Intra-epithelial and invasive cervical neoplasia during HIV infection

Molecular epidemiology of human papillomavirus among HIV infected women in developing countries: systematic review and meta-analysis

Background

Although, there is a variable burden of human papillomavirus (HPV) in women infected with HIV in developing countries, there are few studies that attempted to surmise such variable evidences. This review aimed to estimate the pooled prevalence of HPV genotype distribution and risk factors contributing to HPV infection among women infected with HIV in low- and middle-income countries.

Methods

We conducted a systematic review and meta-analysis of studies conducted in developing countries and reported HPV prevalence. We searched electronic databases: PubMed/Medline, SCOPUS, ScienceDirect, Excerpta Medical Database from Elsevier, Web of science, Cumulative Index of Nursing and allied Health Sciences and Google scholar databases to retrieve primary studies published in English language till 11th August 2019. We used random-effects model to estimate the pooled prevalence of HPV genotypes, and funnel plot to assess publication bias. The registration number of this review study protocol is CRD42019123549.

Results

We included nineteen studies with a total of 8,175 participants in this review. The prevalence of HPV was extremely heterogeneous across the studies (χ²₌ 3782.80, p value < 0.001, I² = 99.6%). The estimated pooled prevalence of all HPV genotypes was 63.0% (95% CI: 48.0–78.0) while the pooled prevalence of high risk and low risk HPV genotypes were 51.0% (95% CI: 38.0–63.0) and 28.0% (95% CI: 12.0–43.0), respectively. The pooled prevalence of HPV genotype 16 was 20%, while genotype 18 and 52 were 15% and 13%, respectively. Different risk factors reported for HPV infection and the frequently reported were low CD4 count below 200 cells/mm³ and high HIV viral load.

Conclusion

The pooled prevalence of HPV among HIV infected women in low- and middle-income countries was considerable and the proportion of high risk HPV genotypes were high when compared with low risk genotypes. Therefore, it is essential for the HPV prevention program to prevent the double burden of HPV and HIV in women.

Cervical cancer in Ethiopia - predictors of advanced stage and prolonged time to diagnosis

Introduction

In Ethiopia, most cervical cancer patients present at advanced cancer stages, long time after they experience first symptoms. We investigated possible predictors of long time spans between symptom onset and pathologic diagnosis (patient intervals). We also aimed to seek out predictors for advanced cancer stage diagnosis.

Methods

We conducted a retrospective cohort study among 1575 cervical cancer patients who were registered at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia between September 2008 and September 2012. Cox proportional hazards regression was used to find predictors of long patient intervals. Cumulative odds ordinal logistic regression was used to identify predictors of cancer stage at diagnosis.

Results

Median patient interval was 30 weeks, with the interval substantially longer in patients residing in rural than urban areas. Longer patient intervals were associated with more advanced cancer stages at pathologic diagnosis. HIV-positive women had an almost 1.5 times increased risk of diagnosis at a more advanced stage.

Conclusion

Cervical cancer patients are diagnosed after long time periods leading to advanced stages at diagnosis. Measures to raise awareness about cervical cancer, to increase screening and to shorten the time interval from recognition of symptoms to diagnosis are urgently needed.

HIV-1-infected cell-derived exosomes promote the growth and progression of cervical cancer

Background: Women infected with HIV are more likely to have aggressive cervical cancer, and patients with HIV infection are often more severely ill than those without HIV infection. However, the underlying mechanism for the progression of cervical cancer is not yet fully understood and requires further research.

Methods: Exosomes were isolated from cell culture supernatants using differential ultracentrifugation. Confirmation of exosome isolation was based upon identification by electron microscopy and NanoSight particle tracking analysis of the purified fraction. The function of exosomes derived from HIV-infected T-cells in cervical cancer was determined by CCK8 and Transwell invasion assays.

Results: Exosomal miR-155-5p derived from HIV-infected T-cells promotes the proliferation, migration and invasion of cervical cancer cells. Furthermore, we found that HIV-infected T-cells secrete exosomal miR-155-5p that directly targets ARID2 degradation, leading to activation of the NF-κB signaling pathway. MiR-155-5p promotes cervical cancer progression by secreting proinflammatory cytokines, including IL-6 and IL-8.

Conclusions: In conclusion, we demonstrate that intercellular crosstalk between HIV-infected T-cells and cervical cancer is mediated by exosomes from HIV-infected T-cells that contribute to the malignant progression of cervical cancer, providing potential targets for the prevention and treatment of HIV-associated cervical cancer.

Influence of HIV/AIDS on Cervical Cancer: A Retrospective Study From Tanzania

Purpose

Cervical cancer is the leading cause of cancer-related morbidity and mortality in women in Tanzania. Any impact of the HIV/AIDS epidemic on cervical precancerous lesions and invasive cervical cancer has a significant implication, as for any public health concern, especially in an area such as the Morogoro region in Tanzania, which has one of the highest rates of cervical cancer in the world.

Methods

A comparative retrospective study was performed of 536 women screened for cervical cancer by visual inspection methods at the Morogoro Regional Referral Hospital over a period of 3 years; the women were grouped according to their HIV status. The odds ratios (OR) with 95% CIs were estimated using χ² test and multivariate analysis. The test statistics were evaluated with a significance level of P < .05.

Results

The prevalence of precancerous lesions was 71.8% in HIV-positive women and 27.3% in HIV-seronegative women. Furthermore, the prevalence of extensive or large precancerous lesions was 40.5% in HIV-positive women and 13.5% in HIV-seronegative women. The prevalence of invasive cervical cancer was 8% in HIV-seronegative women and 11% in HIV-positive women. The risk factors for the cervical lesions were HIV-positive status (OR, 6.8; 95% CI, 4.2 to 11.2; P < .001) and being older than 30 years of age (OR, 11.99; 95% CI, 6.86 to 21.21; P < .001).

Conclusion

HIV/AIDS has a highly statistically significant association with (P < .001) and a great influence on the development of cervical precancerous lesions in HIV-positive women; however, its direct involvement in the progression to invasive cervical cancer, especially in this era of highly active antiretroviral therapy, is questionable.

MTHFR C677T polymorphism was an ethnicity-dependent risk factor for cervical cancer development: evidence based on a meta-analysis

INTRODUCTION

Many studies have studied the associations between 5, 10-methylene tetrahydrofolate reductase (MTHFR) polymorphisms and susceptibilities of cervical cancer and cervical intraepithelial neoplasia (CIN); however, the results were inconsistent. The aim of this study was to further assess the relationships by the method of meta-analysis.

MATERIALS AND METHODS

Two investigators independently searched the PubMed, Embase, Wang Fang (Chinese database) and CNKI (China National Knowledge Infrastructure), with latest update to July 1st, 2011. The pooled odds ratio (OR) and 95 % confidence interval (95 % CI) were used to assess the strength of the associations by using fixed- or random-effect model.

RESULTS

Ten case-control studies were included in this meta-analysis including a total of 1,803 cervical cancer or CIN cases and 2,363 controls. Pooled analyses showed that T allele of MTHFR C677T was significantly associated with increased CIN risk [OR (95 % CI): 1.28 (1.03-1.50) for CT vs. CC], especially for low-grade CIN risk. In addition, MTHFR C677T rather than A1298C polymorphism was associated with risk of cervical cancer. Stratifying analyses for ethnicity indicated that T allele of MTHFR C677T was associated with increased cervical cancer risk for Asian [OR (95 % CI): 1.56 (1.17-2.08) for TT vs. CC; 1.53 (1.19-1.96) for TT vs. C carriers] while decreased risk for Caucasian [OR (95 % CI): 0.63 (0.45-0.89) for TT vs. CC; 0.66 (0.56-0.79) for T carriers vs. CC].

CONCLUSION

This meta-analysis suggested that there was no association between MTHFR A1298C polymorphism and cervical cancer risk. However, MTHFR C677T was an ethnicity-dependent risk factor for cervical cancer occurrence. In addition, T allele of C677T was significantly associated with risk of low grade of CIN incidence. Because of modest limitations of our study, well-designed studies with large sample size were needed to confirm our findings in the future.

Stress Management, Depression and Immune Status in Lower Income Racial/Ethnic Minority Women Co-infected with HIV and HPV

The stress of co-infection with HIV and Human Papillomavirus (HPV), in race/ethnic minority women, may increase depression and immune decrements. Compromised immunity in HIV+ HPV+ women may increase the odds of cervical dysplasia. Thus we tested the efficacy of a 10-wk cognitive behavioral stress management (CBSM) group intervention and hypothesized that CBSM would decrease depression and improve immune status (CD4+ T-cells, natural killer [NK] cells). HIV+HPV+ women (n=71) completed the Beck Depression Inventory (BDI) and provided blood samples, were randomized to CBSM or a control condition, and were re-assessed post-intervention. Women in CBSM revealed less depression, greater NK cells, and marginally greater CD4+ T-cells post-intervention vs. controls. Stress management may improve mood and immunity in HIV+HPV+ lower income minority women.

Tissue expression of TGF-β1 in uterine cervical samples from HIV/AIDS patients

Case-control study based on the immunohistochemistry for TGF-β1 evaluation of cervical samples obtained from two groups of women: CIN/HIV- and CIN/HIV+. Eleven women infected with HIV and with a histopathological diagnosis of CIN were included. The control group consisted of 12 patients with CIN. Cervical tissue samples obtained from all patients were submitted to histopathology and semiquantitative analysis of immunostaining for TGF-β1 protein. In addition, the peripheral CD4+ cell count and viral load were evaluated in HIV + patients. Tissue expression of the cytokine was higher in the CIN/HIV+ group compared to control (p = 0.0023). In addition, higher TGF-β1 expression was observed in higher grade cervical lesions in the two groups. There was a trend toward a direct correlation between peripheral CD4+ T cell count and tissue TGF-β1, and toward an inverse correlation between viral load and cytokine expression. Thus, TGF-β1 was more marked in situations in which cervical lesions are known to present a more aggressive behavior, suggesting that this cytokine is involved in the pathogenesis of tumor growth in these lesions. Tissue expression of TGF-β1 is increased in cervical samples from HIV-infected women with CIN.

Invasive cervical cancer and human immunodeficiency virus (HIV) infection in KwaZulu-Natal, South Africa

The human immunodeficiency virus (HIV) can be expected to influence the course of disease and response to treatment of invasive carcinoma of the cervix. The extent and nature of this influence, however remains largely unknown. We therefore undertook a retrospective analysis of patients with carcinoma of the cervix at a tertiary referral centre in an African setting where HIV prevalence is high. There were 271 patients seen during a period of 1 year. Of these, 45 of the 206 tested were HIV infected (21.8%). The corresponding HIV prevalence for antenatal attendees was 38.7% in the region. The HIV-infected patients had lower mean haemoglobin levels and body mass indices than the HIV-non-infected women and were on average 13 years younger (p < 0.001), but otherwise did not differ with respect to demographics or disease parameters. They were, however, less likely to complete planned treatment. CD4 counts were below 200 in only 6 (21%) of 29 women tested. HIV-infected women in the African setting present with carcinoma of the cervix at a younger age, but the same disease stage as HIV-non-infected women, and without evidence of advanced immunocompromise. Circumstantial evidence is put forward by the study to suggest a more rapid decline in health and earlier demise for HIV-infected women with carcinoma of the cervix.

HIV Health Care Services For Mexican Migrants

This article reviews the literature on HIV/AIDS health care services for Mexican migrants in the United States. Because so little research has been conducted on Mexican migrants per se, we include literature on Latinos/Hispanics in the United States, because some characteristics may be shared. Furthermore, we focus special attention on data from California because it is on the front line of issues regarding health care for Mexican migrants. The types of health care services needed to improve on the quality of care provided to Mexican migrants living with HIV are highlighted, and recommendations are made for future interventions, research, and binational collaborations.

Pathology of the cervix: recent developments

In the UK, cervical carcinoma is still the eleventh most common cause of cancer in women--it comprises 2% of all female cancers, and accounts for 927 deaths in 2002 alone. The most effective treatments to date are surgery in the form of loop excision of the transformation zone (LLETZ) for pre-invasive disease, LLETZ or simple hysterectomy with laparoscopic pelvic lymphadenectomy for International Federation of Gynecology and Obstetrics (FIGO) Stages IA1 and IA2 microinvasive carcinomas, and Wertheim's hysterectomy or Coelio-Schauta for FIGO Stage IB disease along with concurrent chemoradiotherapy in patents with at least FIGO Stage IB disease. However, radical trachelectomy, which involves a radical excision of the cervix with simultaneous laparoscopic or extraperitoneal lymphadenectomy, may be used selectively in patients with up to FIGO Stage IB1 cancers, as this may preserve fertility in younger women. This paper briefly discusses the role of human papilloma viruses (HPV) and human immunodeficiency virus (HIV) in the development of cervical pre-cancer, and some of the improvements in the techniques used in the cervical carcinoma screening programme. In addition, the diagnosis, staging, spread and prognostic factors involved in invasive cervical carcinoma are mentioned. We will also discuss the role of immunohistochemistry in the diagnosis of invasive cervical carcinoma and recent advances in the molecular pathology of cervical carcinomas.

Squamous cell carcinoma of the uterine cervix in association with stage 0 chronic lymphocytic leukemia/small lymphocytic lymphoma

BACKGROUND

There have been many cases of multiple malignant neoplasms involving the female genital tract reported, but involvement by epithelial and hematologic malignancy is extremely rare.

CASE

A 52-year-old woman, who was followed for stage 0 chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), had developed invasive squamous cell carcinoma of the uterine cervix. Microscopic examination of the hysterectomy specimen disclosed invasive squamous cell carcinoma in the cervix and monotonous populations of small lymphoid cells with proliferation centers, which are consistent with CLL/SLL, in the cervix as well as parametrium. Thirty months after the initial diagnosis of CLL/SLL, the patient died with systemic dissemination of squamous cell carcinoma, but the CLL/SLL remained a local disease.

CONCLUSION

The clinical course of squamous cell carcinoma in this case appeared to be aggressive, but it was unclear whether the outcome was associated with an altered immune status due to the presence of concurrent CLL/SLL.

Pathologic aspects of AIDS malignancies

Since the emergence of the HIV pandemic, a close association between HIV infection and the development of a selected group of cancers has been acknowledged. The introduction of highly active antiretroviral therapy, however, has had a dramatic impact on the incidences of several AIDS-defining malignancies. This suggests the possibility of a direct and indirect role of HIV in HIV-related tumor genesis. The aim of this paper is to review the pathology of AIDS-related malignancies, taking into account the pathogenetic mechanisms and their potential for improving the treatment of these tumors.

Postmodern cancer: the role of human immunodeficiency virus in uterine cervical cancer

The association between cervical cancer and human papillomavirus (HPV) is well known, but its association with human immunodeficiency virus (HIV) is controversial. Coinfection with HPV and HIV is to be expected and recent epidemiological data from Africa show that cervical cancer is the most common AIDS defining neoplasm in women. Unlike other AIDS defining neoplasms, the occurrence of cervical cancer is not dependent on immune compromise. HIV alters the natural history of HPV infection, with decreased regression rates and more rapid progression to high grade and invasive lesions, which are refractory to treatment, requiring more stringent intervention and monitoring. The more aggressive behaviour is mirrored by a different molecular pathway. HIV associated cervical cancers are thought to progress through the microsatellite instability pathway, whereas HIV negative ones progress through loss of heterozygosity. Interaction is probably via viral proteins, with HIV proteins enhancing effectiveness of HPV proteins, and perhaps contributing to cell cycle disruption. Dysregulation of the cellular and humoral arms of the local and systemic immune systems may ensure disease progression. Furthermore, HPV infection may predispose to HIV infection and facilitate its progression.

Improving rates of cervical cancer screening and Pap smear follow-up for low-income women with limited health literacy

Adult literacy is an independent and important predictor of health behavior. In 1993, the National Adult Literacy Survey conducted by the U.S. Department of Education demonstrated that one-third of the U.S. population over age 16 (44 million adults) is functionally illiterate. Several studies link low health literacy to self-reported poor health status, poor health behavior, and inadequate knowledge about disease. Epidemiologic studies of cancer prevention have not detected strong racial and ethnic disparities in disease detection and progression, resulting in an emphasis on behavioral and intervention-based research. Low literacy presents a wide-reaching barrier to disease prevention that, unlike race/ethnicity, is potentially modifiable. Here, we explore the relationship between health literacy and health behaviors related to cervical cancer prevention in an effort to address concerns about low rates of screening and follow-up in vulnerable populations. Our goal is to improve our understanding of the health impact of low literacy among urban women and to inspire interventions that will promote disease prevention behaviors in this population, particularly with regard to cervical cancer.

Invasive cervical cancer and human immunodeficiency virus (HIV) infection: a South African perspective

The aim of this study was to compare the prevalence and presentation of cervical cancer in HIV-positive and HIV-negative women in our local population. Six hundred and seventy-two patients with cervical cancer presented to the gynecology oncology unit of King Edward VIII Hospital, South Africa. The HIV seroprevalence among these patients was 21%. There was an increase in the background prevalence of HIV infection (1.6-32.5%) as well as a quadrupling in the prevalence of HIV infection among patients with invasive cervical cancer (5-21%) over a 10-year period. The mean ages of the HIV-negative patients and HIV-positive patients were 55.2 and 39.8 years, respectively. Most of the HIV-positive patients were in the 30- to 40-year-old age group (51%), whereas the majority of patients who were HIV negative were in the 50- to 60-year-old age group (36%). The majority of patients, irrespective of HIV status, were more likely to have late stage disease than early stage disease. There was an increase in HIV infection in patients with both types of background prevalence and among patients with invasive cervical cancer. The mean age of HIV-positive patients was 15 years younger than that of the HIV-negative patients. The majority of patients, irrespective of HIV status, presented with late stage disease.

Acceptance of voluntary HIV testing and the prevalence of HIV infection in women with cervical neoplasia in Toronto

Over a 13-month period (1998-99), 661 adult women under the age of 50 years with a diagnosis of high grade squamous intraepithelial lesions (HSIL) or invasive cervical cancer in the previous 5 years and who were unaware of their HIV status were approached to participate in this study. After pretest counseling, patients completed a short questionnaire about risk factors for HIV infection, had blood samples drawn for HIV testing,and arranged a follow-up appointment for test results and post-test counseling. The acceptance rate for HIV testing was 73% (N = 432 with HSIL and N = 51 with invasive cervical cancer). Most women reported heterosexual intercourse as their only risk factor for HIV infection, with the majority (95.1%) reporting more than one lifetime sexual partner. Women who declined participation were significantly older (P < 0.01) than participants and nonwhites were more likely to decline (P < 0.001). None of the study participants had positive HIV test results (0/483; 95% CI, 0.00-0.009). Although HIV testing was accepted by most women following pretest counseling, there were no women who tested HIV-positive who were previously unaware of their status. Consequently we do not recommend routine HIV testing in this population.

[HIV infection and cervical cancer: a note of caution for clinicians and health planners]

BACKGROUND

To estimate the association between HIV infection and cervical intraepithelial neoplasia (CIN).

PATIENTS AND METHODS

Cross-sectional study based on data from 251 women from a Sexually Transmitted Diseases clinic. Patients with CIN were compared with those without CIN in terms of HIV infection and exposure to other risk factors, calculating the corresponding adjusted odds ratio (ORA) by logistic regression.

RESULTS

HIV infection (ORA = 7.5; CI 95%: 2.5-22.1), having previous cytologies with cellular changes associated with human papillomavirus infection (ORA = 3.6; CI 95%: 1.3-10.2) and history of condylomas (ORA = 3.2; CI 95%: 1.2-8.4) were associated with CIN.

CONCLUSIONS

The strong association observed between HIV and CIN, shows that it is necessary for health services planners and clinicians caring for HIV infected women to ensure that the latter receive the appropriate care to guarantee its early detection.

Cidofovir, a new approach for the treatment of cervix intraepithelial neoplasia grade III (CIN III)

Cervix intraepithelial neoplasia grade III (CIN III) is an intraepithelial proliferative process with different levels of severity depending on both the extension of the proliferation in the epithelium and the presence of cellular atypia. Human papillomavirus (HPV) has been clearly associated with such lesions. The results of a preliminary study are described on the local application of cidofovir, an acyclic nucleoside phosphonate derivative with broad-spectrum anti-DNA virus activity for the treatment of CIN III. Cidofovir 1% in gel was applied three times, every other day, on the cervix of each of 15 women with biopsy proven CIN III. Within 1 month after the start of treatment, the cervix was removed surgically. Histology and human papillomavirus polymerase chain reaction (HPV-PCR) were carried out. In 7 of the 15 patients the histology showed a complete response, whereas 5 patients had a partial response characterized by the persistence of CIN II-III lesions, 1 patient had a dysplasia of lower grade (CIN I), and 2 patients did not show differences in the histology. Complete response was confirmed by PCR in 4 of the 7 patients, with complete response histologically. Cidofovir was not toxic to the normal epithelium. Cidofovir 1% gel was able to inhibit partially or completely cervical dysplasia lesions after only three applications (every other day). This effect was specific and tissue other than the dysplastic epithelium was not affected by the treatment.

Infrared spectroscopic study of cervical smears in patients with HIV: implications for cervical carcinogenesis

Patients with HIV have an increased incidence of cervical cancer, necessitating increased surveillance. Infrared spectroscopy (IRS) has the potential of aiding the diagnosis of cervical neoplasia and also of providing clues into its pathogenesis. We studied by IRS cervical scrapings from 22 HIV-infected and 23 control women; 8 of the former and none of the latter had dysplasia. The infrared spectra followed three patterns, designated pattern I (similar to that previously associated with normal cervical samples), pattern II (intermediate between patterns I and III), and pattern III (associated with cervical neoplasia). Compared with HIV-negative controls, HIV-infected women had a higher prevalence of pattern III and a lower prevalence of pattern II; these differences were statistically significant (P = .015 by chi2 analysis). Similar spectroscopic changes were present even when only the cytologically normal samples from HIV-positive and HIV-negative women were analyzed. We speculate that these changes may reflect early structural changes associated with cervical neoplasia that are not detectable cytologically. The infrared spectra in the region 950 to 1,300 cm(-1) could not differentiate cervical samples from HIV-infected and uninfected patients. The potential practical applications of IRS in HIV cervical disease are discussed.

Audit of cervical screening and colposcopy in HIV-positive women at a central London teaching hospital

The purpose of this audit was to assess the prevalence of cervical pathology and clinical outcome in HIV-infected women as well as adherence to local screening guidelines. As there are no national screening guidelines for HIV-positive patients, recommendations vary widely. At St Stephen's Centre, these included annual cytology and a baseline colposcopy. We audited this recommendation by a clinical notes review using a computer database. Analysis was performed using Statistical Package for Social Sciences (SPSS). Two hundred and twenty-two patients were eligible for analysis, their mean age was 33.6 years, median CD4 count was 239 and median viral load was 7836 RNA copies. Cytology was undocumented in 72 women (32.4%), while overall 42 (28%) smears of the remaining 150 patients were abnormal: borderline 17.3%, mild dyskaryosis 4.6%, moderate dyskaryosis 4%, severe dyskaryosis 2%. The results were normal in 64% and unsatisfactory in 4.6%. Colposcopy was offered to 93 (42%) women who attended at least once in 71 cases (32%). Thirty-one women had biopsies taken (43.6% of all colposcopies). Twenty-four (77.4%) had a histology more severe than HPV and 15 (48.4%) more severe than cervical intraepithelial neoplasia (CIN)-1. Overall, 49.7% had management not complying with the guidelines. This audit led to a critical literature review and of local screening guidelines. A computer aided reminder program has now been installed and re-auditing of the management of HIV-positive women is planned.

Adherence to colposcopy among women with HIV infection

In the general population, nonadherence to the recommendation to have colposcopy in women with abnormal cytologic smears is estimated at 30% to 80%, but studies have failed to identify consistent risk factors for nonadherence. The purpose of this analysis is to assess adherence to colposcopy in a subset of participants in the Women's Interagency HIV Study (WIHS), an ongoing multisite longitudinal study of HIV infection in women in the United States and determine factors associated with nonadherence. Identification of such predictors would be useful in designing strategies to improve adherence in this group.

METHODS

Adherence to colposcopy was examined in a cohort of 462 women with, or at risk for, HIV infection with abnormal cervical cytology on entry into WIHS. Adherence was defined as having colposcopy done within 6 months of an abnormal cytology result.

RESULTS

Overall adherence to colposcopy was 65% (302 of 462). A multivariate logistic regression model revealed that the odds of adherence were significantly lower for the women who were HIV-infected (p = .011), current crack/cocaine users (p = .040), ever too ill to get medical care (p = .033), not recruited by WIHS study staff (p = .004), and less concerned about the care of their children (p = .037). Among HIV-seropositive women, low CD4 counts, high viral loads, and presence of AIDS-defining illness were not predictive of nonadherence.

DISCUSSION

Adherence to colposcopy among WIHS participants was at the upper limit of the reported range in the United States. Chemical dependency and domestic violence may negatively impact on colposcopy adherence whereas supportive study personnel, having health insurance, and concerns about raising one's children appear to be motivators for adherence to colposcopy in this study. HIV infection was a risk factor for nonadherence, but markers of advanced disease were not predictive of nonadherence.

AIDS-related malignancies

In the US over one million persons are currently infected with the HIV, over half a million have had AIDS, and over 300,000 have died from AIDS. Worldwide, it is estimated that more than 17 million people are currently infected with HIV, and over 1,200,000 cases of AIDS have been reported to the World Health Organization. By some estimates, up to 40% of patients with AIDS will ultimately develop some form of cancer. Non-Hodgkin's lymphoma, Kaposi's sarcoma and invasive cervical cancer have a higher incidence in persons with HIV infection and all three are AIDS-defining illnesses. In addition, several reports suggest that a number of other malignancies may occur at an increased incidence in persons with HIV infection, including squamous-cell carcinoma of the head, neck and anus, plasmacytoma, melanoma, small-cell lung cancer, basal-cell cancer, and germ-cell tumours. Clinicians should become familiar with HIV-related malignancies as their incidence is expected to further increase as more effective therapies for HIV and associated opportunistic infections allow patients to live longer in an advanced state of immunodeficiency. In the current article, we will review the clinical and therapeutic aspects of the most common AIDS-related malignancies including non-Hodgkin's and Hodgkin's lymphomas, Kaposi's sarcoma and anogenital epithelial neoplasias.