Recrudescence of cervical dysplasia among women who are infected with the human immunodeficiency virus: a case-control analysis

Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study

INTRODUCTION

Cervical cancer continues to pose a major public health challenge in low-income countries. Cervical cancer screening programs enable early detection and effectively reduce the incidence of cervical cancer as well as late-stage diagnosis and mortality. However, screening uptake remains suboptimal in Uganda. This study assessed correlates of intention to screen for cervical cancer among women in the Kyotera district of Central Uganda.

METHODS

We analyzed cross-sectional data collected to determine the effectiveness of community audio towers (CATs) as a modality of health communication to support cervical cancer prevention. Women (n = 430) aged 21-60 years without a prior history of cervical cancer screening were surveyed about demographics, sources of health information and cervical cancer screening intentions in 2020. We used generalized linear modelling with modified Poisson regression and backwards variable elimination to identify adjusted prevalence ratios and 95% confidence intervals (CI) to determine factors associated with intention to screen for cervical cancer.

RESULTS

Half (50.2%) of the participants had intentions to screen for cervical cancer within twelve months and 26.5% had moderate knowledge about cervical cancer. Nearly half (46.0%) considered themselves at risk of cervical cancer. Compared to residents who primarily received their health information from social media and radio, participants who received health information primarily from CATs (aPR:0.64, 95% CI:0.52-0.80, p < 0.001) and TV (aPR:0.52, 95% CI:0.34-0.82, p = 0.005) had a lower prevalence of intention to screen for cervical cancer. The prevalence of intentions to screen for cervical cancer in twelve months was higher among those resided in town councils (aPR:1.44, 95% CI:1.12-1.86, p = 0.004) compared to rural areas, and higher among those who considered themselves to be at risk of cervical cancer (aPR:1.74, 95% CI:1.28-2.36, p < 0.001) compared to those who did not.

CONCLUSIONS

We found suboptimal prevalence of intentions to screen for cervical cancer among women in central Uganda. Additional research and implementation projects are needed to increase cervical cancer screening. Targeting risk perceptions and behavioral approaches to increase intentions could be effective in future intervention work. Based on urban-rural differences, additional work is needed to support equitable sharing of information to support cancer prevention messaging; CATs and TV may best help reach those with lower intentions to screen based on our research.

HPV and HIV Coinfection in Women from a Southeast Region of Romania-PICOPIV Study

Background and Objectives: Romania faces one of the highest cervical cancer burdens in Europe though it is a preventable cancer through population screening by cytology and human papillomavirus (HPV) detection. Also, it has one of the highest incidences of human immunodeficiency virus (HIV) infection. HPV and HIV coinfection are frequently encountered. The aim of study was to establish the prevalence of HPV infection among HIV-positive women in Southeast Region of Romania, to genotype high risk HPV types -and to correlate the results with clinical data and cytological cervical lesions. Materials and Methods: 40 HIV-positive women were screened for HPV types and for cytological cervical lesions. The findings were evaluated in correlation with CD4 cell counts, HIV viral load, age at first sexual intercourse, number of sexual partners, vaginal candidiasis, and Gardnerella using statistical methods. Results: 19/40 (47.5%) women were positive for HPV types, 63.15% infected with single HPV type and 36.85% with multiple HPV types. The most frequent types were type: 31 (42.1%), 56 (31.57%), 53 (15.78%). On cytology, 34 (85%) women were found with NILM of which 38.23% were HPV-positive. Fifteen percent of women had abnormal cytology (three ASC-US, three LSIL), and all of them were HPV-positive. Through analyzing the value of CD4 count, women with CD4 count ≤ 200 cells/μL were found to be significantly more likely to be infected with HPV; meanwhile there was no correlation between the detection of HPV types and HIV viral load. Candida or Gardnerella were more often associated with HIV-positive women with HPV, than in women without HPV. Conclusions: Infection with HPV types is common among HIV-positive women in the Southeast Region of Romania and it is associated with age at the beginning of sexual life, number of sexual partners, CD4 value, vaginal candidiasis, and Gardnerella infection.

Cervical cancer prevention and control in women living with human immunodeficiency virus

Despite being highly preventable, cervical cancer is the fourth most common cancer and cause of cancer death in women globally. In low-income countries, cervical cancer is often the leading cause of cancer-related morbidity and mortality. Women living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome are at a particularly high risk of cervical cancer because of an impaired immune response to human papillomavirus, the obligate cause of virtually all cervical cancers. Globally, approximately 1 in 20 cervical cancers is attributable to HIV; in sub-Saharan Africa, approximately 1 in 5 cervical cancers is due to HIV. Here, the authors provide a critical appraisal of the evidence to date on the impact of HIV disease on cervical cancer risk, describe key methodologic issues, and frame the key outstanding research questions, especially as they apply to ongoing global efforts for prevention and control of cervical cancer. Expanded efforts to integrate HIV care with cervical cancer prevention and control, and vice versa, could assist the global effort to eliminate cervical cancer as a public health problem.

Residual or Recurrent Precancerous Lesions After Treatment of Cervical Lesions in Human Immunodeficiency Virus-infected Women: A Systematic Review and Meta-analysis of Treatment Failure

BACKGROUND

Screening and treating premalignant cervical lesions (cervical intraepithelial neoplasia 2+ [CIN2+]) is an effective way to prevent cervical cancer, and recommendations exist for the monitoring of treatment success. Yet, there is no specific recommendation for human immunodeficiency virus (HIV)-infected women, who are at a known, increased risk of cervical cancer.

METHODS

A systematic review was performed by searching MEDLINE, EMBASE, and Web of Science for studies published from January 1980 through May 2018. Eligible studies described the prevalence of histologically- and/or cytologically-defined lesions in HIV-infected women at least 6 months post-treatment. The primary endpoint was treatment failure, defined as the presence of residual and/or recurrent high-grade CIN2+/high-grade squamous intraepithelial lesions post-treatment. The pooled prevalence in HIV-infected women and the odds ratios (ORs) for HIV-infected compared to HIV-uninfected women were estimated using random-effects models.

RESULTS

Among 40 eligible studies, the pooled prevalence of treatment failure in HIV-infected women was 21.4% (95% confidence interval [CI] 15.8-27.0). There was no significant difference in the treatment failure prevalence for cryotherapy (13.9%, 95% CI 6.1-21.6) versus loop electrosurgical excision procedure (13.8%, 95% CI 8.9-18.7; P = .9), but the treatment failure prevalence was significantly higher in women with positive (47.2%, 95% CI 22.0-74.0) than with negative (19.4%, 95% CI 11.8-30.2) excision margin (OR 3.4, 95% CI 1.5-7.7). Treatment failure was significantly increased in HIV-infected versus HIV-uninfected women, both overall (OR 2.7, 95% CI 2.0-3.5) and in all sub-group analyses.

CONCLUSIONS

There is strong evidence for an increased risk of treatment failure in HIV-infected women, in comparison to their HIV-negative counterparts. The only significant predictor of treatment failure in HIV-infected women was a positive margin status, but further data is needed on long-term outcomes after ablative treatment in HIV-infected women.

A trial of radiofrequency ablation for anal intraepithelial neoplasia

PURPOSE

Radiofrequency ablation (RFA) effectively treats esophageal high-grade dysplasia, but its efficacy in treating anal canal high-grade squamous intraepithelial lesions (HSILs) is unsubstantiated. This prospective study assessed the safety and efficacy of applying hemi-circumferential RFA to anal canal HSIL.

METHODS

Twenty-one HIV-negative participants with HSIL occupying ≤ half the anal canal circumference were treated with hemi-circumferential anal canal RFA. Participants were assessed every 3 months for 12 months with high-resolution anoscopy; recurrence in the treatment zone was re-treated with focal RFA.

RESULTS

Twenty-one participants with a mean of 1.7 lesions (range 1-4) enrolled and completed the trial. Six (29 %) participants had recurrent HSIL within the treated hemi-circumference within 1 year. Four participants (19 %) had persistence of an index lesion at 3 months. One (2.9 %) index HSIL persisted again at 12 months. No participants had more than two RFA treatments. KM curve-predicted HSIL-free survival within the treatment zone at 1 year was 76 % (95 % CI 52-89 %). Comparing the first 7 and last 14 participants, the predicted 1-year HSIL-free survivals are 43 % (95 % CI 10-73 %) and 93 % (95 % CI 59-99 %), respectively (p = 0.008), suggesting a learning curve with the treating physician. Multivariable analysis showed decreased recurrence in the last 14 participants (HR 0.02; 95 % CI 0.001-0.63) while increasing BMI increased recurrence (HR 1.43, 95 % CI 1.01-2.01). No participants had device or procedure-related serious adverse events, anal stricture, or heavy bleeding.

CONCLUSIONS

Hemi-circumferential RFA yielded a high rate of anal HSIL eradication in HIV-negative patients at 1 year with minimal adverse events. Lesion persistence was probably related to incomplete initial ablation.

Cervical conization for cervical intraepithelial neoplasia (CIN) 2 and 3 in HIV-positive women: a case-control study

OBJECTIVE

The purposes of the study were to investigate the outcomes of cervical conization for cervical intraepithelial neoplasia (CIN) 2 and 3 in HIV-positive women and age-matched HIV-negative controls and to determine whether positive margin, positive endocervical curettage, CD4 count, or viral load was associated with the persistence of CIN 2,3 or residual CIN 2,3 on the specimen from repeat excision procedure or hysterectomy.

MATERIALS AND METHODS

HIV-positive women and HIV-negative controls with CIN 2,3 on cervical conization were enrolled in the study. Patients who underwent repeat conization or hysterectomy were identified, and the specimens were evaluated for residual CIN 2,3. CD4 count and viral load within 8 weeks of procedure were analyzed.

RESULTS

A total of 44 patients and 44 age-matched controls were identified. Persistent CIN 2,3 was diagnosed in 28 HIV-positive (63.6%) and 14 HIV-negative patients (31.8%; odds ratio [OR] = 4.7, 95% confidence interval [CI] = 1.9-11.5, p < .001). In HIV-positive women, a positive margin was associated with a higher persistence rate after cervical conization (OR = 5.3, 95% CI = 1.17-24.14, p = .03). In HIV-negative patients, positive endocervical curettage was associated with a higher persistence rate after conization (OR = 12, 95% CI = 2.24-64.23, p = .004). Of HIV-positive women, 75% had residual CIN 2,3 on the specimen from repeat procedure compared to 45.2% of controls (OR = 3.6, 95% CI = 1.3-10.6, p = .018). CD4 count or viral load was not associated with the rate of residual disease or persistence rate after cervical conization, but the lowest OR that the sample size allowed to assess with 90% power was 5.02.

CONCLUSIONS

HIV-positive women have a higher rate of residual disease and higher persistence rate after conization for CIN 2,3 than age-matched HIV-negative controls.

Residual disease and HPV persistence after cryotherapy for cervical intraepithelial neoplasia grade 2/3 in HIV-positive women in Kenya

OBJECTIVE

To assess residual cervical intraepithelial neoplasia (CIN) 2/3 disease and clearance of high-risk (hr) human papillomavirus (HPV) infections at 6 months after cryotherapy among HIV-positive women.

DESIGN

Follow-up study.

METHODS

79 HIV-positive women received cryotherapy for CIN2/3 in Nairobi, Kenya, and underwent conventional cytology 6 months later. Biopsies were performed on high grade cytological lesions and hrHPV was assessed before (cervical cells and biopsy) and after cryotherapy (cells).

RESULTS

At 6 months after cryotherapy CIN2/3 had been eliminated in 61 women (77.2%; 95% Confidence Interval, (CI): 66.4-85.9). 18 women (22.8%) had residual CIN2/3, and all these women had hrHPV at baseline. CD4 count and duration of combination antiretroviral therapy (cART) were not associated with residual CIN2/3. CIN3 instead of CIN2 was the only significant risk factor for residual disease (odds ratio, OR vs CIN2 = 4.3; 95% CI: 1.2-15.0) among hrHPV-positive women after adjustment for age and HPV16 infection. Persistence of hrHPV types previously detected in biopsies was found in 77.5% of women and was associated with residual CIN2/3 (OR = 8.1, 95% CI: 0.9-70). The sensitivity, specificity, and negative predictive value of hrHPV test in detecting residual CIN2/3 were 0.94, 0.36, and 0.96 respectively.

CONCLUSIONS

Nearly one quarter of HIV-positive women had residual CIN2/3 disease at 6 months after cryotherapy, and the majority had persistent hrHPV. CD4 count and cART use were not associated with residual disease or hrHPV persistence. The value of hrHPV testing in the detection of residual CIN2/3 was hampered by a low specificity.

Factors influencing decisions about surgical treatment of cervical precancerous lesions

Cervical precancerous lesions represented by cervical intraepithelial neoplasia (CIN) and cervical glandular intraepithelial neoplasia may progress to invasive cancer. The principle treatment of CIN is eradication of the transformation zone. However, all eradication methods are associated with some adverse events, particularly with perinatal consequences. It is therefore necessary to identify which women have CIN that has a low risk of transformation into invasive cancer. The presence of modifying factors can help to stratify CIN lesions according to their malignant potential. The evaluation of HPV genotype in particular holds great promise for defining patients at greater risk. Tailoring treatment to the individual patient is going to become a major consideration in the management of cervical precancerous lesions.

HPV genotyping in north Indian women infected with HIV

Investigating the prevalence of high-risk human papilloma virus (HPV) genotypes in human immunodeficiency virus (HIV)-infected women is vital to generate data for formulating guidelines for prevention/screening of cervical cancer in this vulnerable group. The study was aimed to analyze the HPV genotypes in HIV-infected women. It was a prospective, hospital-based, and cross-sectional study. HIV-infected women were enrolled from the antiretroviral clinic and controls from the gynecology outpatient. The HPV genotyping array kit was used for identifying 21 HPV genotypes. Detection of HPV was confirmed by performing an HPV type-specific polymerase chain reaction. A Pap smear was collected in all women. One hundred thirty HIV-infected women and 64 controls were enrolled. All women with low CD4 counts (n=97) were receiving antiretroviral therapy. Twenty-six (20%) HIV-infected women and 12 (18.7%) women in the control group tested positive for high-risk HPV (P=1.0). HPV 16 was the most common type, detected in 42% of HPV-positive women in the HIV-infected cohort, followed by HPV 45 (15%), HPV 18/52/31/58 (11.5% each), and HPV 33 (7.6%). The corresponding figures in the control group were as follows: HPV 16 (66.6%), HPV 45/18/31 (16.6% each), and HPV 33/58/68 (8.3% each). Cervical intraepithelial neoplasia was detected in 2.3% of HIV-infected women. The prevalence of high-risk HPV in HIV-infected women (20%) was similar to the prevalence in controls (18.7%). This and the incidence of cervical intraepithelial neoplasia are lower than those in previous reports. It is plausible that administration of antiretroviral therapy contributed to the reduced prevalence. The currently available vaccine would likely be beneficial to the local HIV-infected population, as nearly half the HPV-infected women harbored genotypes 16 or 18.

Impact of timing of antiretroviral therapy initiation on survival of cervical squamous intraepithelial lesions: a cohort analysis from South Africa

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.

Electrocautery ablation of high-grade anal squamous intraepithelial lesions in HIV-negative and HIV-positive men who have sex with men

BACKGROUND

Anal squamous cell carcinoma (ASCC) incidence has been rising over the past decade, most dramatically in HIV-positive men who have sex with men (MSM). We aimed to identify a novel in-office approach for ablating high-grade anal intraepithelial neoplasia (HGAIN), the believed precursor lesion to ASCC.

MATERIALS AND METHODS

We performed a retrospective analysis of medical records from a New York City surgical practice, identifying patients with HGAIN treated with electrocautery ablation (ECA) and followed for at least 5 months with high-resolution anoscopy, biopsies, and/or cytology. We sought to determine HGAIN recurrence and progression to ASCC after ECA.

RESULTS

Two hundred thirty-two MSM, 132 HIV positive and 100 HIV negative, with median follow-up of 19.0 and 17.5 months, respectively, met inclusion criterion. In HIV-negative and HIV-positive MSM, the probability of curing a lesion after first ECA was 85% and 75%, respectively. Over follow-up, 53% of HIV-negative and 61% of HIV-positive patients recurred. After first and second ECA, HIV-positive MSM were 1.28 times (P = 0.16) and 2.34 times (P = 0.009) more likely to recur than HIV-negative MSM. The majority of recurrence was due to development of additional lesions at untreated sites (metachronous recurrence). One patient (0.4%) developed ASCC. At last visit, 83% of HIV-negative and 69% of HIV-positive patients were HGAIN free.

CONCLUSIONS

ECA is an effective treatment for HGAIN, with fewer patients progressing to ASCC than predicted with expectant management. HIV-positive patients are significantly more likely to recur than HIV-negative patients.

Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.

Cervical cancer prevention in low- and middle-income countries: feasible, affordable, essential

The annual worldwide burden of the preventable disease cervical cancer is more than 530,000 new cases and 275,000 deaths, with the majority occurring in low- and middle-income countries (LMIC), where cervical cancer screening and early treatment are uncommon. Widely used in high-income countries, Pap smear (cytology based) screening is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid human papillomavirus (HPV)-based screening tests offer promise for scaling up prevention services. Integrating HPV screening with VIA in "screen-and-treat-or-refer" programs offers the dual benefits of HPV screening to maximize detection and using VIA to triage for advanced lesions/cancer, as well as a pelvic exam to address other gynecologic issues. A major issue in LMICs is coinfection with human immunodeficiency virus (HIV) and HPV, which further increases the risk for cervical cancer and marks a population with perhaps the greatest need of cervical cancer prevention. Public-private partnerships to enhance the availability of cervical cancer prevention services within HIV/AIDS care delivery platforms through initiatives such as Pink Ribbon Red Ribbon present an historic opportunity to expand cervical cancer screening in LMICs.

Long-term follow-up of infrared coagulator ablation of anal high-grade dysplasia in men who have sex with men

BACKGROUND

We previously reported on infrared coagulator ablation of anal high-grade intraepithelial squamous lesions in HIV-positive and HIV-negative men who have sex with men (MSM) with a median follow-up of 1.5 years.

OBJECTIVE

We sought to determine high-grade intraepithelial squamous lesion recurrence rates after long-term follow-up for infrared coagulator ablation, and whether patients progressed to invasive cancer.

DESIGN

: This study investigated a retrospective cohort.

SETTING

This study was set in an office-based practice.

PATIENTS

The patients evaluated were MSM who underwent at least 1 infrared coagulator anal high-grade intraepithelial squamous lesion ablation between 1999 and 2005 with at least 1-year additional follow-up.

INTERVENTION

Infrared coagulator ablation had been performed.

MAIN OUTCOME MEASUREMENT

The primary outcomes measured were high-grade intraepithelial squamous lesion recurrence and progression to anal squamous-cell carcinoma.

RESULTS

Ninety-six MSM were included (44 HIV-positive) with a median follow-up of 48 and 69 months in HIV-negative and HIV-positive MSM. Thiry-five percent of HIV-positive and 31% of HIV-negative subjects from the original cohort were lost to follow-up. In HIV-negative MSM, 32 (62%) had a recurrence in a mean of 14 months. Recurrence rates after the second and third treatments were 48% and 57%. In HIV-positive MSM, 40 (91%) had a recurrence in a mean of 17 months. Recurrence rates after the second, third, and fourth infrared coagulator ablations were 63%, 85%, and 47%. After the first ablation, HIV-positive MSM were 1.9 times more likely to have a recurrence than HIV-negative MSM (P = .009). One year after the first ablation, 61% of HIV-positive MSM had recurrent high-grade intraepithelial squamous lesions in comparison with 38% of HIV-negative MSM. One year after the second ablation, 49% of HIV-positive MSM had recurrent high-grade intraepithelial squamous lesions in comparison with 28% of HIV-negative MSM. In HIV-negative and HIV-positive MSM, the probability of curing an individual lesion after first ablation was 80% and 67%. Most recurrence was due to the development of metachronous lesions occurring in 82% and 52% of HIV-positive and HIV-negative subjects after their first infrared coagulator treatment. The mean number of recurrent lesions for both HIV-positive and HIV-negative MSM was never >2. No MSM developed squamous-cell carcinoma, and there were no serious adverse events. At last visit, 82% of HIV-positive MSM and 90% of HIV-negative MSM were high-grade intraepithelial squamous lesion free.

LIMITATIONS

This was a retrospective, observational study with significant loss to follow-up.

CONCLUSIONS

Infrared coagulator ablation is an effective treatment for high-grade intraepithelial squamous lesions, and no patients progressed to cancer. HIV-positive patients are significantly more likely to have a recurrence, and recurrence occurred more rapidly in these patients. Continued follow-up is important.

Outcomes after an excisional procedure for cervical intraepithelial neoplasia in HIV-infected women

OBJECTIVE

To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women.

METHODS

A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up.

RESULTS

Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15-2.64), and low CD4+ count (p=0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55-7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90-19.73).

CONCLUSIONS

Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population.

Human papillomavirus prevalence, viral load and pre-cancerous lesions of the cervix in women initiating highly active antiretroviral therapy in South Africa: a cross-sectional study

Background

Cervical cancer and infection with human immunodeficiency virus (HIV) are both important public health problems in South Africa (SA). The aim of this study was to determine the prevalence of cervical squamous intraepithelial lesions (SILs), high-risk human papillomavirus (HR-HPV), HPV viral load and HPV genotypes in HIV positive women initiating anti-retroviral (ARV) therapy.

Methods

A cross-sectional survey was conducted at an anti-retroviral (ARV) treatment clinic in Cape Town, SA in 2007. Cervical specimens were taken for cytological analysis and HPV testing. The Digene Hybrid Capture 2 (HC2) test was used to detect HR-HPV. Relative light units (RLU) were used as a measure of HPV viral load. HPV types were determined using the Roche Linear Array HPV Genotyping test. Crude associations with abnormal cytology were tested and multiple logistic regression was used to determine independent risk factors for abnormal cytology.

Results

The median age of the 109 participants was 31 years, the median CD4 count was 125/mm³, 66.3% had an abnormal Pap smear, the HR-HPV prevalence was 78.9% (Digene), the median HPV viral load was 181.1 RLU (HC2 positive samples only) and 78.4% had multiple genotypes. Among women with abnormal smears the most prevalent HR-HPV types were HPV types 16, 58 and 51, all with a prevalence of 28.5%. On univariate analysis HR-HPV, multiple HPV types and HPV viral load were significantly associated with the presence of low and high-grade SILs (LSIL/HSIL). The multivariate logistic regression showed that HPV viral load was associated with an increased odds of LSIL/HSIL, odds ratio of 10.7 (95% CI 2.0 – 57.7) for those that were HC2 positive and had a viral load of ≤ 181.1 RLU (the median HPV viral load), and 33.8 (95% CI 6.4 – 178.9) for those that were HC2 positive with a HPV viral load > 181.1 RLU.

Conclusion

Women initiating ARVs have a high prevalence of abnormal Pap smears and HR-HPV. Our results underscore the need for locally relevant, rigorous screening protocols for the increasing numbers of women accessing ARV therapy so that the benefits of ARVs are not partially offset by an excess risk in cervical cancer.

Predictors of persistent cytologic abnormalities after treatment of cervical intraepithelial neoplasia in Soweto, South Africa: a cohort study in a HIV high prevalence population

BACKGROUND

In the presence of both HIV infection and cervical intraepithelial neoplasia (CIN), the risk of cancer development despite treatment may be greater. We investigated clinical predictors of persistent cytological abnormalities in women who had had a large loop excision of the transformation zone (LLETZ).

METHODS

Women with high grade squamous intraepithelial lesions or worse (HSIL), less severe abnormalities which persisted and any abnormality in women who are HIV-infected, were referred to the colposcopy clinic. HIV infection was ascertained by self-report. A LLETZ was performed on all patients with HSIL or higher on Papanicolaou (Pap) smear or colposcopy, LSIL or higher in patients who are HIV-infected, where the colposcopy is inadequate, and when there was a discrepancy between colposcopy and cytology by one or more grades. Women with abnormal follow-up smears were compared to those with normal smears. We examined the association between abnormal follow-up smears and demographic and clinical predictors using logistic regression

RESULTS

The median time between LLETZ and first follow-up Pap smear was rather short at 122 days. Persistent cytological abnormalities occurred in 49% of our patients after LLETZ. Predictors of persistence included the presence of disease at both margins and HIV infection. Among the latter, disease at the excision margins and CD4+ cell count were important predictors. In these women, disease at the endocervical margin, both margins, and disease only at the ectocervical margin were associated with increased odds of persistent abnormalities on follow-up cervical smear.

CONCLUSION

We showed extremely high risk of cytological abnormality at follow-up after treatment more so in patients with incomplete excision and in the presence of immunocompromise. It remains uncertain whether recurrent CIN is a surrogate marker for invasive cervical cancer.

Recurrence of cervical intraepithelial neoplasia grades 2 or 3 in HIV-infected women treated by large loop excision of the transformation zone (LLETZ)

CONTEXT AND OBJECTIVE

Women infected by HIV are more likely to have cervical cancer and its precursors. Treatment of the precursor lesions can prevent this neoplasia. The aim of this study was to assess the likelihood of recurrent cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) in HIV-infected women, compared with HIV-negative women, all treated by large loop excision of the transformation zone (LLETZ).

DESIGN AND SETTING

A cohort study in Instituto Fernandes Figueira, Fundação Oswaldo Cruz (IFF-Fiocruz), Rio de Janeiro.

METHOD

55 HIV-positive and 212 HIV-negative women were followed up after LLETZ for CIN 2-3 (range: 6-133 months).

RESULTS

The incidence of recurrent CIN 2-3 was 30.06/10,000 woman-months in the HIV-positive group and 4.88/10,000 woman-months in the HIV-negative group (relative risk, RR = 6.16; 95% confidence interval, CI: 2.07-18.34). The likelihood of recurrence reached 26% at the 62nd month of follow-up among the HIV-positive women, and remained stable at almost 0.6% at the 93rd month of follow-up among the HIV-negative women. We were unable to demonstrate other prognostic factors relating to CIN recurrence, but the use of highly active antiretroviral therapy (HAART) may decrease the risk of this occurrence among HIV patients.

CONCLUSION

After LLETZ there is a higher risk of recurrence of CIN 2-3 among HIV-positive women than among HIV-negative women. This higher risk was not influenced by margin status or grade of cervical disease treated. The use of HAART may decrease the risk of this occurrence in HIV patients.

Risk factors, diagnosis and prognosis of cervical intraepithelial neoplasia among HIV-infected women

The prevalence of cervical intraepithelial neoplasia (CIN) is high among HIV-infected women. Decreased CD4 lymphocytes, high human immunodeficiency viral load (HIVL) and human papillomavirus (HPV) infection are risk factors for CIN. We characterized the prevalence, risk factors and prognosis of histologically-verified CIN among systematically followed HIV-infected women enrolled from a low HIV-prevalence population. The study population comprised 153 HIV-infected women followed between 1989 and 2006. The mean ± SD duration of follow-up was 5.6 ± 3.8 years. Demographic as well as treatment-related data were derived from medical reports. During the follow-up, 51 subjects (33%) displayed CIN (16% CIN 1 and 18% CIN 2 +), whereas 102 subjects had Pap smear results of normal cells, atypical squamous cells of uncertain significance, or signs of low-grade squamous intraepithelial lesion (LSIL) but no CIN in histological specimens from the cervix. Only one case of cancer of the uterine cervix was detected. Pap smears were reliable in screening for CIN; 75% of patients with CIN had high-grade squamous intraepithelial lesion (HSIL) or LSIL in Pap smears taken at the time of dysplasia. The incidence of CIN decreased from 12.7 to 3.5 (per 100 subjects) between 2000 and 2005 (P = 0.07). The risk of CIN was not associated with decreased levels of CD4 lymphocytes, duration of HIV infection, use of antiretroviral medication or plasma HIVL. In univariate analysis, bacterial vaginosis (BV) was associated with a significantly increased risk of CIN, whereas parity was associated with lower risk of CIN. Each delivery lowered the risk of CIN by 30% (P = 0.02). The significantly lower risk of CIN among parous women (P = 0.04) persisted in multivariate analysis. CIN was treated by means of loop electrosurgical excision procedure (LEEP), (n = 34). The recurrence rate was low; seven subjects (14%) had a recurrence of CIN during follow-up. The nadir of CD4 lymphocytes was lower (P = 0.04) and the HIVL higher (P = 0.03) among subjects with recurrence of CIN. Duration of HIV infection, use of antiretroviral medication and positive margins in LEEP specimens were indistinguishable among subjects with vs. without recurrence of CIN. The prevalence of CIN is high among systematically managed HIV-infected women. However, the incidence of CIN decreased during the 21st century. BV was associated with an increased risk of CIN whereas parous women had lower risk of CIN. However, the patients with and without CIN could not be distinguished on the basis of previously described risk factors. Regular follow-up by means of Pap smears is warranted in all HIV-infected women.

Outcomes after treatment of cervical intraepithelial neoplasia among women with HIV

OBJECTIVE

To describe outcomes after treatment of cervical intraepithelial neoplasia (CIN) in women with HIV.

MATERIALS AND METHODS

Women in two prospective cohort studies, the Women's Interagency HIV Study (WIHS) and the HIV Epidemiology Research Study (HERS), were followed every 6 months after treatment of CIN using human papillomavirus (HPV) testing and cytology with colposcopy as indicated. Identification of CIN or a squamous intraepithelial lesion (SIL) within 6 months was defined as treatment failure and later disease as recurrence.

RESULTS

Follow-up was available for 170 HIV-seropositive and 15 HIV-seronegative women. Treatment failed in 84 (45%) women (79 HIV seropositive and 5 HIV seronegative). Failure was more likely in women with lower CD4 counts (CD4 < 200 cells/microL: odds ratio [OR] = 2.96; 95% CI = 1.4-6.2) and detectable HPV DNA (OR 8.20; 95% CI = 1.8-37.4; p = .01). After successful treatment, recurrence-free probabilities at 1,2, 3, and 5 years were .79, .64, .49, and .34, respectively. HIV-seronegative women were less likely to recur than HIV-seropositive women (p = .03). In multivariable analysis of HIV-positive women, recurrence was more likely among women treated for CIN 2,3 (hazard ratio [HR] = 2.4; 95% CI = 1.4-4.8), those with CD4 count of less than 200 cells/microL (HR = 2.9; 95% CI = 1.3-6.5) and those with HPV after treatment (HR 2.9; 95% CI = 1.4-6.1); oncogenic HPV was more strongly associated with recurrence than nononcogenic HPV (p(trend) = .009). Most failures and recurrences were low grade, but one adenocarcinoma was diagnosed 4.2 years after therapy for CIN 1.

CONCLUSION

Treatment failure and recurrence are common in women with HIV but are usually low grade.

Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women

The objective of this study was to evaluate the treatment outcomes and complications in human immunodeficiency virus (HIV)-infected women undergoing loop electrosurgical excision procedure (LEEP) for cervical neoplasia. The medical record of 60 evaluable HIV-infected women who had abnormal Papanicolaou (Pap) smear and underwent LEEP following colposcopy at Chiang Mai University Hospital between May 1998 and June 2004 was reviewed. Thirty-one (51.7%) had associated genital infection at screening. Twenty-five (41.7%) had opportunistic infection, but only 18 (30.0%) were treated with antiretroviral therapy. The most common abnormal Pap smear was high-grade squamous intraepithelial lesion (46.7%), followed by low-grade squamous intraepithelial lesion (40.0%). Forty (66.7%) women had clear surgical margins after LEEP. Only one (1.7%) woman had severe intraoperative hemorrhage. Early and late postoperative hemorrhage were noted in three (5%) women of each period. Localized infection of the cervix was detected in seven (11.7%) women. Two (3.3%) women developed cervical stenosis at 6 months after LEEP. There was no significant difference in overall complications between HIV-infected women and the control group (P= 0.24). Among 60 HIV-infected women, no statistical difference in the rate of margins involvement (P= 1.00) and complications (P= 0.85) could be demonstrated between HIV-infected women who received antiretroviral therapy and those who did not. Disease-free rate at 6 and 12 months were 97.1% and 88%, respectively. These data demonstrated that LEEP appears to be safe and effective in HIV-infected women.

AIDS malignancies

Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.

Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia

OBJECTIVES

HIV-infected women living in resource-constrained nations like Zambia are now accessing antiretroviral therapy and thus may live long enough for HPV-induced cervical cancer to manifest and progress. We evaluated the prevalence and predictors of cervical squamous intraepithelial lesions (SIL) among HIV-infected women in Zambia.

METHODS

We screened 150 consecutive, non-pregnant HIV-infected women accessing HIV/AIDS care services in Lusaka, Zambia. We collected cervical specimens for cytological analysis by liquid-based monolayer cytology (ThinPrep Pap Test) and HPV typing using the Roche Linear Array PCR assay.

RESULTS

The median age of study participants was 36 years (range 23-49 years) and their median CD4+ count was 165/microL (range 7-942). The prevalence of SIL on cytology was 76% (114/150), of which 23.3% (35/150) women had low-grade SIL, 32.6% (49/150) had high-grade SIL, and 20% (30/150) had lesions suspicious for squamous cell carcinoma (SCC). High-risk HPV types were present in 85.3% (128/150) women. On univariate analyses, age of the participant, CD4+ cell count, and presence of any high-risk HPV type were significantly associated with the presence of severely abnormal cytological lesions (i.e., high-grade SIL and lesions suspicious for SCC). Multivariable logistic regression modeling suggested the presence of any high-risk HPV type as an independent predictor of severely abnormal cytology (adjusted OR: 12.4, 95% CI 2.62-58.1, p=0.02).

CONCLUSIONS

The high prevalence of abnormal squamous cytology in our study is one of the highest reported in any population worldwide. Screening of HIV-infected women in resource-constrained settings like Zambia should be implemented to prevent development of HPV-induced SCC.

Fall 2002

OBJECTIVE

The Home Study Course is intended for the practicing colposcopist or practitioner who is seeking to develop or enhance his or her colposcopic skills. The goal of the course is to present colposcopic cases that are unusual or instructive in terms of appearance, presentation, or management or that demonstrate new and important knowledge in the area of colposcopy or pathology. Participants may benefit from reading and studying the material or from testing their knowledge by answering the questions.

ACCME ACCREDITATION

The American Society for Colposcopy and Cervical Pathology (ASCCP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education for physicians. The ASCCP designates this continuing medical education activity for 1 credit hour in Category I of the Physician's Recognition Award of the American Medical Association. Credit is available for those who choose to apply. The Home Study Course is planned and produced in accordance with the ACCME's Essential Areas and Elements.

Screening HIV-infected individuals for anal cancer precursor lesions: a systematic review

Individuals with human immunodeficiency virus (HIV) infection are at increased risk for human papillomavirus-related squamous cell cancer of the anus. Screening HIV-infected patients for squamous cell cancer of the anus and human papillomavirus-related anal dysplasia may prevent excess morbidity and mortality. We have conducted a systematic review of the indirect evidence in the literature regarding the utility of anal Papanicolau (Pap) smear screening of HIV-infected individuals in the highly active antiretroviral therapy era. Although there are no published studies evaluating the efficacy of anal Pap smear screening for preventing squamous cell cancer of the anus or anal intraepithelial neoplasia, we reviewed data regarding the burden of disease, anal Pap smear sensitivity and specificity, the prevalence of anal dysplasia, and 1 cost effectiveness study. The available evidence demonstrates that HIV-infected individuals have an increased risk for squamous cell cancer of the anus and anal intraepithelial neoplasia. This review identifies important areas for further study before routine anal Pap smear screening can be recommended.

High rate of recurrence of cervical intraepithelial neoplasia after surgery in HIV-positive women

OBJECTIVE

Our study investigated the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after surgery in the era of highly active antiretroviral therapy (HAART).

METHODS

One hundred twenty-one HIV-positive women were followed-up with cytology, colposcopy, and histology after surgery for CIN. We conducted univariate and multivariate analyses to determine the relation between recurrence of CIN and risk factors using Cox proportional hazard models with left truncation.

RESULTS

The rate of recurrence of any CIN was 22.3 per 100 patient-years and the rate of high-grade CIN was 8.6 per 100 patient-years during 166 and 279 patient-years of follow-up, respectively. In multivariate analysis, a positive margin was associated with a risk of recurrence of any CIN (relative risk [RR] = 3.5, 95% confidence interval [CI]: 1.2-9.8) and a risk of recurrence of high-grade CIN (RR = 9.0, 95% CI: 2.2-36.5). CD4 counts <200 cells/mm were associated with a risk of recurrence of any CIN (RR = 9.4, 95% CI: 2.7-32.7) but not with a risk of recurrence of high-grade CIN. HAART exhibited a protective effect on the recurrence of any CIN (RR = 0.3, 95% CI: 0.1-0.7) and of high-grade CIN (RR = 0.2, 95% CI: 0.1-0.7).

CONCLUSION

CD4 cell counts <200/mm(3) and a positive margin were predictors of recurrence, whereas HAART had a strong protective effect. Although surgery is highly effective in immunocompetent patients, it seems to be effective only in preventing progression to cancer in HIV-infected women.

Infrared coagulator: a useful tool for treating anal squamous intraepithelial lesions

PURPOSE

The incidence of invasive anal squamous carcinoma in men who have sex with men is rising, particularly in those with human immunodeficiency virus. As in the cervix the high-grade squamous intraepithelial lesion is thought to be an invasive squamous cell carcinoma precursor. Cervical high-grade squamous intraepithelial lesions are treated by removing the squamocolumnar transition zone. This is not possible in the anus, where treatment is often surgical and is accompanied by significant pain and morbidity. Better office-based techniques to treat anal high-grade squamous intraepithelial lesions are needed. We employed the infrared coagulator in an office setting to ablate high-grade squamous intraepithelial lesions.

METHODS

A retrospective review of medical records was performed on 68 human immunodeficiency virus-positive men who have sex with men who underwent infrared coagulator ablation of biopsy-proven high-grade dysplasia from the time we began using the procedure in 1999. All patients have had at least six months of follow-up. Procedures were performed with local anesthesia on patients with discrete high-grade squamous intraepithelial lesions. Follow-up consisted of anal cytology with high-resolution anoscopy and biopsy of suspicious areas every three to six months. New or recurrent high-grade dysplasia was retreated. Patients with circumferential or bulky disease were treated in the operating room and were excluded from the study.

RESULTS

Altogether, 68 patients met the enrollment criteria. The median patient age was 41 years (range 29-62 years). A total of 165 lesions were treated (mean 1.6 lesions, range 1-5) and only 46 (28 percent) persisted. However, 44 patients (65 percent) developed a new or persistent high-grade squamous intraepithelial lesion within a median time of 217 days (range 27-566 days) after infrared coagulation. The remaining 24 patients (35 percent) were free of high-grade dysplasia for a median of 413 days (range 162-1313 days) after infrared coagulation. When patients were treated a second or third time, the incidence of new or persistent high-grade dysplasia dropped to 58 percent and 40 percent, respectively. The probability of curing a retreated lesion was 72 percent. Using generalized estimating equations, the incidence of high-grade dysplasia decreased with repeated infrared coagulator treatments. No patient developed squamous-cell carcinoma, had a serious adverse event, or developed anal stenosis.

CONCLUSIONS

The infrared coagulator is a safe, office-based modality for treating anal high-grade squamous intraepithelial lesion in human immunodeficiency virus-positive men who have sex with men. Successive treatments led to decreased recurrence rates.

Screening for cervical cancer in the developing world

Cervical cancer remains the most common malignancy amongst females in countries of low income, mainly due to a lack of screening. Responsible factors are centred around inadequacies of the Pap smear: high cost; low sensitivity; the need of a laboratory with high human expertise; and a demanding logistic system for mass screening. No alternative screening method seems to be clearly advantageous. Although combinations of tests have higher sensitivities, they are complex, costly and associated with low specificities. Adding the problem of effective treatment, it seems that mass screening with adequate coverage of the population is an unreachable goal for many developing countries. The most promising development in the control of cervical cancer seems to be vaccination against the human papillomavirus, either as a preventative measure or for stimulating immunity in infected women.

Management and outcome of cervical intraepithelial neoplasia lesions: a study of matched cases according to HIV status

OBJECTIVES

To assess whether adequate strategies are used for the management of cervical intraepithelial neoplasia (CIN) in HIV-positive patients.

METHODS

SETTING

Retrospective study in a HIV reference university hospital. Sixty-eight HIV-infected patients who had undergone a cervical biopsy between January 1995 and March 2002 were matched for CIN and age with HIV-negative patients.

OUTCOME

Assess mean of treatment strategy. Assess mean of treatment failure by immediate follow-up PAP smear and recurrence rate by long-term follow-up smears.

RESULTS

Both groups of patients received similar treatments for their cervical anomalies. HIV-positive women were two times more likely to have involved margins after conisation than HIV-negative women (P < 0.01). Globally, two thirds of HIV-negative patients had a first follow-up PAP smear that was normal, while this was the case in only one third of HIV-positive women. These proportions were also significantly different after conisation (P < 0.01). The same differences were also observed after sustained follow-up. HIV-infected women who showed a recurrence of dysplasia were more likely to have failed antiviral therapy (9/44) than those without any recurrence (7/12) (P < 0.01).

CONCLUSIONS

Higher rates of recurrence were observed among HIV-infected women, indicating that CIN management is more difficult and may require adapted guidelines in HIV-positive patients. In HIV-infected patients, an association was found between the absence of recurrence and a viral response to antiviral therapy.

Anogenital neoplasia in AIDS

PURPOSE OF REVIEW

We review the recent literature on anogenital neoplasms in AIDS, with emphasis on cancers associated with HPV infection. Immune reactivity to HPV as well as novel immunotherapeutic and preventative strategies are discussed.

RECENT FINDINGS

Many AIDS-associated neoplasms are associated with HPV infection. Whether cervical cancer is truly an AIDS-associated neoplasm has recently been questioned, while the association of anal cancer with AIDS in both males and females is more convincing. Recent reports cast doubt on the efficacy of HAART therapy for HPV-induced anogenital neoplasms, despite efficacy in improving disease caused by other infectious agents. We include here new data on humoral and cellular immune responses to HPV. VLP serology has been reported to be associated with outcome of cervical cancer. VLP seropositivity has been reported to be a favorable prognostic sign in women with HPV 16 positive cervical carcinoma. Several investigators have questioned the immunogenicity of the oncogenic HPV type 16 compared with other HPV types. It has recently been found that in HIV-infected patients, lymphoproliferative cellular immune responses (CMI) to HPV 16 peptides are not associated with CD4 counts, whereas responses to recall antigens and mitogens are associated with CD4 counts. CD4 + T cells may not be responsible for protective cellular immune responses to HPV. VLP serology and CMI responses may be the future intermediate surrogate biomarkers for HPV-associated anogenital neoplasia trials. Several new therapeutic vaccine strategies for management of HPV-induced neoplasia are reviewed.

SUMMARY

Most anogenital neoplasms occurring with increased frequency in patients with HIV/AIDS are associated with HPV infections. Current treatment strategies are not effective in clearing anogenital HPV infection and need improvement. Immunotherapy with novel vaccines will provide both prevention and therapy for these common malignancies.

Screening for cervical cancer in developing countries

Cervical cancer is the most common malignancy amongst females in developing countries, mainly due to a lack of precursor screening. This absence of screening is the result of inherent disadvantages of the Pap smear: high cost, low sensitivity, the need for a laboratory with high human expertise and a complex screening program logistic system. The prerequisites for screening in a developing country include a screening method that is affordable, which can be effectively applied once in a lifetime at the age of 30-35 years, provide an immediate result and thereby allowing for on-site treatment of positive cases. None of the current screening methods comply with these prerequisites. More research is necessary into different combinations of tests, which improve sensitivity. On-site human papillomavirus (HPV) identification, alone or in combination with other tests, is promising. Another promising development is immunization against HPV infection, either as a preventative measure or for stimulating immunity in infected women.

Abnormal Vaginal Cytology in HIV-Infected and At-Risk Women After Hysterectomy

OBJECTIVE

To determine the frequency of and risk factors for abnormal vaginal Papanicolaou smears in HIV-infected women after hysterectomy.

METHODS

Data were from the HIV Epidemiology Research (HER) study, a prospective multisite study of HIV-infected and uninfected women. Semiannual vaginal Papanicolaou smears and colposcopy data were obtained from 102 HIV-infected and 46 at-risk women who had hysterectomy either before or during the study. Analytic models used include Cox proportional hazards (women with hysterectomy during the study) and multiple logistic regressions, which corrected for repeated measures (all women).

RESULTS

Among the HIV-infected women, evidence of cervical intraepithelial neoplasia before or at hysterectomy was associated with abnormal cytology during follow-up; 63% had squamous intraepithelial lesions (SIL) on vaginal Papanicolaou smears following hysterectomy. CD4 counts of <200 cells/microL at hysterectomy and HIV viral load of >10,000 copies/mL at hysterectomy were predictive of SIL vaginal cytology. Prevalent SIL vaginal cytology was associated with low CD4 count and human papillomavirus risk type. Of the 102 HIV-infected women, 16 (16%) had vaginal intraepithelial neoplasia on biopsy.

CONCLUSIONS

The high rate of SIL on vaginal Papanicolaou smears and the presence of high-grade vaginal intraepithelial neoplasia among HIV-infected women after hysterectomy demonstrate the need for continued follow-up for lower genital tract lesions.

Cervical human papillomavirus infection and cervical intraepithelial neoplasia in women positive for human immunodeficiency virus in the era of highly active antiretroviral therapy

PURPOSE OF REVIEW

Human papillomavirus (HPV) has been strongly implicated in the pathogenesis of cervical intraepithelial neoplasia (CIN) and cervical cancer. Women who are positive for the human immunodeficiency virus (HIV) have been shown to be at increased risk for cervicovaginal HPV infection and CIN, and cervical cancer is an acquired immunodeficiency syndrome-defining illness. The purpose of this review is to summarize recent studies of cervical HPV infection and CIN in HIV-positive women and to describe the effect of highly active antiretroviral therapy (HAART) on the course of CIN.

RELEVANT FINDINGS

HIV-positive women have a higher prevalence of cervical HPV infection than HIV-negative women, and HPV infection is more persistent in the HIV-positive population. The incidence of high-grade CIN is increased in HIV-positive women. HAART has not been shown to affect HPV detection, and data on its effect on the natural history of CIN are mixed. Some studies show no effect of HAART on the natural history of CIN, and others show a statistically significant but modest beneficial effect.

SUMMARY

Cervical HPV infection and CIN are clearly increased in HIV-positive women when compared with risk-matched HIV-negative women. HAART appears to have limited ability to clear HPV infection and induce regression of CIN in HIV-positive women. Combined with the high prevalence of cervical HPV infection and CIN, current data suggest that CIN should be aggressively sought and treated in HIV-positive women, including those who have responded well to HAART with good HIV viral load suppression and increasing CD4+ levels.

Cervical neoplasia and the HIV-infected patient

HPV infection and cervical dysplasia occur more frequently in HIV-infected women. All HIV-infected women should be screened at least annually for cervical cancer with cervical cytology. All patients with any abnormality in the Pap smear should be referred for colposcopic evaluation. Patients with documented high-grade dysplasia should be treated. All patients must be observed closely after treatment for recurrence. Treatment with agents such as imiquimod or 5-FU may help to decrease recurrence rates. Patients who are diagnosed with cervical cancer should be treated with surgery or concurrent chemotherapy and radiation as determined by extent of disease and health status. It appears that HAART may have a positive impact on cervical dysplasia and cancer. Thus, all HIV-infected patients should be managed optimally on HAART. Hopefully, as patients live longer and healthier on HAART, they will be more compliant with cervical cancer screening, and cervical cancer will become an increasingly rare disease.