Incidence of cervical intraepithelial neoplasia in women infected with human immunodeficiency virus (HIV) with no evidence of disease at baseline: Results of a prospective cohort study with up to 6.4 years of follow-up from India

Can we increase the cervical cancer screening interval with an HPV test for women living with HIV? Results of a cohort study from Maharashtra, India

We are reporting (a) updated incidence of cervical intraepithelial neoplasia (CIN) among women who did not have colposcopic or histopathological disease at baseline and (b) disease outcomes among women treated for CIN and their follow-up HPV status; in a cohort of women living with HIV (WHIV). The median overall follow-up was 3.5 years (IQR 2.8-4.3). The incidence of any CIN and that of CIN 2 or worse disease was 16.7 and 7.0 per 1000 person-years of observation (PYO), respectively. Compared with women who were HPV negative at baseline, women who cleared HPV infection had 23.95 times increased risk of incident CIN 2 or worse lesions (95% CI 2.40-661.07). Women with persistent HPV infection had 138.18 times increased risk of CIN 2 or worse lesions (95% CI 20.30-3300.22). Complete disease regression was observed in 65.6% of the HPV positive women with high-grade CIN and were treated with thermal ablation but HPV persistence was seen in 44.8% of those with high-grade disease. Among those who did not have any disease at baseline and were also HPV negative, about 87% (95% CI 83.79-89.48) women remained HPV negative during consecutive HPV test/s with the median interval of 3.5 years. Long-term surveillance of WHIV treated for any CIN is necessary for the prevention of cervical cancer among them. Our study provides an early indication that the currently recommended screening interval of 3 to 5 years among WHIV may be extended to at least 5 years among HPV negative women. Increasing the screening interval can be cost saving and improve scalability among WHIV to support WHO's cervical cancer elimination initiative.

Persistence and clearance of high-risk human papillomavirus and cervical dysplasia at 1 year in women living with human immunodeficiency virus: a prospective cohort study

OBJECTIVE

Evaluate 1-year outcomes of cervical cancer screening and treatment using primary high-risk human papillomavirus (HPV) testing in women living with human immunodeficiency virus (HIV).

DESIGN

Prospective cohort study.

SETTING

HIV treatment centre in Botswana.

POPULATION

Women living with HIV.

METHODS

Participants underwent cervical cancer screening with high-risk HPV testing and triage evaluation at baseline and 1-year follow up. Excisional treatment was offered as indicated. Histopathology was the reference standard.

MAIN OUTCOME MEASURES

Persistence, clearance and incidence of high-risk HPV infection; and persistence, progression, regression, cure and incidence of cervical dysplasia.

RESULTS

Among 300 women screened at baseline, 237 attended follow up (79%). High-risk HPV positivity significantly decreased from 28% at baseline to 20% at 1 year (P = 0.02). High-risk HPV persistence was 46% and clearance was 54%; incidence was high at 9%. Prevalence of cervical intraepithelial neoplasia Grade 2 (CIN2) or higher was most common in participants with incident high-risk HPV (53%). CIN2 or higher was also common in those with persistent high-risk HPV (32%) and even in those who cleared high-risk HPV (30%). Of the high-risk HPV-positive participants at baseline with <CIN2, 40% progressed to CIN2 or higher at follow up.

CONCLUSION

The high incidence of high-risk HPV and high-grade cervical dysplasia in women living with HIV after one round of high-risk HPV-based screening and treatment raises concern about the rate of progression of high-risk HPV infection to dysplasia. Persistent disease is common. Caution in spacing cervical cancer screening intervals using high-risk HPV testing in women living with HIV is warranted.

TWEETABLE ABSTRACT

High incidence and persistence of HPV and CIN2+ in women living with HIV 1 year after screening and treatment.

Current Status and Future Perspectives of Molecular Prevention Strategies for Cervical Cancers

Cervical cancer continues to be a global health problem; despite the potential for prevention through organised screening programmes that can detect and treat pre-cancerous lesions and also more recently, the availability of HPV (Human Papilloma Virus) vaccines. While routine screening with Pap smear testing has reduced the burden of cervical cancer in the high-income countries, the implementation of organised Pap-based screening programmes has not been found feasible in low-resource settings due to a lack of health care delivery infrastructure and limited health budgets. The well-established causal relationship between cervical cancer development and high-risk-HPV (HR-HPV) infection and the subsequent appreciation of the greater sensitivity of HPV testing over Pap smear cytology eventually lead to HPV testing being incorporated in the primary cervical cancer prevention programmes. An organised cervical cancer screening programme incorporating HR-HPV testing and HPV vaccine administration are currently considered to be the two major interventions for a comprehensive cervical cancer control programme worldwide. However, there are concerns that the requirement of a sophisticated infrastructure with its associated costs may make cervical cancer screening using molecular prevention by HPV testing impracticable to be implemented, especially in resource-poor, low-income countries. Visual Inspection with Acetic acid (VIA) represents one of the alternative methods for cervical cancer screening proposed for the countries with low- to middle-income resources and has gained popularity in India following the successful completion of two randomised controlled trials, but this method but has low sensitivity to detect cervical pre-cancers. More recently, the cost-effectiveness analysis of many studies including randomised controlled trials, even from the low-resource settings, has found that HPV testing is followed by treatment for HPV-positive women to be an effective and cost-effective screening strategy as compared to other screening methods including VIA. The incorporation of self-sampling and HPV testing by partial genotyping has the potential to significantly add to the effectiveness and the cost-effectiveness. The current status and future perspectives of molecular prevention strategies for cervical cancer prevention is further discussed.

HIV and development of epithelial cell abnormalities in women with prior normal cervical cytology in Nigeria

BACKGROUND

HIV-associated cellular immune dysfunction has been linked to higher risk of cervical dysplasia and cancer in HIV infected women. We sought to understand the relationship between HIV and development of epithelial cell abnormalities (ECA) at follow-up in women with prior normal cervical cytology (NCC).

METHODS

Retrospective cohort analysis of women who received a Pap test at the Operation Stop Cervical Cancer Unit in Jos, Nigeria over a 10-year period (2006-2016). We analyzed the data of women with NCC at first Pap who had at least one follow-up cytology result for time-to-detection of ECA. We determined follow-up time in years from date of first NCC to date of first ECA report or date of last NCC follow up report with censoring at last follow-up date or December 31st, 2016 whichever came first. The primary outcome was development of any ECA as defined by the Bethesda 2001 reporting system. We identified demographic and clinical factors associated with incident ECA using multivariable Cox regression.

RESULTS

A total of 1599 women were eligible for this analysis. Overall, 3.7% (57/1556) of women reported being HIV infected. The median age at first Pap was 39 years (IQR; 33-45). The HIV infected women were younger (36.3 ± 8.1) compared to those uninfected (39.3 ± 6.6), p = 0.005. After an accrued follow-up time of 3809 person-years (PYs), 243 women (15%) had an ECA with an event rate of 6.38 per 100 PYs. Women ≥35 years at first Pap were more likely to have an ECA compared to those < 35 years (7.5 per 100 PYs vs 3.8 per 100 PYs, HR = 1.96; 95% CI: 1.4, 2.8). HIV status was not significantly associated with developing ECA in either unadjusted (7.4 per 100 PYs vs 6.4 per 100 PYs, HR = 1.17; 95% CI: 0.53, 2.3) or adjusted analyses (aHR = 1.78; 95% CI: 0.87, 3.65).

CONCLUSION

Women living with HIV and on successful antiretroviral treatment may not have a differential hazard in the development of ECA during follow up after a prior normal Pap. Offering a repeat CCS to women who are 35 years or older irrespective of HIV status is likely an effective strategy in resource limited settings.

HIV status, age at cervical Cancer screening and cervical cytology outcomes in an opportunistic screening setting in Nigeria: a 10-year Cross sectional data analysis

BACKGROUND

Invasive cervical cancer (ICC) is more prevalent in HIV infected women and occurs at younger median age than in HIV negative women. Organized cervical cancer screening (CCS) is presently lacking in Nigeria, and the age at CCS is not known in this population. We sought to examine the age at CCS, the cytology outcomes and whether outcomes differ by HIV infection status in an opportunistic screening setting.

METHODS

Cross-sectional analysis of data on a sample of women who had received a CCS in an opportunistic screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used logistic regression models to estimate the independent effect of patient-reported HIV and age at CCS and odds ratios for abnormal cytology outcomes adjusting for other covariates. We also assessed the correlation between median age at CCS and severity of abnormal cervical cytology outcomes. Statistical analyses were done on STATA version 14, College Station, Texas, USA.

RESULTS

In a sample of 14,088, the median age at CCS was 37 years (IQR; 30-45). For HIV infected women vs. uninfected women, CCS occurred at earlier ages (35.0 ± 7.4 vs 38.2 ± 10.2 years, p < 0.001). All women, regardless of HIV status, who completed at least 7 or more years of education were 1.27 to 3.51 times more likely to have CCS before age 35 than women with less education. The predictors of an abnormal cervical cytology outcome at CCS were: age at CCS ≥ 35 (aOR = 3.57; 95% CI: 2.74, 4.64), multiparity ≥5 (aOR = 1.27; 95% CI: 1.03, 1.56), and provider-referral (aOR = 1.34; 95% CI: 1.09, 1.64). Irrespective of reported HIV status, we found a positive correlation between median age at CCS and severity of cytology outcome.

DISCUSSION

The age at CCS in women who have utilized cervical cancer screening in the study population is relatively late compared to the recommended age by most guidelines from developed settings. Late age at CCS correlates positively with severity of abnormal cytology outcome irrespective of HIV status. More educated women are more likely to have CCS at early age and less likely to have underlying abnormal cytology outcomes.