reduction in invasive cervical cancer incidence (crude HR 0·40, 95% CI 0·18-0·87, I2=33%). INTERPRETATION Early ART initiation and sustained adherence is likely to reduce incidence and progression of SIL and CIN and ultimately incidence of invasive cervical cancer. Future cohort studies should aim to confirm this possible effect. FUNDING UK Medical Research Council.
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Affiliation(s)
- Helen Kelly
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK,Correspondence to: Dr Helen Kelly, Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UKCorrespondence to: Dr Helen Kelly, Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene & Tropical MedicineLondonUK
| | - Helen A Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Yolanda Benavente
- Cancer Epidemiology Research Program, Catalan Institute of Oncology, IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Philippe Mayaud
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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Menon S, Rossi R, Zdraveska N, Kariisa M, Acharya SD, Vanden Broeck D, Callens S. Associations between highly active antiretroviral therapy and the presence of HPV, premalignant and malignant cervical lesions in sub-Saharan Africa, a systematic review: current evidence and directions for future research. BMJ Open 2017; 7:e015123. [PMID: 28780541 PMCID: PMC5724112 DOI: 10.1136/bmjopen-2016-015123] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES In sub-Saharan Africa, substantial international funding along with evidence-based clinical practice have resulted in an unparalleled scale-up of access to antiretroviral treatment at a higher CD4 count. The role and timing of highly active antiretroviral therapy (HAART) in mediating cervical disease remains unclear. The aim of this article is to systematically review all evidence pertaining to Africa and identify research gaps regarding the epidemiological association between HAART use and the presence of premalignant/malignant cervical lesions. METHOD Five databases were searched until January 2017 to retrieve relevant literature from sub-Saharan Africa. Publications were included if they addressed prevalence, incidence or clearance of human papillomavirus (HPV) infection in women undergoing HAART as well as cytological or histological neoplastic abnormalities. RESULTS 22 studies were included, of which seven were prospective studies. Women receiving HAART are less likely to develop squamous intraepithelial lesions (SILs). There is evidence that duration of HAART along with the CD4 count may reduce the prevalence of high-risk HPV (HR-HPV), suggesting that without HAART, severe immunosuppression increases the risk of becoming or remaining infected with HR-HPV. Furthermore, according to existent literature, the CD4 count, rather than HAART coverage or its duration, plays a central role in the prevalence of cervical intraepithelial neoplasia (CIN) 2 and CIN 3. CONCLUSION Our findings suggest a positive impact of HAART duration, in conjunction and interaction with CD4 count, on reducing the prevalence of HR-HPV. The greatest treatment effect might be seen among women starting at the lowest CD4 count, which may have a more instrumental role in cervical oncogenesis than either HAART use or the treatment duration on the prevalence of CIN 2 and CIN 3. There is still insufficient evidence to show a clear association between HAART coverage and the incidence of invasive cervical cancer. Enhanced surveillance on the impact of HAART treatment is crucial.
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Affiliation(s)
- Sonia Menon
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
- CDC Foundation, Atlanta, Georgia, USA
| | - Rodolfo Rossi
- Laboratory for Cell Biology & Histology, University of Antwerp, Antwerp, Belgium
| | - Natasha Zdraveska
- Department of Clinical Pharmacy, Saints Cyril and Methodius, Republic of Macedonia
| | | | | | - Davy Vanden Broeck
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
- AMBIOR, Laboratory for Cell Biology & Histology, University of Antwerp, National Reference Centre for HPV, Laboratory of Molecular Pathology, Antwerp, Belgium
| | - Steven Callens
- Department of Internal Medicine & Infectious diseases, University Hospital, Ghent, Belgium
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Rohner E, Sengayi M, Goeieman B, Michelow P, Firnhaber C, Maskew M, Bohlius J. Cervical cancer risk and impact of Pap-based screening in HIV-positive women on antiretroviral therapy in Johannesburg, South Africa. Int J Cancer 2017; 141:488-496. [PMID: 28440019 PMCID: PMC5504282 DOI: 10.1002/ijc.30749] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 04/07/2017] [Accepted: 04/13/2017] [Indexed: 12/28/2022]
Abstract
Data on invasive cervical cancer (ICC) incidence in HIV-positive women and the effect of cervical cancer screening in sub-Saharan Africa are scarce. We estimated i) ICC incidence rates in women (≥18 years) who initiated antiretroviral therapy (ART) at the Themba Lethu Clinic (TLC) in Johannesburg, South Africa, between 2004 and 2011 and ii) the effect of a Pap-based screening program. We included 10,640 women; median age at ART initiation: 35 years [interquartile range (IQR) 30-42], median CD4 count at ART initiation: 113 cells/µL (IQR 46-184). During 27,257 person-years (pys), 138 women were diagnosed with ICC; overall incidence rate: 506/100,000 pys [95% confidence interval (CI) 428-598]. The ICC incidence rate was highest (615/100,000 pys) in women who initiated ART before cervical cancer screening became available in 04/2005 and was lowest (260/100,000 pys) in women who initiated ART from 01/2009 onward when the cervical cancer screening program and access to treatment of cervical lesions was expanded [adjusted hazard ratio (aHR) 0.42, 95% CI 0.20-0.87]. Advanced HIV/AIDS stage (4 versus 1, aHR 1.95, 95% CI 1.17-3.24) and middle age at ART initiation (36-45 versus 18-25 years, aHR 2.51, 95% CI 1.07-5.88) were risk factors for ICC. The ICC incidence rate substantially decreased with the implementation of a Pap-based screening program and improved access to treatment of cervical lesions. However, the risk of developing ICC after ART initiation remained high. To inform and improve ICC prevention and care for HIV-positive women in sub-Saharan Africa, implementation and monitoring of cervical cancer screening programs are essential.
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Affiliation(s)
- Eliane Rohner
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
| | - Mazvita Sengayi
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
| | | | - Pamela Michelow
- Cytology Unit, Department of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Cytology Unit, National Health Laboratory Service, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Right to Care, Johannesburg, South Africa
- Department of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Mhairi Maskew
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Julia Bohlius
- Institute of Social and Preventive Medicine, University of Bern, Switzerland
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20
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Bacigalupo I, Palladino C, Leone P, Toschi E, Sgadari C, Ensoli B, Barillari G. Inhibition of MMP-9 expression by ritonavir or saquinavir is associated with inactivation of the AKT/Fra-1 pathway in cervical intraepithelial neoplasia cells. Oncol Lett 2017; 13:2903-2908. [PMID: 28521396 PMCID: PMC5431249 DOI: 10.3892/ol.2017.5835] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 10/19/2016] [Indexed: 01/07/2023] Open
Abstract
A reduced incidence and decreased clinical progression of uterine cervical intraepithelial neoplasia (CIN) has been observed in women infected with human immunodeficiency virus (HIV) treated with HIV-protease inhibitors (PIs). The HIV-PIs saquinavir (SQV) and ritonavir (RTV) have been demonstrated to efficiently inhibit invasion of human primary CIN cells by downregulating the expression of matrix metalloproteinase (MMP)-9. The present study further investigated the molecular mechanisms underlying the activity of SQV and RTV in CIN. The results of the present study indicate that the treatment of human primary CIN cells with SQV or RTV directly impairs events leading to MMP-9 expression, including the phosphorylation of AKT and the nuclear localisation of the Fos-related antigen transcription factor. In addition, neither SQV nor RTV affected the expression of human papilloma virus proteins, such as E6 or E7. In view of the important role that the AKT/Fra-1/MMP-9 signalling pathway serves in CIN progression to invasive cervical carcinoma, these data further support the use of HIV-PIs in the treatment of CIN in women infected with HIV and women who are not infected with HIV. Furthermore, the present study identified a molecular mechanism underlying the anti-invasive effects of SQV/RTV, providing useful information for the development of SQV/RTV derivatives, which may be employed as novel anticancer drugs.
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Affiliation(s)
- Ilaria Bacigalupo
- National Acquired Immune Deficiency Syndrome Center, National Institute of Health, I-00161 Rome, Italy
| | - Clelia Palladino
- National Acquired Immune Deficiency Syndrome Center, National Institute of Health, I-00161 Rome, Italy
| | - Patrizia Leone
- National Acquired Immune Deficiency Syndrome Center, National Institute of Health, I-00161 Rome, Italy
| | - Elena Toschi
- Department of Haematology, Oncology and Molecular Medicine, National Institute of Health, I-00161 Rome, Italy
| | - Cecilia Sgadari
- National Acquired Immune Deficiency Syndrome Center, National Institute of Health, I-00161 Rome, Italy
| | - Barbara Ensoli
- National Acquired Immune Deficiency Syndrome Center, National Institute of Health, I-00161 Rome, Italy
| | - Giovanni Barillari
- Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, I-00133 Rome, Italy
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21
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Katz IT, Butler LM, Crankshaw TL, Wright AA, Bramhill K, Leone DA, Giddy J, Mould S. Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates. J Glob Oncol 2016; 2:375-380. [PMID: 28717723 PMCID: PMC5493244 DOI: 10.1200/jgo.2015.002469] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
PURPOSE To determine the prevalence of screening, cervical dysplasia, and malignancy on the basis of histologic diagnoses from colposcopy and large loop excision of the transformation zone among women living with HIV (WLWH) who attended an urban antiretroviral treatment (ART) clinic in KwaZulu-Natal, South Africa. MATERIALS AND METHODS We performed a retrospective cohort study to examine a random sample of 462 WLWH during a 5-year period from 2004 to 2009. Women on ART for < 3 months were excluded. Data were abstracted from electronic records and paper charts to assess rates of cervical abnormalities detected on Pap smears as well as time to colposcopy. RESULTS During the study period, 432 women (93.5%) had at least one evaluable Papanicolau test. At baseline, 237 women (54.9%) had an abnormal Papanicolau test, and of these patients, 181 (76.3%) had a Papanicolau test that qualified for further colposcopic evaluation. In addition, 115 women (63.5%) received colposcopy within a median of 39 days from referral. This yielded 74 evaluable histologic samples (64.3%), of which 21.6%, 27.0%, 27.0%, and 1.4% had cervical intraepithelial neoplasia (CIN) 1, CIN2, CIN3, and invasive cervical cancer, respectively. CONCLUSION In a large sample of WLWH who received ART in KwaZulu-Natal, South Africa, where Papanicolau test coverage and rates of referral for colposcopy and large loop excision of the transformation zone were high, > 75% of women with evaluable histologic samples had evidence of cervical dysplasia or malignancy. These findings underscore the importance of routine cervical screening upon entry into HIV care to optimize survival.
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Affiliation(s)
- Ingrid T. Katz
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Lisa M. Butler
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Tamaryn L. Crankshaw
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Alexi A. Wright
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Karen Bramhill
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Dominick A. Leone
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Janet Giddy
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
| | - Sean Mould
- Ingrid T. Katz and Dominick A. Leone, Brigham and Women’s Hospital; Ingrid T. Katz, Lisa M. Butler, and Alexi A. Wright, Harvard Medical School; Ingrid T. Katz, Massachusetts General Hospital Center for Global Health; Lisa M. Butler, Boston Children’s Hospital; Alexi A. Wright, Dana-Farber Cancer Institute; Dominick A. Leone, Boston University, Boston, MA; Tamaryn L. Crankshaw, University of KwaZulu-Natal, Durban; Janet Giddy, Western Cape Province Department of Health, Cape Town; Sean Mould, R.K. Khan Hospital, Chatsworth, South Africa; and Karen Bramhill, Canadian Red Cross, Ontario, Canada
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Moodley N, Gray G, Bertram M. The Price of Prevention: Cost Effectiveness of Biomedical HIV Prevention Strategies in South Africa. CLINICAL RESEARCH IN HIV/AIDS 2016; 3:1031. [PMID: 28824960 PMCID: PMC5562157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND South Africa has the highest global burden of human immunodefciency virus [HIV]. The study compared the cost-effectiveness of individual and combination HIV preventive strategies against the current rollout of ART and possible ART scale-up. METHODS Adolescents attending South African schools in 2012 were included in the semi-Markov running annual cycles. The ART and HIV counseling and testing program [comparator] was weighed against the interventions [viz. HIV vaccine, a dual vaccine strategy [HIV and HPV vaccines], oral pre-exposure prophylaxis [PrEP] and voluntary medical male circumcision [VMMC]; and various combinations thereof. Quality-adjusted life years [QALY] determined changes in HIV associated mortality and infections averted. One-way and probabilistic sensitivity analysis determined parameter uncertainty. Discount rates of 3% with a lifetime horizon [70 years] were applied. RESULTS Dual vaccination was highly cost-effective strategy [US$ 7 per QALY gained] and averted 29% of new HIV infections. VMMC [US$ 30 per QALY gained] proved more cost-effective than HIV vaccination alone [US$ 93 per QALY gained], though VMMC averted 6% more new infections than the HIV vaccine when considered among male participants. PrEP interventions were the least cost-effective with pharmaceutical and human resource spending driving the costs. Combined dual vaccination and VMMC strategies were a dominant intervention. Strategies involving PrEP were the least cost-effective. CONCLUSION VMMC, HIV vaccination and dual vaccination strategies were more cost-effective than any PrEP strategies. A multi-intervention biomedical approach could avert considerable new HIV infections and present a cost-effective use of resources; particularly where large scale multi-interventional randomized controlled trials are absent.
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Affiliation(s)
- Nishila Moodley
- Department of Health Sciences, University of the Witwatersrand, South Africa
- South African HVTN AIDS Vaccine Early Stage Investigator Program [SHAPe]
- Department of Science and Technology, University of Stellenbosch, South Africa
| | - Glenda Gray
- Department of Health Sciences, University of the Witwatersrand, South Africa
- South African HVTN AIDS Vaccine Early Stage Investigator Program [SHAPe]
- Department Medical Research Council, Fred Hutchinson Cancer Research Centre, South Africa
| | - Melanie Bertram
- Department of Health Systems Governance and Finance, World Health Organization, Geneva
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23
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Finocchario-Kessler S, Wexler C, Maloba M, Mabachi N, Ndikum-Moffor F, Bukusi E. Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective. BMC Womens Health 2016; 16:29. [PMID: 27259656 PMCID: PMC4893293 DOI: 10.1186/s12905-016-0306-6] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 05/21/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa. METHODS We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories. RESULTS A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts. CONCLUSIONS Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.
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Affiliation(s)
| | - Catherine Wexler
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - May Maloba
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
| | - Natabhona Mabachi
- Department of Family Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Florence Ndikum-Moffor
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, USA
| | - Elizabeth Bukusi
- Family AIDS Care and Education Services, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya
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Firnhaber C, Goeieman B, Faesen M, Levin S, Williams S, Rameotshela S, Swarts A, Michelow P, Omar T, Williamson AL, Allan B, Schnippel K, Smith JS. Prospective One Year Follow Up of HIV Infected Women Screened for Cervical Cancer Using Visual Inspection with Acetic Acid, Cytology and Human Papillomavirus Testing in Johannesburg South Africa. PLoS One 2016; 11:e0144905. [PMID: 26730710 PMCID: PMC4701358 DOI: 10.1371/journal.pone.0144905] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/26/2015] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cervical cancer is the most common cancer in Sub-Saharan Africa. There are little of HIV-infected women one-year after screening using visual inspection with acetic acid (VIA), HPV or cytology in sub-Saharan Africa. METHODS HIV-infected women in Johannesburg South Africa were screened one year later by Pap smear, VIA and human papillomavirus (HPV) testing. Women qualified for the 12 month follow-up visit if they had a negative or cervical intra-epithelial neoplasia (CIN) 1 results at the baseline visit. Modified Poisson regression was used to analyse associations between patient baseline characteristics and progression. RESULTS A total of 688 of 1,202 enrolled at baseline study who were CIN-2+ negative and qualified for a 12 month follow-up visit. Progression to CIN-2+ was higher in women with positive VIA results (12.6%; 24/191) than those VIA-negative (4.4%; 19/432). HPV-positive women at baseline were more likely to progress to CIN-2+ (12.3%; 36/293) than those HPV-negative (2.1%; 7/329). Cytology-positive women at baseline were more likely to progress to CIN-2+ (9.6%; 37/384) than cytology-negative women (2.5%; 6/237). Approximately 10% (10.4%; 39/376) of women with CIN 1 at baseline progressed to CIN 2+. Women who were VIA or HPV positive at baseline were more likely to progress aIRR 1.85, CI 95% (1.46 to 2.36), aIRR 1.41 CI 95% (1.14 to 1.75) respectively. CONCLUSION Progression to CIN-2+ in HIV-infected women is significant when measured by baseline positive VIA, HPV or Pap and yearly screening by any method should be considered in this population if possible.
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Affiliation(s)
- Cynthia Firnhaber
- Clinical HIV Research Unit, Faculty of Health Sciences, Department of Internal Medicine, University Witwatersrand, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | | | | | - Simon Levin
- Right to Care, Johannesburg, South Africa
- Department of OB/GYN, Coronation Hospital, University of Witwatersrand, Johannesburg, South Africa
| | | | | | - Avril Swarts
- Clinical HIV Research Unit, Faculty of Health Sciences, Department of Internal Medicine, University Witwatersrand, Johannesburg, South Africa
| | - Pam Michelow
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Science, University of Witwatersrand, Johannesburg, South Africa
- National Health Laboratory Service, Johannesburg, South Africa
| | - Tanvier Omar
- National Health Laboratory Service, Johannesburg, South Africa
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Division of Medical Virology, Department of Clinical Laboratory Sciences, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Bruce Allan
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | | | - Jennifer S. Smith
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Li X, Stander MP, Van Kriekinge G, Demarteau N. Cost-effectiveness analysis of human papillomavirus vaccination in South Africa accounting for human immunodeficiency virus prevalence. BMC Infect Dis 2015; 15:566. [PMID: 26652918 PMCID: PMC4676856 DOI: 10.1186/s12879-015-1295-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 11/25/2015] [Indexed: 11/24/2022] Open
Abstract
Background This study aims at evaluating the cost-effectiveness of a 2-dose schedule human papillomavirus (HPV) vaccination programme of HPV and human immunodeficiency virus (HIV) naïve 12-year-old girls, in addition to cervical cancer (CC) screening alone, in South Africa. The study aims to account for both the impact of the vaccine among girls who are HIV-positive (HIV+) as well as HIV-negative (HIV-) population. Methods A previously published Markov cohort model was adapted to assess the impact and cost-effectiveness of a HPV vaccination programme in girls aged 12 years (N = 527 900) using the AS04-adjuvanted HPV-16/18 vaccine from a public payer perspective. Two subpopulations were considered: HIV- and HIV+ women. Each population followed the HPV natural history with different transition probabilities. Model input data were obtained from the literature, local databases and Delphi panel. Costs and outcomes were discounted at 5 %. Extensive sensitivity analyses were conducted to assess the robustness of the evaluation. Results Implementation of the AS04-adjuvanted HPV-16/18 vaccine in combination with current cytological screening in South African girls could prevent up to 8 869 CC cases and 5 436 CC deaths over the lifetime of a single cohort. Without discounting, this HPV vaccine is dominant over screening alone; with discounting, the incremental cost-effectiveness ratio is ZAR 81 978 (South African Rand) per quality-adjusted life years (QALY) gained. HPV vaccination can be considered cost-effective based on World Health Organization (WHO) recommended threshold (3 x gross domestic product/capita = ZAR 200 293). In a scenario with a hypothetical targeted vaccination in a HIV+ subpopulation alone, the modelled outcomes suggest that HPV vaccination is still cost-effective, although the incremental cost-effectiveness ratio increases to ZAR 102 479. Results were sensitive to discount rate, vaccine efficacy, HIV incidence and mortality rates, and HPV-related disease transition probabilities. Conclusions The AS04-adjuvanted HPV-16/18 vaccine can be considered cost-effective in a South African context although the cost-effectiveness is expected to be lower in the HIV+ subpopulation than in the overall female population. With improved access to HIV treatment, the HIV mortality and incidence rates are likely to be reduced, which could improve cost-effectiveness of the vaccination programme in South Africa. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1295-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiao Li
- Health Economics, GSK Vaccines, Avenue Fleming 20, 1300, Wavre, Belgium.
| | - Martinus P Stander
- Health Economic Research, HEXOR (Pty) Ltd, Block J, Central Park, 400 16th Road, Midrand, Republic of South Africa.
| | | | - Nadia Demarteau
- Health Economics, GSK Vaccines, Avenue Fleming 20, 1300, Wavre, Belgium.
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Costs and Cost Effectiveness of Three Approaches for Cervical Cancer Screening among HIV-Positive Women in Johannesburg, South Africa. PLoS One 2015; 10:e0141969. [PMID: 26569487 PMCID: PMC4646665 DOI: 10.1371/journal.pone.0141969] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 10/15/2015] [Indexed: 11/29/2022] Open
Abstract
Background South Africa has high rates of HIV and HPV and high incidence and mortality from cervical cancer. However, cervical cancer is largely preventable when early screening and treatment are available. We estimate the costs and cost-effectiveness of conventional cytology (Pap), visual inspection with acetic acid (VIA) and HPV DNA testing for detecting cases of CIN2+ among HIV-infected women currently taking antiretroviral treatment at a public HIV clinic in Johannesburg, South Africa. Methods Method effectiveness was derived from a validation study completed at the clinic. Costs were estimated from the provider perspective using micro-costing between June 2013-April 2014. Capital costs were annualized using a discount rate of 3%. Two different service volume scenarios were considered. Threshold analysis was used to explore the potential for reducing the cost of HPV DNA testing. Results VIA was least costly in both scenarios. In the higher volume scenario, the average cost per procedure was US$ 3.67 for VIA, US$ 8.17 for Pap and US$ 54.34 for HPV DNA. Colposcopic biopsies cost on average US$ 67.71 per procedure. VIA was least sensitive but most cost-effective at US$ 17.05 per true CIN2+ case detected. The cost per case detected for Pap testing was US$ 130.63 using a conventional definition for positive results and US$ 187.52 using a more conservative definition. HPV DNA testing was US$ 320.09 per case detected. Colposcopic biopsy costs largely drove the total and per case costs. A 71% reduction in HPV DNA screening costs would make it competitive with the conservative Pap definition. Conclusions Women need access to services which meet their needs and address the burden of cervical dysplasia and cancer in this region. Although most cost-effective, VIA may require more frequent screening due to low sensitivity, an important consideration for an HIV-positive population with increased risk for disease progression.
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Enebe JT, Dim CC, Nnakenyi EF, Ezegwui HU, Ozumba BC. Effect of Low CD4 Cell Count on Cervical Squamous Intraepithelial Lesions among HIV-Positive Women in Enugu, Southeastern Nigeria. J Clin Diagn Res 2015; 9:QC07-10. [PMID: 26674006 PMCID: PMC4668476 DOI: 10.7860/jcdr/2015/14808.6785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 08/13/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION HIV-positive women are more likely to develop cervical neoplasm. HIV-positive women with low CD4 T-lymphocyte cell count may be more predisposed to cervical squamous intraepithelial lesions (SILs). This study aimed to determine the association between low cellular immunity of HIV positive women, and the prevalence and grade of cervical squamous intraepithelial lesions. MATERIALS AND METHODS Pap smear was carried out on two cohorts of Highly Active Anti Retroviral Therapy (HAART) experienced HIV-positive women (178 per group) at the AIDS Prevention Initiative in Nigeria-Centre for Disease Control Adult Anti-Retroviral clinic of the University of Nigeria Teaching Hospital, Enugu, Nigeria from June to November, 2012. The study group had CD4 cell count of < 200 cells/μl while the control group had CD4 cell count of ≥200 cells/μl. RESULTS The mean CD4 cell counts of participants in the study (low CD4) group was 127.9 ± 47.49 cells/ml while that of the control (high CD4) group was 489.2 ± 186.36 cells/ml (p < 0.001). The prevalence of SIL was 10.2% (18/176) for the low CD4 group, and 5.7% (10/176) for the high CD4 group [OR = 1.9 (95% CI: 0.85, 4.22)]. The commonest category of SILs identified was Low-grade Squamous Intraepithelial Lesion (LSIL), thus 11 (6.3%) in the study versus 7 (4.0%) in the control group (p = 0.703). CONCLUSION Prevalence of cervical SILs among HIV positive women on HAART in Enugu, Nigeria is low and has no significant relationship with their CD4 cell count.
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Affiliation(s)
- Joseph Tochukwu Enebe
- Consultant, Department of Obstetrics and Gynaecology, Enugu State University of Technology Teaching Hospital, Parklane Enugu, Nigeria
| | - Cyril Chukwudi Dim
- Senior Lecturer and Honorary Consultant, Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Emeka Francis Nnakenyi
- Lecturer and Honorary Consultant, Department of Morbid Anatomy, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Hyginus Uzochukwu Ezegwui
- Professor and Honorary Consultant, Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Enugu, Nigeria
| | - Benjamin Chukwuma Ozumba
- Professor and Honorary Consultant, Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Enugu, Nigeria
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Kelly H, Mayaud P, de Sanjose S. Concomitant Infection of HIV and HPV: What Are the Consequences? CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0132-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Bateman AC, Katundu K, Mwanahamuntu MH, Kapambwe S, Sahasrabuddhe VV, Hicks ML, Chi BH, Stringer JSA, Parham GP, Chibwesha CJ. The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study. BMC Cancer 2015. [PMID: 26205980 PMCID: PMC4512016 DOI: 10.1186/s12885-015-1558-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. Methods We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia’s most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. Results Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. Conclusions The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
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Affiliation(s)
- Allen C Bateman
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Katundu Katundu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | - Mulindi H Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of Zambia, Lusaka, Zambia.
| | - Sharon Kapambwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | | | | | - Benjamin H Chi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Groesbeck P Parham
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,University of Zambia, Lusaka, Zambia.
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Hecht M, Erber S, Harrer T, Klinker H, Roth T, Parsch H, Fiebig N, Fietkau R, Distel LV. Efavirenz Has the Highest Anti-Proliferative Effect of Non-Nucleoside Reverse Transcriptase Inhibitors against Pancreatic Cancer Cells. PLoS One 2015; 10:e0130277. [PMID: 26086472 PMCID: PMC4473268 DOI: 10.1371/journal.pone.0130277] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/19/2015] [Indexed: 02/06/2023] Open
Abstract
Background Cancer prevention and therapy in HIV-1-infected patients will play an important role in future. The non-nucleoside reverse transcriptase inhibitors (NNRTI) Efavirenz and Nevirapine are cytotoxic against cancer cells in vitro. As other NNRTIs have not been studied so far, all clinically used NNRTIs were tested and the in vitro toxic concentrations were compared to drug levels in patients to predict possible anti-cancer effects in vivo. Methods Cytotoxicity was studied by Annexin-V-APC/7AAD staining and flow cytometry in the pancreatic cancer cell lines BxPC-3 and Panc-1 and confirmed by colony formation assays. The 50% effective cytotoxic concentrations (EC50) were calculated and compared to the blood levels in our patients and published data. Results The in vitro EC50 of the different drugs in the BxPC-3 pancreatic cancer cells were: Efavirenz 31.5μmol/l (= 9944ng/ml), Nevirapine 239μmol/l (= 63786ng/ml), Etravirine 89.0μmol/l (= 38740ng/ml), Lersivirine 543μmol/l (= 168523ng/ml), Delavirdine 171μmol/l (= 78072ng/ml), Rilpivirine 24.4μmol/l (= 8941ng/ml). As Efavirenz and Rilpivirine had the highest cytotoxic potential and Nevirapine is frequently used in HIV-1 positive patients, the results of these three drugs were further studied in Panc-1 pancreatic cancer cells and confirmed with colony formation assays. 205 patient blood levels of Efavirenz, 127 of Rilpivirine and 31 of Nevirapine were analyzed. The mean blood level of Efavirenz was 3587ng/ml (range 162–15363ng/ml), of Rilpivirine 144ng/ml (range 0-572ng/ml) and of Nevirapine 4955ng/ml (range 1856–8697ng/ml). Blood levels from our patients and from published data had comparable Efavirenz levels to the in vitro toxic EC50 in about 1 to 5% of all patients. Conclusion All studied NNRTIs were toxic against cancer cells. A low percentage of patients taking Efavirenz reached in vitro cytotoxic blood levels. It can be speculated that in HIV-1 positive patients having high Efavirenz blood levels pancreatic cancer incidence might be reduced. Efavirenz might be a new option in the treatment of cancer.
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Affiliation(s)
- Markus Hecht
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
- * E-mail:
| | - Sonja Erber
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Thomas Harrer
- Department of Internal Medicine 3, University Hospital Erlangen, Erlangen, Germany
| | - Hartwig Klinker
- Department of Internal Medicine 2, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Roth
- Central Laboratory, University Hospital Erlangen, Erlangen, Germany
| | - Hans Parsch
- Central Laboratory, University Hospital Erlangen, Erlangen, Germany
| | - Nora Fiebig
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Luitpold V. Distel
- Department of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
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Lofgren SM, Tadros T, Herring-Bailey G, Birdsong G, Mosunjac M, Flowers L, Nguyen ML. Progression and regression of cervical pap test lesions in an urban AIDS clinic in the combined antiretroviral therapy era: a longitudinal, retrospective study. AIDS Res Hum Retroviruses 2015; 31:508-13. [PMID: 25693769 DOI: 10.1089/aid.2014.0254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Our objective was to evaluate the progression and regression of cervical dysplasia in human immunodeficiency virus (HIV)-positive women during the late antiretroviral era. Risk factors as well as outcomes after treatment of cancerous or precancerous lesions were examined. This is a longitudinal retrospective review of cervical Pap tests performed on HIV-infected women with an intact cervix between 2004 and 2011. Subjects needed over two Pap tests for at least 2 years of follow-up. Progression was defined as those who developed a squamous intraepithelial lesion (SIL), atypical glandular cells (AGC), had low-grade SIL (LSIL) followed by atypical squamous cells-cannot exclude high-grade SIL (ASC-H) or high-grade SIL (HSIL), or cancer. Regression was defined as an initial SIL with two or more subsequent normal Pap tests. Persistence was defined as having an SIL without progression or regression. High-risk human papillomavirus (HPV) testing started in 2006 on atypical squamous cells of undetermined significance (ASCUS) Pap tests. AGC at enrollment were excluded from progression analysis. Of 1,445 screened, 383 patients had over two Pap tests for a 2-year period. Of those, 309 had an intact cervix. The median age was 40 years and CD4+ cell count was 277 cells/mL. Four had AGC at enrollment. A quarter had persistently normal Pap tests, 64 (31%) regressed, and 50 (24%) progressed. Four developed cancer. The only risk factor associated with progression was CD4 count. In those with treated lesions, 24 (59%) had negative Pap tests at the end of follow-up. More studies are needed to evaluate follow-up strategies of LSIL patients, potentially combined with HPV testing. Guidelines for HIV-seropositive women who are in care, have improved CD4, and have persistently negative Pap tests could likely lengthen the follow-up interval.
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Affiliation(s)
- Sarah M. Lofgren
- Department of Internal Medicine, Emory University, Atlanta, Georgia
| | - Talaat Tadros
- Department of Pathology, Emory University, Atlanta, Georgia
| | - Gina Herring-Bailey
- Infectious Disease Program, Grady Hospital, Ponce De Leon Center, Atlanta, Georgia
| | | | | | - Lisa Flowers
- Department of Obstetrics and Gynecology, Emory University, Atlanta, Georgia
| | - Minh Ly Nguyen
- Department of Internal Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia
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Prevalence of premalignant cervical lesions in women with a long-term nonprogressor or HIV controller phenotype. J Acquir Immune Defic Syndr 2014; 65:e29-32. [PMID: 24419070 PMCID: PMC3987062 DOI: 10.1097/qai.0b013e31829ce738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- O Al-Baghdadi
- Department of Obstetrics and Gynaecology, Luton and Dunstable Hospital , Luton
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Hoffmann CJ, Chaisson RE, Martinson NA. Cotrimoxazole prophylaxis and tuberculosis risk among people living with HIV. PLoS One 2014; 9:e83750. [PMID: 24421903 PMCID: PMC3885446 DOI: 10.1371/journal.pone.0083750] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 11/07/2013] [Indexed: 11/18/2022] Open
Abstract
Objectives Many randomized and cohort studies have reported a survival benefit with cotrimoxazole prophylaxis without detecting a difference in tuberculosis (TB) incidence by cotrimoxazole status. However, several in vitro studies have reported that cotrimoxazole possesses anti-TB activity. We sought to compare TB incidence and TB diagnostic yield by cotrimoxazole use among participants in a well characterized cohort of HIV-infected adults living in a high TB prevalence region. Methods We analyzed prospective data from a long-term longitudinal cohort of adults receiving HIV care and TB investigations in Soweto, South Africa. Using longitudinal analysis, we compared total and laboratory confirmed TB incidence by cotrimoxazole status as well as all-cause mortality. In addition, we compared TB culture results by cotrimoxazole status. Results In a multivariable analysis, adjusted for sex, body mass index, WHO clinical stage, time-updated CD4 count, and antiretroviral therapy status, we observed an association between cotrimoxazole and an increase in TB incidence (hazard ratio 1.7, 95% CI: 1.2, 2.2). However, when restricted to laboratory-confirmed TB, there was no association between cotrimoxazole and TB incidence (hazard ratio: 0.97, 95% CI: 0.39, 2.4). In TB cases, we found no difference in the proportion of positive sputum cultures or days to culture positivity by cotrimoxazole status. Cotrimoxazole was associated with a reduction in mortality. Conclusions In this cohort with a mortality benefit from cotrimoxazole, we found an increased risk of all TB among individuals using cotrimoxazole, likely a result of residual confounding, but no association between use of cotrimoxazole and laboratory-confirmed TB. Cotrimoxazole did not compromise TB diagnosis.
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Affiliation(s)
- Christopher J. Hoffmann
- Johns Hopkins University School of Medicine and Center for TB Research, Baltimore, Maryland, United States of America
- * E-mail:
| | - Richard E. Chaisson
- Johns Hopkins University School of Medicine and Center for TB Research, Baltimore, Maryland, United States of America
| | - Neil A. Martinson
- Johns Hopkins University School of Medicine and Center for TB Research, Baltimore, Maryland, United States of America
- Perinatal HIV Research Unit, Johannesburg, South Africa
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Westreich D, Jamal N, Smith JS, Schulze D, Williams S, Michelow P, Levin S, Firnhaber C. Injectable and oral contraception and the incidence and progression of cervical disease in HIV-infected women in South Africa. Contraception 2014; 89:286-91. [PMID: 24485095 DOI: 10.1016/j.contraception.2013.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 12/11/2013] [Accepted: 12/24/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND Few data exist regarding the effect of hormonal contraception (HC) on incidence and progression of cervical disease (e.g., cervical dysplasia, squamous intraepithelial lesions, cervical intraepithelial neoplasia) in HIV-infected African women. STUDY DESIGN We conducted an observational study of HIV-seropositive women in Johannesburg, South Africa. The effect of individual HC types on the incidence and progression of cervical disease was determined using Poisson regression to obtain adjusted incidence rate ratios. RESULTS We evaluated 594 HIV-infected women, with median follow-up time of 445 days; 75 of these women were receiving some form of HC (largely DMPA, NET-EN, or COCs) at baseline. Risks of incidence and progression of cervical disease were similar comparing women not receiving HCs to women receiving DMPA, NET-EN, or COCs both individually by HC-type and considering all HC together. CONCLUSIONS There was no statistically significant effect of particular HC methods or of HC use in general on rates of incidence or progression of cervical disease in this study. These results should reassure us that use of HC is unlikely to substantially increase risks of cervical disease among HIV-positive women.
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Affiliation(s)
- Daniel Westreich
- Department of Obstetrics and Gynecology and Duke Global Health Institute, Duke University, Durham, NC, USA.
| | - Naiomi Jamal
- Department of Family Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jennifer S Smith
- Department of Epidemiology, Gillings School of Global Public Health and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Doreen Schulze
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Pam Michelow
- Cytology Unit, National Health Laboratory Service and Department of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Simon Levin
- Right to Care, Johannesburg, South Africa; Department of Obstetrics and Gynecology, Rahima Moosa Mother and Child Hospital, University of Witwatersrand, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; Right to Care, Johannesburg, South Africa
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Vogt SL, Gravitt PE, Martinson NA, Hoffmann J, D'Souza G. Concordant Oral-Genital HPV Infection in South Africa Couples: Evidence for Transmission. Front Oncol 2013; 3:303. [PMID: 24377087 PMCID: PMC3860183 DOI: 10.3389/fonc.2013.00303] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2013] [Accepted: 11/28/2013] [Indexed: 02/03/2023] Open
Abstract
Objective: Cervical cancer is a leading cause of cancer mortality in South Africa. However, little is known about oral human papillomavirus (HPV) infection in high human immunodeficiency virus (HIV) seroprevalence settings. Method: Thirty-four adult heterosexual couples attending an HIV testing center in Soweto, South Africa were enrolled. Each participant provided an oral rinse sample and genital swab, which were tested for 37 types of HPV DNA, and completed a risk behavior survey. Results: Median age was 31 years and 9% (3/34) of men and 29% (10/34) of women enrolled tested HIV-positive; median CD4 count was 437 cells/mm3. Oral HPV prevalence was similar in women and men (12 vs. 18%, p = 0.48), and was non-significantly higher in HIV-infected vs. HIV-uninfected (23 vs. 13%, p = 0.34) subjects. Most men (82%) and women (84%) reported ever performing oral sex. Median number of lifetime sexual partners was “2–5” while median number of lifetime oral sex partners was 1. Oncogenic HPV subtypes were detected in 4% of oral, 26% of penile, and 74% of vaginal samples, including HPV16 in 1, 12, and 21% of these samples respectively. Genital HPV prevalence was significantly higher than oral HPV prevalence (75 vs. 15%, p ≤ 0.001). Thirty-five percent of couples (12/34) had at least one type-specific concordant vaginal-penile HPV infection but only one of nine couples with oral HPV had concordant oral–oral infection. However, 67% (4/6) of men and 25% (1/4) of women with oral HPV infection had partners with concordant genital HPV infection. Implications and Impact: Oral–oral HPV concordance between couples is low, but oral-genital and genital–genital HPV concordance is higher, including concordance of male oral HPV infection with their partners’ vaginal HPV infection. This data is consistent with possible transmission of vaginal HPV infection to the oral cavity of sexual partners performing oral sex.
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Affiliation(s)
- Samantha L Vogt
- Department of Internal Medicine, University of Pittsburgh Medical Center , Pittsburgh, PA , USA
| | - Patti E Gravitt
- Department of Epidemiology, Johns Hopkins School of Public Health , Baltimore, MD , USA
| | - Neil A Martinson
- Perinatal HIV Research Unit, University of Witwatersrand , Johannesburg , South Africa ; Johns Hopkins University School of Medicine , Baltimore, MD , USA
| | | | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins School of Public Health , Baltimore, MD , USA
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Comparing Papanicolau smear, visual inspection with acetic acid and human papillomavirus cervical cancer screening methods among HIV-positive women by immune status and antiretroviral therapy. AIDS 2013; 27:2909-19. [PMID: 23842133 DOI: 10.1097/01.aids.0000432472.92120.1b] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A rigorous comparison of cervical cancer screening methods utilizing data on immune status, antiretroviral therapy (ART) and colposcopy-directed biopsy has not been performed among HIV-positive women. METHODS Between June and November 2009, 500 HIV-positive women were enrolled at an HIV treatment clinic in Nairobi, Kenya, and underwent Papanicolau (Pap) smear, visual inspection with acetic acid (VIA), human papillomavirus (HPV) and colposcopy-directed biopsy (gold standard). Positive Pap smear (ASCUS+, LSIL+, HSIL+), VIA, HPV and their combinations were compared with CIN2/3+. Sensitivity, specificity and AUC (sensitivity and 1-specificity) were compared using pairwise tests and multivariate logistic regression models that included age, CD4⁺ cell count and ART duration. RESULTS Of 500 enrolled, 498 samples were collected. On histology, there were 172 (35%) normal, 186 (37%) CIN1, 66 (13%) CIN2, 47 (9%) CIN3 and 27 (5%) indeterminate. Pap (ASCUS+) was the most sensitive screening method (92.7%), combination of both Pap (HSIL+) and VIA positive was the most specific (99.1%) and Pap (HSIL+) had the highest AUC (0.85). In multivariate analyses, CD4⁺ cell count of 350 cells/μl or less was associated with decreased HPV specificity (P = 0.002); ART duration of less than 2 years was associated with decreased HPV (P = 0.01) and VIA (P = 0.03) specificity; and age less than 40 years was associated with increased VIA sensitivity (P < 0.001) and decreased HPV specificity (P = 0.005). CONCLUSION Pap smear is a robust test among HIV-positive women regardless of immune status or ART duration. Results should be cautiously interpreted when using HPV among those younger, immunosuppressed or on ART less than 2 years, and when using VIA among those aged 40 years or more.
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Hank E, Hoque ME, Zungu L. Cervical precancerous lesions and cancer among patients in the gynaecology outpatient department at a tertiary hospital in South Africa. Asian Pac J Cancer Prev 2013; 14:4903-6. [PMID: 24083765 DOI: 10.7314/apjcp.2013.14.8.4903] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to determine proportional rates of cervical precancerous lesions and cancer, and associations with socio-demographic variables, HIV status, and CD4 cell count. MATERIALS AND METHODS A retrospective comparative study was conducted targeting the medical records of all women over age 18 that were diagnosed histologically through colposcopy with cervical precancerous lesions and cancer from 1 December 2011 to 30 November 2012. RESULTS A total of 313 patient records were used for data analysis. The average age was 39.1 (SD=2.04) years. More than a third (37.1%) of the patients had CIN III or cervical cancer. There was a significant association between age, CD4 cell count, HIV status, and cervical lesions (p<0.05). Age was found to be an influential predictor of cervical lesions (OR=0.67, 95%CI: 0.46-0.98). CONCLUSIONS There exists an association between age and cervical lesions, with presentation of cervical precancerous lesions and cervical cancer at a younger age among HIV reactive patients. The National Guidelines should be brought in line with the National HIV Counseling and Testing Policy to offer Pap smears to all sexually active women that test HIV reactive during routine HIV Testing.
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Affiliation(s)
- Edward Hank
- Clinical Manager, Rahima Moosa Hospital, Johannesburg, South Africa E-mail : ,
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Katz IT, Nkala B, Dietrich J, Wallace M, Bekker LG, Pollenz K, Bogart LM, Wright AA, Tsai AC, Bangsberg DR, Gray GE. A qualitative analysis of factors influencing HPV vaccine uptake in Soweto, South Africa among adolescents and their caregivers. PLoS One 2013; 8:e72094. [PMID: 24023613 PMCID: PMC3758285 DOI: 10.1371/journal.pone.0072094] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 07/11/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In South Africa, the prevalence of oncogenic Human Papillomavirus (HPV) may be as high as 64%, and cervical cancer is the leading cause of cancer-related death among women. The development of efficacious prophylactic vaccines has provided an opportunity for primary prevention. Given the importance of psycho-social forces in vaccine uptake, we sought to elucidate factors influencing HPV vaccination among a sample of low-income South African adolescents receiving the vaccine for the first time in Soweto. METHODS The HPV vaccine was introduced to adolescents in low-income townships throughout South Africa as part of a nationwide trial to understand adolescent involvement in future vaccine research targeting human immunodeficiency virus (HIV). We performed in-depth semi-structured interviews with purposively-sampled adolescents and their care providers to understand what forces shaped HPV vaccine uptake. Interviews were recorded, transcribed, translated, and examined using thematic analysis. RESULTS Of 224 adolescents recruited, 201 initiated the vaccine; 192 (95.5%) received a second immunization; and 164 (81.6%) completed three doses. In our qualitative study of 39 adolescent-caregiver dyads, we found that factors driving vaccine uptake reflected a socio-cultural backdrop of high HIV endemnicity, sexual violence, poverty, and an abundance of female-headed households. Adolescents exercised a high level of autonomy and often initiated decision-making. Healthcare providers and peers provided support and guidance that was absent at home. The impact of the HIV epidemic on decision-making was substantial, leading participants to mistakenly conflate HPV and HIV. CONCLUSIONS In a setting of perceived rampant sexual violence and epidemic levels of HIV, adolescents and caregivers sought to decrease harm by seeking a vaccine targeting a sexually transmitted infection (STI). Despite careful consenting, there was confusion regarding the vaccine's target. Future interventions promoting STI vaccines will need to provide substantial information for participants, particularly adolescents who may exercise a significant level of autonomy in decision-making.
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Affiliation(s)
- Ingrid T. Katz
- Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, United States of America
| | - Busisiwe Nkala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Janan Dietrich
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Melissa Wallace
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathryn Pollenz
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Laura M. Bogart
- Harvard Medical School, Boston, Massachusetts, United States of America
- Children’s Hospital Boston, Boston, Massachusetts, United States of America
| | - Alexi A. Wright
- Harvard Medical School, Boston, Massachusetts, United States of America
- Dana Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Alexander C. Tsai
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, United States of America
| | - David R. Bangsberg
- Harvard Medical School, Boston, Massachusetts, United States of America
- Massachusetts General Hospital Center for Global Health, Boston, Massachusetts, United States of America
- Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Boston, Massachusetts, United States of America
| | - Glenda E. Gray
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
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Denslow SA, Rositch AF, Firnhaber C, Ting J, Smith JS. Incidence and progression of cervical lesions in women with HIV: a systematic global review. Int J STD AIDS 2013; 25:163-77. [PMID: 24216030 DOI: 10.1177/0956462413491735] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Global data on cervical lesion incidence and progression in HIV-positive women are essential for understanding the natural history of cervical neoplasia and informing screening policy. A systematic review was performed summarizing the incidence and progression of cervical lesions in HIV-positive women. Of 5882 HIV-positive women from 15 studies, incidence ranged from 4.9 to 21.1 cases per 100 woman-years for any cervical lesion and 0.4 to 8.8 cases per 100 woman-years for high-grade cervical lesions. HIV-positive women showed a median three-fold higher incidence of cervical lesions compared to HIV-negative women. Of 1099 HIV-positive women from 11 studies, progression from low- to high-grade lesions ranged from 1.2 to 26.2 cases per 100 woman-years. Both incidence and progression rates increased with lower CD4 counts. The effect of antiretroviral therapy on the natural history of cervical neoplasia remains unclear. HIV-positive women have higher incidence and progression of cervical neoplasia. Cervical cancer screening should be integrated into HIV treatment programmes.
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Affiliation(s)
- Sheri A Denslow
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, USA
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Cytotoxic effect of efavirenz is selective against cancer cells and associated with the cannabinoid system. AIDS 2013; 27:2031-40. [PMID: 23612009 DOI: 10.1097/qad.0b013e3283625444] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recently, a regression of precancerous lesions in HIV-1-infected patients after initiation of HAART was reported. Nonnucleoside reverse transcriptase inhibitors (NNRTIs) as efavirenz (EFV) might be mediators of this effect, as they are known to have a cytotoxic effect on tumour cells. A potential mechanism involved in this effect may be the activation of the cannabinoid receptor to mediate tumour toxicity. METHODS Several tumour-derived and fibroblast cell lines were studied. Cytotoxicity of EFV was evaluated by Annexin-Pi staining. The expression of the cannabinoid receptors CB1, CB2 and GPR55 was analysed by western blot, quantitative reverse transcriptase (qRT-PCR) and fluorescence activated cell sorting. The influence of the cannabinoid agonists and antagonists on the effects of EFV was investigated. Furthermore, the effect of EFV on the phosphorylation state of the growth factors Erk, Akt and the tumour suppressor protein p53 was tested. RESULTS EFV revealed a selective cytotoxic effect on several tumour cell lines, whereas primary fibroblasts were not affected. The cytotoxic effect was associated with the expression of CB1. The combination of EFV with cannabinoid agonists showed an increase in toxicity. The phosphorylation state of Erk and Akt was not affected by EFV, whereas p53 showed an increased phosphorylation. CONCLUSION EFV has a selective cytotoxic effect on several tumour cells. Furthermore, EFV led to an activating phosphorylation of the tumour suppressor protein p53 going in line with earlier reports that EFV may be antitumourigenic and a potential cytostatic drug. The observed synergistic effect with cannabinoid agonists implicates an involvement of the cannabinoid system.
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42
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Cervical cancer screening in high- and low-resource countries: implications and new developments. Obstet Gynecol Surv 2013; 67:658-67. [PMID: 23112073 DOI: 10.1097/ogx.0b013e3182732375] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The implementation of cytology-based screening programs for precancerous lesions of the cervix has decreased the incidence of and mortality from cervical cancer in much of the developed world. Countries without the resources to install such frequent and laboratory-dependent screening programs have more and more options at their disposal. A screening program based on cytology analysis requires too much training, infrastructure, and repeated screening to be feasible. Visual inspection with acetic acid, often used throughout the world, is inexpensive and both sensitive and specific, but it lacks reproducibility. Although human papillomavirus (HPV) testing is too expensive for widespread use, its negative predictive value and sensitivity make it a promising method of screening. Utilizing HPV vaccines as a primary mode of prevention may not be financially feasible and does not obviate the need for screening. Cervical cancer has been considered an AIDS-defining illness, with HPV and HIV often coexisting, and screening methods have been shown to be as reliable for women with HIV as those without. Ultimately, the most clinically effective and cost-effective methods for reducing cervical cancer incidence are those that limit the number of visits that women are required to attend. Providing immediate cryotherapy for those with a positive screen, whether by visual inspection or HPV testing, is promising to have quite an impact, although the type of program implemented will depend on the needs and expectations of each country.
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Belhadj H, Rasanathan JJK, Denny L, Broutet N. Sexual and reproductive health and HIV services: integrating HIV/AIDS and cervical cancer prevention and control. Int J Gynaecol Obstet 2013; 121 Suppl 1:S29-34. [PMID: 23477703 DOI: 10.1016/j.ijgo.2013.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
People living with HIV are at an increased risk of acquiring HPV and of developing evolutive cervical cancers (women) and penile and anal cancers (men). Low-cost screening-visual inspection with acetic acid, HPV DNA diagnostics and primary care level treatment, cryotherapy for cervical intraepithelial neoplasia (CIN 2), and primary prevention through HPV vaccination of girls aged 9-13 years-makes the goal of eliminating cervical cancer possible in the long term. Integration of cervical cancer screening and treatment into a sexual and reproductive health service package raises programmatic questions and calls for a continuum of care. The latter is only possible when adequate cytopathology skills and treatment for advanced cancer conditions are available. The present paper highlights the role of member societies of the International Federation of Gynecology and Obstetrics (FIGO) in developing the base for an integrated package that responds to women's sexual and reproductive health needs.
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Zeier MD, Nachega JB, Van Der Merwe FH, Eshun-Wilson I, Van Schalkwyk M, La Grange M, Mason D, Louw M, Botha MH. Impact of timing of antiretroviral therapy initiation on survival of cervical squamous intraepithelial lesions: a cohort analysis from South Africa. Int J STD AIDS 2012; 23:890-6. [DOI: 10.1258/ijsa.2012.012040] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
To determine factors that influence excision treatment outcome and recurrence of cervical squamous intraepithelial lesions (SIL) in women living with HIV infection, we analysed 1848 women who underwent excision treatment of cervical SIL at Tygerberg Hospital, Cape Town, South Africa. We compared treatment failure defined as presence of cervical intraepithelial neoplasia (CIN) I (presence of CIN I or higher at first follow-up after excision treatment) and post-excision recurrence of lesions (at one year or later) between women of HIV-positive, -negative or unknown status and examined factors associated with excision treatment outcome and recurrence. HIV-infected women experienced higher treatment failure than uninfected women (53.8% versus 26.9%, P< 0.001). At treatment failure, more HIV-infected women had low-grade squamous intraepithelial lesion (LSIL) compared with uninfected women (64.9% versus 37.3%, P < 0.001). Treatment failure did not differ with the type of excision used in HIV-infected women. HIV-infected women were more likely to experience recurrence of lesions after excision treatment than uninfected women (hazard ratio 1.95, 95% confidence interval [CI] 1.59-2.39; P < 0.001). Antiretroviral therapy (ART) initiated before excision biopsy had a strong protective effect against recurrence (hazard ratio 0.70, 95% CI 0.55-0.89; P = 0.006). Our data suggest that women with cervical SIL initiated on ART earlier may be expected to have better long-term excision treatment outcome. Close follow-up should be maintained after cervical excision treatment, especially in a setting of high HIV prevalence.
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Affiliation(s)
- M D Zeier
- Department of Medicine and Centre for Infectious Diseases (CID)
| | - J B Nachega
- Department of Medicine and Centre for Infectious Diseases (CID)
- Department of International Health, Stellenbosch University, Cape Town, South Africa
- Department of Epidemiology, Baltimore, MD, USA
| | | | - I Eshun-Wilson
- Department of Medicine and Centre for Infectious Diseases (CID)
| | - M Van Schalkwyk
- Department of Medicine and Centre for Infectious Diseases (CID)
| | - M La Grange
- Department of Medicine and Centre for Infectious Diseases (CID)
| | | | - M Louw
- Department of Anatomical Pathology, Stellenbosch University, Faculty of Health Sciences, Cape Town, South Africa
| | - M H Botha
- Department of International Health, Stellenbosch University, Cape Town, South Africa
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Increased regression and decreased incidence of human papillomavirus-related cervical lesions among HIV-infected women on HAART. AIDS 2012; 26:1645-52. [PMID: 22555167 DOI: 10.1097/qad.0b013e32835536a3] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To determine the impact of HAART on incidence, regression, and progression of cytopathological abnormalities in HIV-infected women. DESIGN Prospective cohort. METHODS HIV-infected women (N=1123) from Soweto, South Africa underwent serial cervical smears that were analyzed and reported using the Bethesda System. The results of HAART and non-HAART users were compared using two statistical approaches: a survival analysis assessing risk of incident smear abnormality among women with baseline normal smear results; and analysis with marginal models assessing for an association between HAART use and likelihood of regression/progression in consecutive smears. RESULTS After multivariate survival analysis, women using HAART with a normal baseline smear were 38% less likely to have an incident smear abnormality during follow-up than nonusers [confidence interval (CI) 0.42-0.91; P=0.01]. Multivariate marginal models analysis identified a significantly increased likelihood (odds ratio 2.61; CI 1.75-3.89; P<0.0001) of regression of cervical lesions among women on HAART. CONCLUSION Our large prospective cohort study adds significant weight to the side of the balance of clinical research supporting the positive impact of HAART on the natural history of human papillomavirus-related cervical disease in HIV-infected women.
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Albert SO, Oguntayo OA, Samaila MOA. Comparative study of visual inspection of the cervix using acetic acid (VIA) and Papanicolaou (Pap) smears for cervical cancer screening. Ecancermedicalscience 2012; 6:262. [PMID: 22855689 PMCID: PMC3408898 DOI: 10.3332/ecancer.2012.262] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Indexed: 11/30/2022] Open
Abstract
This article is a comparative study of two screening methods for pre-invasive lesions of the cervix. The Papanicolaou (Pap) smear, an old and tested screening method, is compared with the findings from visual inspection of the cervix following acetic acid (VIA) wash. VIA is a new screening method being advocated by the World Health Organization as an alternative to Pap smear in low-resource settings.
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Affiliation(s)
- SO Albert
- Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Zaria, Nigeria
| | - OA Oguntayo
- Department of Obstetrics and Gynaecology, ABU Teaching Hospital, Zaria, Nigeria
| | - MOA Samaila
- Department of Pathology, ABU Teaching Hospital, Zaria, Nigeria
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Progression and Persistence of Low-Grade Cervical Squamous Intraepithelial Lesions in Women Living With Human Immunodeficiency Virus. J Low Genit Tract Dis 2012; 16:243-50. [DOI: 10.1097/lgt.0b013e3182403d18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Firnhaber C, Westreich D, Schulze D, Williams S, Siminya M, Michelow P, Levin S, Faesen M, Smith JS. Highly active antiretroviral therapy and cervical dysplasia in HIV-positive women in South Africa. J Int AIDS Soc 2012; 15:17382. [PMID: 22713259 PMCID: PMC3499783 DOI: 10.7448/ias.15.2.17382] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 01/15/2012] [Accepted: 02/27/2012] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The risk of squamous intra-epithelial lesions (SIL) is higher in HIV-positive women. As these women begin to live longer due to highly active antiretroviral therapy (HAART), their risk of cervical cancer may increase. Few data exist regarding the effect of HAART on the incidence and progression of SIL in HIV-positive African women. The aim of this study was to evaluate the effect of HAART on the incidence and progression of SIL in HIV-positive women in South Africa. METHODS A prospective observational study of HIV-seropositive women was conducted over 5 years in an HIV treatment clinic in Johannesburg, South Africa. The participants consisted of 601 women on and off HAART who had repeat Pap smears greater than 6 months apart. The effect of HAART use on incidence and progression rates of SIL was determined using multivariate Poisson regression to obtain incidence rate ratios (IRRs), adjusted for age, CD4 count and other potential confounders. RESULTS Median follow-up time was 445 days (inter-quartile range 383, 671). The crude rate of incidence of any SIL was 15.9 episodes (95% confidence limit (CL) 12.7, 19.9) per 100 person-years; the crude rate of all progression of cervical dysplasia among women was 13.5 episodes (95% CL 11.3, 16.1) per 100 person-years. HAART use was associated with a robust reduction in the rate of incidence and progression of cervical lesions, adjusted IRR=0.55 (95% CL 0.37, 0.80). Sensitivity analyses confirmed this main association held for incidence and progression when they were considered separately, and that the result was not dependent on the length of HAART exposure. CONCLUSION HAART use was associated with a reduction in the rate of both incidence and progression of cervical lesions among HIV-positive women.
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Affiliation(s)
- Cynthia Firnhaber
- Faculty of Health Science Center, Department of Medicine, Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa.
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Ritonavir or saquinavir impairs the invasion of cervical intraepithelial neoplasia cells via a reduction of MMP expression and activity. AIDS 2012; 26:909-19. [PMID: 22313963 DOI: 10.1097/qad.0b013e328351f7a5] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE AND DESIGN Treatment of human immunodeficiency virus (HIV)-infected women with the highly active antiretroviral therapy (HAART) has reduced the onset of uterine cervical intraepithelial neoplasia (CIN), and halted its progression to cervical carcinoma. We and others demonstrated that the HIV protease inhibitors (HIV-PIs) used in HAART can exert direct antitumour activities also in HIV-free preclinical or clinical models. As uterine cervical carcinoma is a leading cause of death in women independently of HIV infection, herein we assessed the impact of therapeutic concentrations of HIV-PIs including indinavir (IDV), saquinavir (SQV) or ritonavir (RTV) on cells obtained from CIN or cervical carcinoma lesions of HIV-negative women. METHODS HIV-PI effects were evaluated by cell invasion, growth or toxicity assays, and by RNA, protein or zymogram analyses. RESULTS Both SQV and RTV inhibited CIN cell invasion, and this was paralleled by a reduced expression and proteolytic activity of the matrix metalloproteinase (MMP)-2 and 9 in treated cells. SQV and RTV also reduced CIN cell growth rate, but did not affect the invasion or growth of cells derived from highly progressed cervical carcinoma. CONCLUSION As MMP-2 and MMP-9 have a key role in CIN evolution into cervical carcinoma, these results support the use of SQV or RTV for the block of CIN clinical progression in either HIV-infected or uninfected patients.
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White HL, Mulambia C, Sinkala M, Mwanahamuntu MH, Parham GP, Moneyham L, Grimley DM, Chamot E. 'Worse than HIV' or 'not as serious as other diseases'? Conceptualization of cervical cancer among newly screened women in Zambia. Soc Sci Med 2012; 74:1486-93. [PMID: 22459188 DOI: 10.1016/j.socscimed.2012.01.028] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 01/17/2012] [Accepted: 01/19/2012] [Indexed: 01/13/2023]
Abstract
Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based "see and treat" cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.
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Affiliation(s)
- Heather L White
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA
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