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Metz CK, Skof AS, Sehouli J, Siedentopf JP, Gebert P, Weiss F, Alba Alejandre I, Heinrich-Rohr M, Weizsaecker K, Henrich W, Kaufmann AM, Rohr I. Assessment of high-risk human papillomavirus infections and associated cervical dysplasia in HIV-positive pregnant women in Germany: a prospective cross-sectional two-centre study. Arch Gynecol Obstet 2022; 308:207-218. [PMID: 36576558 DOI: 10.1007/s00404-022-06890-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Invasive cervical cancer (ICC) is associated in nearly 100% with persistent high-risk Human Papillomavirus (HR-HPV) infection. ICC is still one of the leading causes for cancer mortality in women worldwide. The immunosuppressive influence of Human Immunodeficiency Virus (HIV) and the immunocompromised period of pregnancy due to tolerance induction against the hemiallogeneic fetus, are generally risk factors for acquisition and persistence of HR-HPV infections and their progression to precancerous lesions and HPV-associated carcinoma. METHODS Overall, 81 pregnant women living with HIV (WLWH) were included. A medical history questionnaire was used to record clinical and HIV data. Participants received cervicovaginal cytological smear, colposcopy and HPV testing. HPV test was performed using BSGP5+/6+ PCR with Luminex read-out. The HR-HPV genotypes 16, 18, 31, 33, 45, 52, 58 were additionally grouped together as high-high-risk HPV (HHR-HPV) for the purpose of risk-adapted analysis. RESULTS HR-HPV prevalence was 45.7%. Multiple HPV infections were detected in 27.2% of participants, of whom all had at least one HR-HPV genotype included. HR-HPV16 and HR-HPV52 were the most prevalent genotypes and found when high squamous intraepithelial lesion (HSIL) was detected by cytology. HIV viral load of ≥ 50 copies/ml was associated with higher prevalence of HR-HPV infections. Whereas, CD4 T cells < 350/µl showed association with occurrence of multiple HPV infections. Time since HIV diagnosis seemed to impact HPV prevalence. CONCLUSION Pregnant WLWH require particularly attentive and extended HPV-, colposcopical- and cytological screening, whereby clinical and HIV-related risk factors should be taken into account.
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Affiliation(s)
- Charlotte K Metz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Anna S Skof
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department for Gynecology, Laboratory for Gynaecological Tumor Immunology, HPV Laboratory, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jalid Sehouli
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department for Gynecology, Laboratory for Gynaecological Tumor Immunology, HPV Laboratory, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jan-Peter Siedentopf
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Pimrapat Gebert
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, 10117, Berlin, Germany
| | - Fabian Weiss
- Ludwig-Maximilians-University (LMU), University Hospital, Department of Obstetrics and Gynecology, Marchioninistrasse 15, 81377, Munich, Germany
| | - Irene Alba Alejandre
- Ludwig-Maximilians-University (LMU), University Hospital, Department of Obstetrics and Gynecology, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michaela Heinrich-Rohr
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute for Social Medicine, Epidemiology and Health Economic, Luisenstraße 57, 10117, Berlin, Germany
| | - Katharina Weizsaecker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Wolfgang Henrich
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Andreas M Kaufmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department for Gynecology, Laboratory for Gynaecological Tumor Immunology, HPV Laboratory, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Irena Rohr
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Obstetrics, Augustenburger Platz 1, 13353, Berlin, Germany.
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Exploring the Molecular Pathogenesis, Pathogen Association, and Therapeutic Strategies against HPV Infection. Pathogens 2022; 12:pathogens12010025. [PMID: 36678374 PMCID: PMC9865103 DOI: 10.3390/pathogens12010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/10/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
The human papillomavirus (HPV), commonly documented as the cause of warts, has gained much interest recently due to its possible links to several types of cancer. HPV infection is discussed in this review from multiple angles, including its virology, epidemiology, etiology, immunology, clinical symptoms, and treatment. Recent breakthroughs in molecular biology have led to the development of new methods for detecting and treating HPV in tissue. There is no cure for HPV, and although vaccines are available to prevent infection with the most common HPV viruses, their utilization is limited. Destruction and excision are the primary treatment modalities. This review sheds light on the epidemiology, molecular pathogenesis, the association of several other pathogens with HPV, the latest treatment strategies available to treat the same, and an overview of the progress made and the obstacles still to be overcome in the fight against HPV infection.
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Cambrea SC, Aschie M, Resul G, Mitroi AF, Chisoi A, Nicolau AA, Baltatescu GI, Cretu AM, Lupasteanu G, Serbanescu L, Manea M, Topliceanu ST, Petcu LC, Pazara L, Cozaru GC. HPV and HIV Coinfection in Women from a Southeast Region of Romania—PICOPIV Study. Medicina (B Aires) 2022; 58:medicina58060760. [PMID: 35744023 PMCID: PMC9231193 DOI: 10.3390/medicina58060760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Simona Claudia Cambrea
- Faculty of Medicine, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania; (S.C.C.); (M.A.); (L.S.); (L.P.)
- Clinical Hospital of Infectious Diseases, 100 Ferdinand Blvd., 900178 Constanta, Romania
| | - Mariana Aschie
- Faculty of Medicine, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania; (S.C.C.); (M.A.); (L.S.); (L.P.)
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Institute of Doctoral Studies, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania
| | - Ghiulendan Resul
- Clinical Hospital of Infectious Diseases, 100 Ferdinand Blvd., 900178 Constanta, Romania
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Institute of Doctoral Studies, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania
- Correspondence: ; Tel.: +40-74-5904-219
| | - Anca Florentina Mitroi
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Anca Chisoi
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Antonela Anca Nicolau
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Gabriela Izabela Baltatescu
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Ana Maria Cretu
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Gabriela Lupasteanu
- Clinical Hospital of Infectious Disease Sf. Cuvioasa Parascheva, 393 Traian Street, 800179 Galati, Romania;
| | - Lucian Serbanescu
- Faculty of Medicine, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania; (S.C.C.); (M.A.); (L.S.); (L.P.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
| | - Mihaela Manea
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
| | - Sebastian Theodor Topliceanu
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Institute of Doctoral Studies, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania
| | - Lucian Cristian Petcu
- Faculty of Dentistry, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania;
| | - Loredana Pazara
- Faculty of Medicine, Ovidius University of Constanta, 1 Universitatii Street, 900470 Constanta, Romania; (S.C.C.); (M.A.); (L.S.); (L.P.)
| | - Georgeta Camelia Cozaru
- Center for Research and Development of the Morphological and Genetic Studies of Malignant Pathology, Ovidius University of Constanta, 145 Tomis Blvd., 900591 Constanta, Romania; (A.F.M.); (A.C.); (A.A.N.); (G.I.B.); (A.M.C.); (M.M.); (S.T.T.); (G.C.C.)
- Sf. Apostol Andrei Emergency County Hospital, 145 Tomis Blvd., 900591 Constanta, Romania
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Ermel A, Tong Y, Tonui P, Orang'o O, Muthoka K, Wong N, Manai T, Kiptoo S, Loehrer PJ, Brown DR. Longer duration of anti-retroviral therapy is associated with decreased risk of human papillomaviruses detection in Kenyan women living with HIV. Int J STD AIDS 2021; 32:1212-1220. [PMID: 34233531 DOI: 10.1177/09564624211030766] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A longitudinal study was conducted among women living with HIV in Kenya to determine if duration of anti-retroviral (ART) usage altered detection and persistence of oncogenic (high-risk) human papillomaviruses (HR-HPV). METHODS Women living with HIV without cervical dysplasia were enrolled at a cervical cancer screening clinic. Three cervical swabs, HIV viral loads, and CD4 cell counts were obtained at enrollment and at two annual visits. HPV genotyping was performed on swabs (Roche Linear Array). Linear regression models assessed effects of ART duration on HR-HPV detection and persistence. RESULTS Seventy-seven women, median age 38 years, completed three study visits and were included in the analysis. The mean time from HIV diagnosis to enrollment was 9.6 years (SD 3.9 years). The mean ART duration was 6.2 years (SD 3.1 years). Most women had undetectable HIV viral loads and CD4 cell counts above 500 cells/L. Each additional year of ART use reduced the likelihood of detection of HR-HPV by 10-15% and persistent detection of A9 HR-HPV by 20%. CONCLUSION Among Kenyan women living with HIV, longer duration of ART use was associated with significantly reduced risk of all detection and persistent detection of HR-HPV.
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Affiliation(s)
- Aaron Ermel
- 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yan Tong
- 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | - Phillip Tonui
- College of Health Sciences, School of Medicine, Department of Reproductive Health, 107853Moi University, Eldoret, Kenya
| | - Omenge Orang'o
- College of Health Sciences, School of Medicine, Department of Reproductive Health, 107853Moi University, Eldoret, Kenya
| | - Kapten Muthoka
- College of Health Sciences, School of Medicine, Department of Reproductive Health, 107853Moi University, Eldoret, Kenya
| | - Nelson Wong
- 12250Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Stephen Kiptoo
- Academic Model Providing Access to Healthcare (AMPATH) Cervical Cancer Screening Program, 107853Moi University, Eldoret, Kenya
| | - Patrick J Loehrer
- 12250Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University Melvin and Bren Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | - Darron R Brown
- 12250Indiana University School of Medicine, Indianapolis, IN, USA
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Tounkara FK, Téguété I, Guédou FA, Talbot D, Traoré CB, Béhanzin L, Traoré S, Goma-Matsétsé E, Aza-Gnandji M, Keita B, Guenoun J, Coutlée F, Alary M. Type-specific incidence, persistence and factors associated with human papillomavirus infection among female sex workers in Benin and Mali, West Africa. Int J Infect Dis 2021; 106:348-357. [PMID: 33848674 DOI: 10.1016/j.ijid.2021.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES This study in female sex workers (FSWs) aimed to: (1) estimate type-specific incidence and persistence of human papillomavirus (HPV) infection in Cotonou (Benin) and Bamako (Mali); and (2) identify the factors associated with type-specific incidence and persistence of high-risk HPV (HR-HPV) infection. METHODS A 1-year prospective cohort study on cervical cancer screening, and HPV and human immunodeficiency virus (HIV) infections was conducted among FSWs in Cotonou and Bamako from 2017 to 2019. Poisson regression models assessed factors associated with the incidence of HR-HPV infection, while log-binomial regression was performed to identify factors associated with the persistence of HR-HPV infection. Adjusted relative risks (ARR) and 95% confidence intervals (95% CI) were estimated. RESULTS The incidence of HR-HPV infection was 46.98 per 1000 women-months (predominant types HPV16, HPV35 and HPV59). Factors associated with the incidence of HR-HPV infection were age <20 years (ARR 15.10; 95% CI 3.29-69.19), age at sexual debut <18 years (ARR 6.92; 95% CI 1.97-24.27) and sex work duration ≤1 year (ARR 7.40; 95% CI 1.84-29.69). The persistence of HR-HPV infection at 12 months was 38.7% (most persistent types HPV59, HPV52 and HPV51). Persistence of HR-HPV infection was higher in women with chlamydia (P = 0.031), HIV infection (P < 0.001) and multiple-type HPV infections (P < 0.001). CONCLUSION FSWs in West Africa are at high risk of incident and persistent HR-HPV infection, suggesting an urgent need for cervical cancer screening in this population.
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Affiliation(s)
- Fatoumata Korika Tounkara
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Ibrahima Téguété
- Département de Gynécologie-Obstétrique, CHU Gabriel Toure, BP 267, Bamako, Mali
| | - Fernand A Guédou
- Axe Santé des Populations et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; Dispensaire des Infections Sexuellement Transmissibles (DIST), Centre de santé de Cotonou-1, Cotonou, Benin
| | - Denis Talbot
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada
| | - Cheick B Traoré
- Département d'Anatomie-Pathologie, CHU Point G, Bamako, Mali
| | - Luc Béhanzin
- École Nationale de Formation des Techniciens Supérieurs en Santé Publique et en Surveillance Épidémiologique, Université de Parakou, Benin
| | - Sidy Traoré
- Département de Gynécologie-Obstétrique, CHU Gabriel Toure, BP 267, Bamako, Mali
| | - Ella Goma-Matsétsé
- Dispensaire des Infections Sexuellement Transmissibles (DIST), Centre de santé de Cotonou-1, Cotonou, Benin
| | - Marlène Aza-Gnandji
- Dispensaire des Infections Sexuellement Transmissibles (DIST), Centre de santé de Cotonou-1, Cotonou, Benin
| | - Bintou Keita
- Association de Recherche de Communication et d'Accompagnement à Domicile de personnes Vivant avec le VIH (ARCAD-SIDA), Bamako, Mali
| | - Julie Guenoun
- Département de Microbiologie et Infectiologie, Centre de recherche du CHU de Montréal, Montréal, Canada
| | - François Coutlée
- Département de Microbiologie et Infectiologie, Centre de recherche du CHU de Montréal, Montréal, Canada
| | - Michel Alary
- Département de Médecine Sociale et Préventive, Université Laval, Québec, Canada; Axe Santé des Populations et Pratiques Optimales en Santé, Centre de recherche du CHU de Québec-Université Laval, Québec, Canada; Institut national de santé publique du Québec, Québec, Canada.
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Kabuga AI, Nejati A, Arero AG, Jalilvand S, Mokhtari-Azad T, Sighaldeh SS, Wali UH, Shahmahmoodi S, El Zowalaty ME. Prevalence and Type Distribution of Human Papillomavirus
Recovered from the Uterine Cervix of Nigerian Women:
A Systematic Review and Meta-Analysis. Asian Pac J Cancer Prev 2020; 21:2837-2846. [PMID: 33112538 PMCID: PMC7798145 DOI: 10.31557/apjcp.2020.21.10.2837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Infection with an oncogenic type of human papillomavirus is a prerequisite for the development of precancerous cervical lesions and its subsequent progression to cervical cancer. With an alarming increase in the detection of other suspicious papillomavirus genotypes in both healthy and women with cervical lesions, there is a need for comprehensive data on cervical papillomavirus infection to address cervical cancer and other associated disease burden, especially in Sub-Sarahan Africa, where the bulk of the problem exists. The present study was conducted to develop comprehensive data on the prevalence and circulating genotypes of human papillomavirus in various risk categories in Nigeria. Methods: A systematic review and meta-analysis of peer-reviewed publications on cervical papillomavirus infection were performed. Relevant data were extracted from eligible studies published in PubMed, Web of Science, Embase, Scopus, and Google Scholar, from inception to July 31, 2019. The random-effect model was used to estimate the pooled prevalence. We identified 327 potential studies and pooled data from 18, involving 5697 women aged 15-86 years. Results: The overall pooled prevalence of cervical papillomavirus infection was 42% (95%CI: 30-54%) in the general population and 37% (95%CI: 25-50%) among women living with HIV/AIDs, with the predominance of genotypes 16, 18, 31, 35, 52, 58 and 45. The highest prevalence was observed in teenagers and young adults and the second peak in women 50 years and above. Conclusion: The prevalence of cervical human papillomavirus infection is cumulatively high in Nigeria and HIV is a strong co-factor. We, therefore, strongly recommend the co-screening of human papillomavirus and cervical cancer and integration of the intervention strategy into the existing HIV-care guideline in Nigeria.
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Affiliation(s)
- Auwal Idris Kabuga
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Department of Medical Microbiology and Parasitology, Faculty of Clinical Sciences, College of Health Sciences, Bayero University, Kano, PMB 3011 Kano State, Nigeria
| | - Ahmad Nejati
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Amanuel Godana Arero
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Jalilvand
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Talat Mokhtari-Azad
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Shirin Shahbazi Sighaldeh
- Department of Reproductive Health, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Umma Hassan Wali
- Food Microbiology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Shohreh Shahmahmoodi
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.,Food Microbiology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamed E El Zowalaty
- Department of Clinical Sciences, College of Medicine,
University of Sharjah, Sharjah 27272, UAE.,Zoonosis Science Center, Department of Medical Biochemistry and Microbiology,
Uppsala University, Uppsala Se-75 123, Sweden.*
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7
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Tong Y, Tonui P, Ermel A, Orang’o O, Wong N, Titus M, Kiptoo S, Muthoka K, Loehrer PJ, Brown DR. Persistence of oncogenic and non-oncogenic human papillomavirus is associated with human immunodeficiency virus infection in Kenyan women. SAGE Open Med 2020; 8:2050312120945138. [PMID: 32782796 PMCID: PMC7388102 DOI: 10.1177/2050312120945138] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/01/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES Cervical cancer is caused by persistent infection with oncogenic, or "high-risk" types of human papillomaviruses, and is the most common malignancy in Kenyan women. A longitudinal study was initiated to investigate factors associated with persistent human papillomavirus detection among HIV-infected and HIV-uninfected Kenyan women without evidence of cervical dysplasia. METHODS Demographic/behavioral data and cervical swabs were collected from HIV-uninfected women (n = 82) and HIV-infected women (n = 101) at enrollment and annually for 2 years. Human papillomavirus typing was performed on swabs (Roche Linear Array). Logistic regression models of human papillomavirus persistence were adjusted for demographic and behavioral characteristics. RESULTS HIV-infected women were older and less likely to be married and to own a home and had more lifetime sexual partners than HIV-uninfected women. All HIV-infected women were receiving anti-retroviral therapy at enrollment and had satisfactory CD4 cell counts and HIV viral loads. One- and two-year persistent human papillomavirus detection was significantly associated with HIV infection for any human papillomavirus, high-risk human papillomavirus, International Agency for the Research on Cancer-classified high-risk human papillomavirus, and non-oncogenic "low-risk" human papillomavirus. CONCLUSION Persistent detection of oncogenic and non-oncogenic human papillomavirus was strongly associated with HIV infection in Kenyan women with re-constituted immune systems based on satisfactory CD4 cell counts. In addition to HIV infection, factors associated with an increased risk of human papillomavirus persistence included a higher number of lifetime sex partners. Factors associated with decreased risk of human papillomavirus persistence included older age and being married. Further studies are needed to identify the immunological defects in HIV-infected women that allow human papillomavirus persistence, even in women receiving effective anti-retroviral therapy. Further studies are also needed to determine the significance of low-risk human papillomavirus persistence in HIV-infected women.
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Affiliation(s)
- Yan Tong
- Indiana University School of Medicine,
Indianapolis, IN, USA
| | | | - Aaron Ermel
- Indiana University School of Medicine,
Indianapolis, IN, USA
| | | | - Nelson Wong
- Indiana University School of Medicine,
Indianapolis, IN, USA
| | | | | | | | | | - Darron R Brown
- Indiana University School of Medicine,
Indianapolis, IN, USA
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8
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Klein C, Kahesa C, Mwaiselage J, West JT, Wood C, Angeletti PC. How the Cervical Microbiota Contributes to Cervical Cancer Risk in Sub-Saharan Africa. Front Cell Infect Microbiol 2020; 10:23. [PMID: 32117800 PMCID: PMC7028704 DOI: 10.3389/fcimb.2020.00023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/15/2020] [Indexed: 12/29/2022] Open
Abstract
Despite ongoing efforts, sub-Saharan Africa faces a higher cervical cancer burden than anywhere else in the world. Besides HPV infection, definitive factors of cervical cancer are still unclear. Particular states of the cervicovaginal microbiota and viral infections are associated with increased cervical cancer risk. Notably, HIV infection, which is prevalent in sub-Saharan Africa, greatly increases risk of cervicovaginal dysbiosis and cervical cancer. To better understand and address cervical cancer in sub-Saharan Africa, a better knowledge of the regional cervicovaginal microbiome is required This review establishes current knowledge of HPV, HIV, cervicovaginal infections, and the cervicovaginal microbiota in sub-Saharan Africa. Because population statistics are not available for the region, estimates are derived from smaller cohort studies. Microbiota associated with cervical inflammation have been found to be especially prevalent in sub-Saharan Africa, and to associate with increased cervical cancer risk. In addition to high prevalence and diversity of HIV and HPV, intracellular bacterial infections such as Chlamydia, Gonorrhea, and Mycoplasma hominis are much more common than in regions with a low burden of cervical cancer. This suggests the prevalence of cervical cancer in sub-Saharan Africa may be partially attributed to increased cervical inflammation resulting from higher likelihood of cervical infection and/or microbial dysbiosis.
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Affiliation(s)
- Cameron Klein
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, United States
| | | | | | - John T West
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Charles Wood
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, United States
| | - Peter C Angeletti
- Nebraska Center for Virology, School of Biological Sciences, University of Nebraska-Lincoln, Lincoln, NE, United States
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9
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Vasnik GK, Jain G, Husainy FA, Bansal V. Correlation of Cervical Squamous Intraepithelial Lesions with Human Papillomavirus in Women Infected with the Human Immunodeficiency Virus. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2019. [DOI: 10.1007/s40944-018-0251-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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10
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Abstract
Human papillomavirus (HPV) is the first identified necessary cause of human cancers and is associated with nearly 100% of all cervical cancers. Compared to the general female populations, HIV+ women have higher prevalence and incidence of cervical HPV infections, higher risks of persistent HPV infections and subsequent cervical intraepithelial lesions, and a higher incidence of cervical cancer. Although the wide use of combined antiretroviral therapy (cART) has improved the immune function and the longevity of HIV+ women, the incidence of cervical cancer in HIV+ women has not declined. For HIV+ women who follow routine cervical cancer screenings, their incidence of cervical cancer is comparable to that in HIV-negative women. Thus, adherence to the recommended cervical cancer screening is still critical for HIV+ women to prevent cervical cancer. Prophylactic HPV vaccines may also benefit HIV+ women, but prospective studies are needed to determine the effectiveness of HPV vaccination on reducing cervical cancer incidence in HIV+ women.
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Affiliation(s)
- Ping Du
- Department of Medicine, Department of Public Health Sciences, Penn State Hershey College of Medicine, 90 Hope Drive, Suite 2200, A210, Hershey, PA, USA.
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11
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Menon S, Rossi R, Zdraveska N, Kariisa M, Acharya SD, Vanden Broeck D, Callens S. Associations between highly active antiretroviral therapy and the presence of HPV, premalignant and malignant cervical lesions in sub-Saharan Africa, a systematic review: current evidence and directions for future research. BMJ Open 2017; 7:e015123. [PMID: 28780541 PMCID: PMC5724112 DOI: 10.1136/bmjopen-2016-015123] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES In sub-Saharan Africa, substantial international funding along with evidence-based clinical practice have resulted in an unparalleled scale-up of access to antiretroviral treatment at a higher CD4 count. The role and timing of highly active antiretroviral therapy (HAART) in mediating cervical disease remains unclear. The aim of this article is to systematically review all evidence pertaining to Africa and identify research gaps regarding the epidemiological association between HAART use and the presence of premalignant/malignant cervical lesions. METHOD Five databases were searched until January 2017 to retrieve relevant literature from sub-Saharan Africa. Publications were included if they addressed prevalence, incidence or clearance of human papillomavirus (HPV) infection in women undergoing HAART as well as cytological or histological neoplastic abnormalities. RESULTS 22 studies were included, of which seven were prospective studies. Women receiving HAART are less likely to develop squamous intraepithelial lesions (SILs). There is evidence that duration of HAART along with the CD4 count may reduce the prevalence of high-risk HPV (HR-HPV), suggesting that without HAART, severe immunosuppression increases the risk of becoming or remaining infected with HR-HPV. Furthermore, according to existent literature, the CD4 count, rather than HAART coverage or its duration, plays a central role in the prevalence of cervical intraepithelial neoplasia (CIN) 2 and CIN 3. CONCLUSION Our findings suggest a positive impact of HAART duration, in conjunction and interaction with CD4 count, on reducing the prevalence of HR-HPV. The greatest treatment effect might be seen among women starting at the lowest CD4 count, which may have a more instrumental role in cervical oncogenesis than either HAART use or the treatment duration on the prevalence of CIN 2 and CIN 3. There is still insufficient evidence to show a clear association between HAART coverage and the incidence of invasive cervical cancer. Enhanced surveillance on the impact of HAART treatment is crucial.
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Affiliation(s)
- Sonia Menon
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
- CDC Foundation, Atlanta, Georgia, USA
| | - Rodolfo Rossi
- Laboratory for Cell Biology & Histology, University of Antwerp, Antwerp, Belgium
| | - Natasha Zdraveska
- Department of Clinical Pharmacy, Saints Cyril and Methodius, Republic of Macedonia
| | | | | | - Davy Vanden Broeck
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
- AMBIOR, Laboratory for Cell Biology & Histology, University of Antwerp, National Reference Centre for HPV, Laboratory of Molecular Pathology, Antwerp, Belgium
| | - Steven Callens
- Department of Internal Medicine & Infectious diseases, University Hospital, Ghent, Belgium
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12
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Kost BP, Hofmann J, Stoellnberger S, Bergauer F, Blankenstein T, Alba-Alejandre I, Stein A, Stuckart C, Weizsäcker K, Mylonas I, Mahner S, Gingelmaier A. Prevalence of human papillomavirus infection of the anal canal in women: A prospective analysis of high-risk populations. Oncol Lett 2017; 13:2495-2501. [PMID: 28454426 DOI: 10.3892/ol.2017.5714] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 11/23/2016] [Indexed: 12/17/2022] Open
Abstract
Infection with certain types of human papillomavirus (HPV) has been associated with the development of cervical and anal cancer. Worldwide, the incidence of anal cancer has increased markedly. The present study aimed to evaluate the prevalence of HPV infection of the uterine cervix and anal canal in human immunodeficiency virus (HIV)- and non-HIV-infected risk populations. Cervical and anal HPV swabs and cytology samples were collected from 287 patients at the University Hospital of Munich, Germany between 2011 and 2013. Patients were divided into HIV-negative controls (G1) and two risk groups, including HIV-negative patients with cytological abnormalities of the cervix (G2) and HIV-infected patients (G3). Data, including clinical parameters, were analysed. The risk groups had significantly more positive results for HPV in the anus (71.03 and 83.15% for G2 and G3, respectively), as compared with G1. The predominant HPV genotypes found in the anus were high-risk HPV genotypes, which were significantly correlated with concomittant cervical HPV findings. In the risk groups, a significant association between the cytological findings and HPV detection in the cervix was found, while the results of the anus revealed no significance. The results of the present study suggested that the prevalence of HPV infection in the anal canal of risk populations is high. Furthermore, patients with abnormal cervical cytology results and HIV-infected women, irrespective of their individual cervical findings, may have a risk of concomittant anal high-risk HPV infection. Based on the predominant HPV genotypes found in the study, HPV vaccination could reduce the incidence of anal cancer. Nevertheless, high-risk patients should be intensively screened for anal squamous intraepithelial abnormalities to avoid invasive cancer stages.
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Affiliation(s)
- Bernd P Kost
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Jörg Hofmann
- Institute of Medical Virology, Charité-Universitätsmedizin, D-10117 Berlin, Germany
| | - Susanne Stoellnberger
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Florian Bergauer
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Thomas Blankenstein
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Irene Alba-Alejandre
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Angela Stein
- Institute of Medical Virology, Charité-Universitätsmedizin, D-10117 Berlin, Germany
| | - Claudia Stuckart
- STAT-UP Statistical Consulting and Services, D-80802 Munich, Germany
| | - Katharina Weizsäcker
- Department of Obstetrics and Gynecology, Charité-Universitätsmedizin, D-10117 Berlin, Germany
| | - Ioannis Mylonas
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Sven Mahner
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
| | - Andrea Gingelmaier
- Department of Gynecology and Obstetrics, Ludwig-Maximilian University of Munich, D-80337 Munich, Germany
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Yar DD, Salifu SP, Darko SN, Annan AA, Gyimah AA, Buabeng KO, Owusu-Dabo E. Genotypic characterisation of human papillomavirus infections among persons living with HIV infection; a case-control study in Kumasi, Ghana. Trop Med Int Health 2015; 21:275-82. [PMID: 26598430 DOI: 10.1111/tmi.12645] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The objective of this study is to describe the burden of human papillomavirus (HPV) infection among women living with HIV and non-infected women in Ghana. METHODS A case-control study was conducted involving 107 women living with HIV aged between 18 and 59 years (cases) and 100 non-HIV-infected apparently healthy women (controls) who were recruited from the Kumasi South Hospital, from July to December, 2014. Cervicovaginal swabs were taken from study participants to characterise 28 high- and low-risk HPV genotypes using a multiplex real-time PCR. RESULTS The overall mean age for the participants was 40.10 ± 9.76 years. The prevalence of high-risk (hr)-HPV genotypes was significantly higher among the cases than the controls (77.4% vs. 41.6%, P < 0.0001). Overall, HPV 58 and 54 were the most predominant high-risk (18.8%) and low-risk (15.0%) genotypes detected. The two most common hr-HPV genotype isolates were 58 (18.8%) and 35 (15.9%) with 58 being the most prevalent among age group 35-44 years compared with hr-HPV 16, 18, 35 and 45, found predominantly among 18-34 age group. CONCLUSIONS Significant variations exist in HPV genotypes among HIV-infected and uninfected women.
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Affiliation(s)
- Denis Dekugmen Yar
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Samson Pandam Salifu
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Samuel Nkansah Darko
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Augustina Angelina Annan
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Kwame Ohene Buabeng
- Department of Clinical and Social Pharmacy, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ellis Owusu-Dabo
- Kumasi Centre for Collaborative Research in Tropical Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.,School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Bateman AC, Katundu K, Mwanahamuntu MH, Kapambwe S, Sahasrabuddhe VV, Hicks ML, Chi BH, Stringer JSA, Parham GP, Chibwesha CJ. The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study. BMC Cancer 2015. [PMID: 26205980 PMCID: PMC4512016 DOI: 10.1186/s12885-015-1558-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC. Methods We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia’s most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally. Results Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC. Conclusions The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
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Affiliation(s)
- Allen C Bateman
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Katundu Katundu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | - Mulindi H Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of Zambia, Lusaka, Zambia.
| | - Sharon Kapambwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | | | | | - Benjamin H Chi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Groesbeck P Parham
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. .,University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. .,University of Zambia, Lusaka, Zambia.
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15
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Castilho JL, Levi JE, Luz PM, Cambou MC, Vanni T, de Andrade A, Derrico M, Veloso VG, Grinsztejn B, Friedman RK. A cross-sectional study of high-risk human papillomavirus clustering and cervical outcomes in HIV-infected women in Rio de Janeiro, Brazil. BMC Cancer 2015; 15:478. [PMID: 26100400 PMCID: PMC4477502 DOI: 10.1186/s12885-015-1486-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 06/09/2015] [Indexed: 01/22/2023] Open
Abstract
Background In Brazil, the rate of cervical cancer remains high despite the availability of screening programs. With ongoing vaccine development and implementation, information on the prevalence of specific HPV types is needed, particularly among high-risk populations, such as HIV-infected women. Methods We performed a study of HIV-infected women in Rio de Janeiro, Brazil, who underwent cervical HPV genotype testing between 2005-2013. We examined the prevalence of high-risk HPV types and the patterns of high-risk HPV type clustering. Using logarithmic binomial regression, we estimated the risk of abnormal cytology by HPV genotype result. Results Of the 562 women included, 498 (89 %) had at least one HPV type detected. 364 women (65 %) had at least one high-risk HPV type detected and 181 (32 %) had more than one high-risk type detected. HPV 58 was the most frequent HPV type detected overall (prevalence 19.8 % [95 % confidence interval 16.4–23.1]), followed by HPV 53 (prevalence 15.5 % [12.5–18.5]) and HPV 16 (prevalence 13 % [10.2–15.8]). Women infected with more than one high-risk HPV type were younger, had lower CD4+ lymphocyte counts, and were more likely to be infected with HPV 16 or 18. In adjusted analyses, presence of more than one high-risk HPV type was associated with a two-fold increased risk of abnormal cytology after adjusting for presence of individual high-risk type, age, and CD4+ lymphocyte count (adjusted prevalence ratios 1.88–2.07, all p <0.001). No single high-risk HPV type was statistically associated with abnormal cytology after adjusting for the presence of more than one high-risk HPV type. Conclusions In the largest study of cervical HPV genotypes among HIV-infected women in Latin America, infection by high-risk HPV types other than 16 or 18 and infection by more than one high-risk HPV types were common. Infection by more than one high-risk type was more strongly associated with abnormal cervical cytology than any individual high-risk HPV type, highlighting the need for multi-valent HPV vaccines.
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Affiliation(s)
- Jessica L Castilho
- Division of Infectious Diseases, Vanderbilt University School of Medicine, Nashville, USA.
| | - José Eduardo Levi
- Virology Lab, Instituto de Medicina Tropical da Universidade de São Paulo, São Paulo, Brazil.
| | - Paula M Luz
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | - Mary Catherine Cambou
- Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine at UCLA, Los Angeles, USA.
| | - Tazio Vanni
- Departamento de Ciência e Tecnologia, Ministério da Saúde, Brasília, Brazil.
| | - Angela de Andrade
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | - Mônica Derrico
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | - Valdiléa G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
| | - Ruth K Friedman
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil.
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16
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Human papilloma virus vaccination induces strong human papilloma virus specific cell-mediated immune responses in HIV-infected adolescents and young adults. AIDS 2015; 29:739-43. [PMID: 25849837 DOI: 10.1097/qad.0000000000000597] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The ability of a quadrivalent human papilloma virus (HPV)-16/18/6/11 virus-like particles vaccine (Gardasil) to elicit HPV-specific cell-mediated immune responses was evaluated in antiretroviral therapy (ART)-treated HIV-infected young adults. Results showed that, after three doses of vaccine, central memory and effector memory CD4(+) and CD8(+) T lymphocytes, as well as HPV-specific interleukin (IL)2(+)/CD4(+), interferon-gamma (IFN-γ(+))/CD4(+), IFN-γ(+)/CD8(+) and tumour necrosis factor-alpha (TNF-α)(+)/CD8(+) T lymphocytes and Perforin and Granzyme B secreting CD8(+) T lymphocytes were significantly increased. Notably, results obtained in HIV-infected patients were comparable to those seen in HIV-uninfected age-matched healthy controls.
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Ports KA, Haffejee F, Mosavel M, Rameshbabu A. Integrating cervical cancer prevention initiatives with HIV care in resource-constrained settings: A formative study in Durban, South Africa. Glob Public Health 2015; 10:1238-51. [PMID: 25654190 DOI: 10.1080/17441692.2015.1008021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Cervical cancer screening rates remain suboptimal among women in South Africa (SA), where cervical cancer prevalence is high. The rollout of HIV-related services across SA may provide a means to deliver cervical cancer screening to populations with limited access to health care systems. In this mixed methods study, psychosocial factors influencing cervical cancer prevention and perceptions of the provision of Pap smears in HIV care settings were examined. Structured interviews were conducted with women (n = 67) from a municipal housing estate in Durban, SA. Key informants (n = 12) also participated in semi-structured interviews. Findings revealed that participants had low cervical cancer knowledge, but desired more information. Relevant themes included the normalisation of HIV and beliefs that cervical cancer might be worse than HIV. A comprehensive community clinic was desired by most, even if HIV-positive patients were treated there. This study provides important insight into integrating cervical cancer screening with HIV clinics, which may increase cancer screening among South African women.
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Affiliation(s)
- Katie A Ports
- a Department of Social and Behavioral Health , Virginia Commonwealth University School of Medicine , Richmond , VA , USA
| | - Firoza Haffejee
- b Department of Basic Medical Sciences , Durban University of Technology , Durban , South Africa
| | - Maghboeba Mosavel
- a Department of Social and Behavioral Health , Virginia Commonwealth University School of Medicine , Richmond , VA , USA
| | - Anjali Rameshbabu
- c Department of Psychology , University of Wisconsin Milwaukee , Milwaukee , WI , USA
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Munthali AC, Ngwira BM, Taulo F. Exploring barriers to the delivery of cervical cancer screening and early treatment services in Malawi: some views from service providers. Patient Prefer Adherence 2015; 9:501-8. [PMID: 25848229 PMCID: PMC4376260 DOI: 10.2147/ppa.s69286] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cervical cancer is the most common reproductive health cancer in Malawi. In most cases, women report to health facilities when the disease is in its advanced stage. In this study, we investigate service providers' perceptions about barriers for women to access cervical cancer screening and early treatment services in Malawi. METHODS We conducted in-depth interviews with 13 district coordinators and 40 service providers of cervical cancer screening and early treatment services in 13 districts in Malawi. The study was conducted in 2012. The district coordinators helped the research team identify the health facilities which were providing cervical cancer screening and early treatment services. RESULTS Almost all informants reported that cervical cancer was a major public health problem in their districts and that prevention efforts for this disease were being implemented. They were aware of the test and treat approach using visual inspection with acetic acid (VIA). They, however, said that the delivery of cervical cancer screening and early treatment services was compromised because of factors such as gross shortage of staff, lack of equipment and supplies, the lack of supportive supervision, and the use of male service providers. Informants added that the lack of awareness about the disease among community members, long distances to health facilities, the lack of involvement of husbands, and prevailing misperceptions about the disease (eg, that it is caused by the exposure to the VIA process) affect the uptake of these services. CONCLUSION While progress has been made in the provision of cervical cancer screening and early treatment services in Malawi, a number of factors affect service delivery and uptake. There is a need to continue creating awareness among community members including husbands and also addressing identified barriers such as shortage of staff and supplies in order to improve uptake of services.
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Affiliation(s)
- Alister C Munthali
- Centre for Social Research, University of Malawi, Zomba, Malawi
- Correspondence: Alister C Munthali, Centre for Social Research, University of Malawi, Chancellor College, PO Box 278, Zomba, Malawi, Email
| | | | - Frank Taulo
- College of Medicine, University of Malawi, Blantyre, Malawi
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Williams M, Moneyham L, Kempf MC, Chamot E, Scarinci I. Structural and sociocultural factors associated with cervical cancer screening among HIV-infected African American women in Alabama. AIDS Patient Care STDS 2015; 29:13-9. [PMID: 25514125 DOI: 10.1089/apc.2014.0063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
African American women have disproportionately high prevalence rates of HIV and cervical cancer. HIV-infected women are significantly less likely to obtain recommended cervical cancer screenings than HIV-uninfected women. The purpose of this study was to examine sociocultural and structural factors associated with cervical cancer screening among HIV-infected African American in Alabama. The PEN-3 Model and the Health Belief Model were used as theoretical frameworks. In-depth interviews were conducted with twenty HIV-infected African American women to identify perceptions, enablers, and nurturers, perceived susceptibility, perceived severity, and perceived benefits related to cervical cancer and screening. The most common positive perceptions, enablers, and nurturers that contributed to cervical cancer screening included internal motivation and awareness of the importance of HIV-infected women getting Pap tests due to their weakened immune system. Negative perceptions, enablers, and nurturers included lack of knowledge about cervical cancer and screening, and lack of perceived susceptibility to cervical cancer. The results of this study can be used to guide the development of culturally relevant cervical cancer and screening education interventions aimed at increasing cervical cancer screening adherence among HIV-infected African American women.
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Affiliation(s)
- Michelle Williams
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Linda Moneyham
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Eric Chamot
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Isabel Scarinci
- Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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21
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Guimarães MVMB, Michelin MA, Lucena AADS, Lodi CTDC, Lima MIDM, Murta EFC, Melo VH. Cytokine expression in the cervical stroma of HIV-positive and HIV-negative women with cervical intraepithelial neoplasia. Viral Immunol 2014; 27:350-5. [PMID: 25014220 DOI: 10.1089/vim.2014.0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Cervical intraepithelial neoplasias (CINs) are a major public health issue. The prevalence of CINs is higher in women with the human immunodeficiency virus (HIV). The objective of this study was to determine whether there are differences in the immune responses in the cervical stroma of HIV-infected and -uninfected women with CIN. The responses were assessed according to the immunohistochemical expression of cytokines interleukin (IL)-4, IL-12, interferon gamma (IFN-γ), and tumor growth factor beta (TGF-β). In addition, we determined whether there were differences in the local immune responses between patients with CIN1 and CIN 2/3. A cross-sectional study was performed using material collected by cervical conization in HIV-infected and -uninfected women with CIN. The conization was performed using loop electrical excision procedure (LEEP) from January 1999 to May 2004. The evaluation of cytokines in the cervical stroma was based on immunohistochemistry. No differences were found between the two groups of women regarding HIV status. However, the associations between IL-12 expression and CIN 2/3 (p=0.016) in HIV-infected women and between IL-4 expression and CIN 1 (p=0.0456) in HIV-infected women were significant when the interaction between HIV infection and lesion grade was assessed. Additionally, a significant association between TGF-β expression and CIN 2/3 in both groups was observed regardless of HIV infection (p=0.000). An interaction between HIV infection and CIN grade was detected because IL-12 and IL-4 expression increased in the presence of HIV infection. Regarding the CIN grade, there was a high prevalence of TGF-β in CIN 2/3 lesions, which reflected the predominance of an immunoregulatory environment.
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International scientific collaboration in HIV and HPV: a network analysis. PLoS One 2014; 9:e93376. [PMID: 24682041 PMCID: PMC3969316 DOI: 10.1371/journal.pone.0093376] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 03/03/2014] [Indexed: 12/25/2022] Open
Abstract
Research endeavours require the collaborative effort of an increasing number of individuals. International scientific collaborations are particularly important for HIV and HPV co-infection studies, since the burden of disease is rising in developing countries, but most experts and research funds are found in developed countries, where the prevalence of HIV is low. The objective of our study was to investigate patterns of international scientific collaboration in HIV and HPV research using social network analysis. Through a systematic review of the literature, we obtained epidemiological data, as well as data on countries and authors involved in co-infection studies. The collaboration network was analysed in respect to the following: centrality, density, modularity, connected components, distance, clustering and spectral clustering. We observed that for many low- and middle-income countries there were no epidemiological estimates of HPV infection of the cervix among HIV-infected individuals. Most studies found only involved researchers from the same country (64%). Studies derived from international collaborations including high-income countries and either low- or middle-income countries had on average three times larger sample sizes than those including only high-income countries or low-income countries. The high global clustering coefficient (0.9) coupled with a short average distance between researchers (4.34) suggests a “small-world phenomenon.” Researchers from high-income countries seem to have higher degree centrality and tend to cluster together in densely connected communities. We found a large well-connected community, which encompasses 70% of researchers, and 49 other small isolated communities. Our findings suggest that in the field of HIV and HPV, there seems to be both room and incentives for researchers to engage in collaborations between countries of different income-level. Through international collaboration resources available to researchers in high-income countries can be efficiently used to enroll more participants in low- and middle-income countries.
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Willemot P, Klein MB. Prevention of HIV-associated opportunistic infections and diseases in the age of highly active antiretroviral therapy. Expert Rev Anti Infect Ther 2014; 2:521-32. [PMID: 15482218 DOI: 10.1586/14787210.2.4.521] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Since the introduction of highly active antiretroviral therapy (HAART), the rates of opportunistic infections have decreased markedly as has overall morbidity and mortality from HIV infection in developed countries. However, opportunistic infections remain the most important cause of death in HIV-infected people due to both late presentation of HIV infections and failure of HAART to adequately restore cell-mediated immunity in all individuals. While prophylaxis may be discontinued in patients who have responded to HAART with sustained increases of their CD4 counts above risk thresholds, for those patients who fail HAART, those who are unable to tolerate it, or whose treatments are interrupted, opportunistic-infection prophylaxis remains essential. Some HIV-associated diseases, such as anogenital human papilloma virus-induced neoplasia and hepatitis C infection, have not decreased in frequency with the advent of HAART. For these conditions, effective screening and treatment programs will be necessary to prevent ongoing morbidity. This review will provide an update on HIV-associated opportunistic infections and their prevention in the age of HAART, as well as discuss novel presentations of opportunistic illnesses, such as immune restoration syndromes.
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Affiliation(s)
- Patrick Willemot
- Royal Victoria Hospital, McGill University Health Center, Montreal, Quebec H2X 2P4, Canada.
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Cespedes MS, Kerns SL, Holzman RS, McLaren PJ, Ostrer H, Aberg JA. Genetic predictors of cervical dysplasia in African American HIV-infected women: ACTG DACS 268. HIV CLINICAL TRIALS 2013; 14:292-302. [PMID: 24334182 DOI: 10.1310/hct1406-292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To examine genome-wide associations in HIV-infected women with a history of cervical dysplasia compared with HIV-infected women with no history of abnormal Papanicolaou (Pap) tests. DESIGN Case-control study using data from women analyzed for the HIV Controllers Study and enrolled in HIV treatment-naïve studies in the AIDS Clinical Trials Group (ACTG). METHODS Genotyping utilized Illumina HumanHap 650 Y or 1MDuo platforms. After quality control and principal component analysis, ~610,000 significant single nucleotide polymorphisms (SNPs) were tested for association. Threshold for significance was P < 5 × 10(-8) for genome-wide associations. RESULTS No significant genomic association was observed between women with low-grade dysplasia and controls. The genome-wide association study (GWAS) analysis between women with high-grade dysplasia or invasive cervical cancer and normal controls identified significant SNPs. In the analyses limited to African American women, 11 SNPs were significantly associated with the development of high-grade dysplasia or cancer after correcting for multiple comparisons. The model using significant SNPs alone had improved accuracy in predicting high-grade dysplasia in African American women compared to the use of clinical data (area under the receiver operating characteristic curve for genetic and clinical model = 0.9 and 0.747, respectively). CONCLUSIONS These preliminary data serve as proof of concept that there may be a genetic predisposition to developing high-grade cervical dysplasia in African American HIV-infected women. Given the small sample size, the results need to be validated in a separate cohort.
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Affiliation(s)
| | | | | | - Paul J McLaren
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Harry Ostrer
- Albert Einstein College of Medicine, Bronx, New York
| | - Judith A Aberg
- New York University School of Medicine, New York, New York
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Patrelli TS, Gizzo S, Peri F, Franchi L, Volpi L, Esposito F, Pedrazzi G, Antoni AD, Modena AB. Impact of Highly Active Antiretroviral Therapy on the Natural History of Cervical Precancerous Lesions: A 17-Year Institutional Longitudinal Cohort Study. Reprod Sci 2013; 21:837-845. [PMID: 24336675 DOI: 10.1177/1933719113512531] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
We performed an observational cohort study in order to assess the correlation between precancerous cervical lesions (cervical intraepithelial neoplasia [CIN]) and immunological state in human immunodeficiency virus (HIV)-positive women treated by highly active antiretroviral therapy (HAART). We analyzed 194 HIV-infected women referred to the Parma-Universitary Hospital for early detection of human papilloma virus-induced CINs. We analyzed cytology, colposcopy, and CIN degree according to HAART: group A untreated and group B treated. We compared the CD4+ count and viral load at the time of CIN onset and the time interval between diagnosis of HIV and the onset of CIN. Group A and group B showed homogeneous results for general features, CD4+ count, viral load, and Papanicolaou test features. Differences were not found in terms of histology and CD4+ value, viral load count, pharmacological treatment, years since the diagnosis of HIV, age, smoking, sexual promiscuity, previous intravenous narcotics abuse, prostitution, sexually transmitted diseases, ethnicity, and age at diagnosis. Histology and the clinical stage of HIV showed significant concordances between the high degree of cervical dysplasia and advanced stage of HIV disease.
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Affiliation(s)
| | - Salvatore Gizzo
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | - Francesca Peri
- Department of Surgical Sciences, University of Parma, Parma, Italy
| | - Laura Franchi
- Department of Surgical Sciences, University of Parma, Parma, Italy
| | - Lavinia Volpi
- Department of Surgical Sciences, University of Parma, Parma, Italy
| | - Federica Esposito
- Department of Woman and Child Health, University of Padua, Padua, Italy
| | | | - Anna Degli Antoni
- Division of Infectious Diseases and Hepatology, University of Parma, Parma, Italy
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26
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Hanisch RA, Sow PS, Toure M, Dem A, Dembele B, Toure P, Winer RL, Hughes JP, Gottlieb GS, Feng Q, Kiviat NB, Hawes SE. Influence of HIV-1 and/or HIV-2 infection and CD4 count on cervical HPV DNA detection in women from Senegal, West Africa. J Clin Virol 2013; 58:696-702. [PMID: 24210330 DOI: 10.1016/j.jcv.2013.10.012] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 09/16/2013] [Accepted: 10/09/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND HIV infection is associated with greater risk of precancerous lesions and cervical cancer in women. However, several factors remain unclarified regarding the association between HIV infection and HPV detection, especially among those with HIV type 2 versus type 1 infection and severely immunocompromised persons. OBJECTIVES To evaluate HPV overall and type-specific detection among HIV-infected and uninfected women in Senegal. STUDY DESIGN Detection of HPV DNA for 38 genotypes in cervical swabs using PCR-based methods was evaluated in HIV-positive (n=467) and HIV-negative (n=2139) women participating in studies in Senegal. Among HIV-1 and/or HIV-2 positive women, CD4 counts were assessed. Adjusted multivariable prevalence ratios (PR) were calculated. RESULTS The prevalence of any HPV DNA and multiple HPV types was greater among HIV-infected individuals (78.2% and 62.3%, respectively) compared with HIV-negative women (27.1% and 11.6%). This trend was also seen for HPV types 16 and 18 (13.1% and 10.9%) compared to HIV-negative women (2.2% and 1.7%). HIV-infected women with CD4 cell counts less than 200 cells/μl had a higher likelihood of any HPV detection (PRa 1.30; 95% CI 1.07-1.59), multiple HPV types (PRa 1.52; 95% CI 1.14-2.01), and HPV-16 (PRa 9.00; 95% CI 1.66-48.67), but not HPV-18 (PRa 1.20, 95% CI 0.45-3.24) compared to those with CD4 counts 500 cells/μl or above. CONCLUSION HIV-infected women, especially those most severely immunocompromised, are more likely to harbor HPV. Measures to prevent initial HPV infection and subsequent development of cervical cancer through focused screening efforts should be implemented in these high risk populations.
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Affiliation(s)
- R A Hanisch
- Department of Epidemiology, School of Public Health, University of Washington, Box 357236, Seattle, WA 98195, USA; International Agency for Research on Cancer, Section of Environment and Radiation, 150 Cours Albert Thomas, Lyon, 69372 Cedex 08, France.
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Konopnicki D, De Wit S, Clumeck N. HPV and HIV coinfection: a complex interaction resulting in epidemiological, clinical and therapeutic implications. Future Virol 2013. [DOI: 10.2217/fvl.13.69] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
HPV and HIV each display interactions favoring the other infection at the cellular level. HPV infection favors HIV acquisition in women and men, and HIV-infected individuals encompass a heavier burden of HPV-induced dysplasia and cancer due to progressive immune suppression. Both infections contribute to a vicious circle that may account for the scale-up of both pandemics in some regions of the world. HAART might be beneficial in reducing HPV infection and associated lesions, but only after several years with optimal control of HIV viremia and an immune reconstitution of great amplitude. Yet, the incidence of cervical and anal cancer has not decreased in the HAART era. In this review, we will look at the viral interactions between HPV and HIV at the cellular and clinical levels. We will analyze the epidemiological link between the two epidemics and try to propose therapeutic and vaccine strategies to act on both pandemics.
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Affiliation(s)
- Deborah Konopnicki
- Infectious Diseases Department & AIDS Reference Center, Saint-Pierre University Hospital, Brussels, Belgium
| | - Stephane De Wit
- Infectious Diseases Department & AIDS Reference Center, Saint-Pierre University Hospital, Brussels, Belgium
| | - Nathan Clumeck
- Infectious Diseases Department & AIDS Reference Center, Saint-Pierre University Hospital, Brussels, Belgium
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Sudenga SL, Wiener HW, Shendre A, Wilson CM, Tang J, Shrestha S. Variants in interleukin family of cytokines genes influence clearance of high risk HPV in HIV-1 coinfected African-American adolescents. Hum Immunol 2013; 74:1696-700. [PMID: 23973891 DOI: 10.1016/j.humimm.2013.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 06/19/2013] [Accepted: 08/10/2013] [Indexed: 10/26/2022]
Abstract
Our work aimed to examine the potential influence of variants in interleukin/interleukin receptors genes on high-risk (HR-HPV) HPV clearance. Clearance of genital HR-HPV infection was evaluated for 134 HIV-1 seropositive African-American female adolescents from the Reaching for Excellence in Adolescent Care and Health (REACH) cohort. Genotyping targeted 225 single nucleotide polymorphisms (SNPs) within the exons, 5' untranslated region (UTR) and 3' UTR sequences of 27 immune-related candidate genes encoding interleukin family of cytokines. Cox proportional hazard models were used to determine the association of type-specific HPV clearance adjusting for time-varying CD4+ T-cell count and low-risk (LR-HPV) HPV co-infections. HR-HPV clearance rates were significantly (p < 0.001) associated with five SNPs (rs228942, rs419598, rs315950, rs7737000, and rs9292618) mapped to coding and regulatory regions in three genes (IL2RB, IL1RN, and IL7R). These data suggest that the analyzed genetic variants in interleukin family of cytokines modulate HR-HPV clearance in HIV-1 seropositive African-Americans that warrants replication.
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Affiliation(s)
- Staci L Sudenga
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
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Garcia-Chagollan M, Jave-Suarez LF, Haramati J, Sanchez-Hernandez PE, Aguilar-Lemarroy A, Bueno-Topete MR, Pereira-Suarez AL, Fafutis-Morris M, Cid-Arregui A, del Toro-Arreola S. Substantial increase in the frequency of circulating CD4+NKG2D+ T cells in patients with cervical intraepithelial neoplasia grade 1. J Biomed Sci 2013; 20:60. [PMID: 23947399 PMCID: PMC3751941 DOI: 10.1186/1423-0127-20-60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/15/2013] [Indexed: 01/13/2023] Open
Abstract
Background The NKG2D receptor confers important activating signals to NK cells via ligands expressed during cellular stress and viral infection. This receptor has generated great interest because not only is it expressed on NK cells, but it is also seen in virtually all CD8+ cytotoxic T cells and is classically considered absent in CD4+ T cells. However, recent studies have identified a distinctive population of CD4+ T cells that do express NKG2D, which could represent a particular cytotoxic effector population involved in viral infections and chronic diseases. On the other hand, increased incidence of human papillomavirus-associated lesions in CD4+ T cell-immunocompromised individuals suggests that CD4+ T cells play a key role in controlling the viral infection. Therefore, this study was focused on identifying the frequency of NKG2D-expressing CD4+ T cells in patients with cervical intraepithelial neoplasia (CIN) 1. Additionally, factors influencing CD4+NKG2D+ T cell expansion were also measured. Results Close to 50% of patients with CIN 1 contained at least one of the 37 HPV types detected by our genotyping system. A tendency for increased CD4+ T cells and CD8+ T cells and decreased NK cells was found in CIN 1 patients. The percentage of circulating CD4+ T cells co-expressing the NKG2D receptor significantly increased in women with CIN 1 versus control group. Interestingly, the increase of CD4+NKG2D+ T cells was seen in patients with CIN 1, despite the overall levels of CD4+ T cells did not significantly increase. We also found a significant increase of soluble MICB in CIN 1 patients; however, no correlation with the presence of CD4+NKG2D+ T cells was seen. While TGF-beta was significantly decreased in the group of CIN 1 patients, both TNF-alpha and IL-15 showed a tendency to increase in this group. Conclusions Taken together, our results suggest that the significant increase within the CD4+NKG2D+ T cell population in CIN 1 patients might be the result of a chronic exposure to viral and/or pro-inflammatory factors, and concomitantly might also influence the clearance of CIN 1-type lesion.
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Affiliation(s)
- Mariel Garcia-Chagollan
- Laboratorio de Inmunología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Sierra Mojada # 950, Colonia Independencia, Guadalajara, Jalisco CP 44340, México
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Isaakidis P, Pimple S, Varghese B, Khan S, Mansoor H, Ladomirska J, Sharma N, Silva ED, Metcalf C, Caluwaerts S, Alders P, Ntzani EE, Reid T. HPV infection, cervical abnormalities, and cancer in HIV-infected women in Mumbai, India: 12-month follow-up. Int J Womens Health 2013; 5:487-94. [PMID: 23976867 PMCID: PMC3746789 DOI: 10.2147/ijwh.s47710] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background HIV-infected women are at a higher risk of cervical intraepithelial neoplasia (CIN) and cancer than women in the general population, partly due to a high prevalence of persistent human papillomavirus (HPV) infection. The aim of the study was to assess the burden of HPV infection, cervical abnormalities, and cervical cancer among a cohort of HIV-infected women as part of a routine screening in an urban overpopulated slum setting in Mumbai, India. Methods From May 2010 to October 2010, Médecins Sans Frontières and Tata Memorial Hospital Mumbai offered routine annual Pap smears and HPV DNA testing of women attending an antiretroviral therapy (ART) clinic and a 12-month follow-up. Women with abnormal test results were offered cervical biopsy and treatment, including treatment for sexually transmitted infections (STIs). Results Ninety-five women were screened. Median age was 38 years (IQR: 33–41); median nadir CD4-count 143 cells/μL (IQR: 79–270); and median time on ART 23 months (IQR:10–41). HPV DNA was detected in 30/94 women (32%), and 18/94 (19%) showed either low-grade or high-grade squamous intraepithelial lesions (LSIL/HSIL) on Pap smear. Overall, >50% had cervical inflammatory reactions including STIs. Of the 43 women with a cervical biopsy, eight (8.4%) had CIN-1, five (5.3%) CIN-2, and two (2.1%) carcinoma in situ. All but one had HPV DNA detected (risk ratio: 11, 95% confidence interval: 3.3–34). By October 2011, 56 women had completed the 12-month follow-up and had been rescreened. No new cases of HPV infection/LSIL/HSIL were detected. Conclusion The high prevalence of HPV infection, STIs, and cervical lesions among women attending an ART clinic demonstrates a need for routine screening. Simple, one-stop screening strategies are needed. The optimal screening interval, especially when resources are limited, needs to be determined.
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Affiliation(s)
- Petros Isaakidis
- Médecins sans Frontières, Mumbai, India ; Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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Lopez CR, Antoni MH, Pereira D, Seay J, Whitehead N, Potter J, O'Sullivan M, Fletcher MA. Stress Management, Depression and Immune Status in Lower Income Racial/Ethnic Minority Women Co-infected with HIV and HPV. ACTA ACUST UNITED AC 2013; 18:37-57. [PMID: 23526866 DOI: 10.1111/jabr.12003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Konopnicki D, Manigart Y, Gilles C, Barlow P, de Marchin J, Feoli F, Larsimont D, Delforge M, De Wit S, Clumeck N. Sustained viral suppression and higher CD4+ T-cell count reduces the risk of persistent cervical high-risk human papillomavirus infection in HIV-positive women. J Infect Dis 2013; 207:1723-9. [PMID: 23463709 DOI: 10.1093/infdis/jit090] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Studies analyzing the impact of combination antiretroviral therapy (cART) on cervical infection with high-risk human papillomavirus (HR-HPV) have generated conflicting results. We assessed the long-term impact of cART on persistent cervical HR-HPV infection in a very large cohort of 652 women who underwent follow-up of HIV infection for a median duration of 104 months. METHODS Prospective cohort of HIV-infected women undergoing HIV infection follow-up who had HR-HPV screening and cytology by Papanicolaou smear performed yearly between 2002 and 2011. RESULTS At baseline, the median age was 38 years, the race/ethnic origin was sub-Sarahan Africa for 84%, the median CD4(+) T-cell count was 426 cells/µL, 79% were receiving cART, and the HR-HPV prevalence was 43%. The median interval of having had an HIV load of <50 copies/mL was 40.6 months at the time of a HR-HPV-negative test result, compared with 17 months at the time of a HR-HPV-positive test result (P < .0001, by univariate analysis). The median interval of having had a CD4(+) T-cell count of >500 cells/µL was 18.4 months at the time of a HR-HPV-negative test result, compared with 4.45 months at the time of a HR-HPV-positive test result (P < .0001). In multivariate analysis, having had an HIV load of <50 copies/mL for >40 months (odds ratio [OR], 0.81; 95% confidence interval [CI], .76-.86; P < .0001) and having had a CD4(+) T-cell count of >500 cells/µL for >18 months (OR, 0.88; 95% CI, .82-.94; P = .0002) were associated with a significantly decreased risk of HR-HPV infection. CONCLUSION Sustained HIV suppression for >40 months and a sustained CD4(+) T-cell count of >500 cells/µL for >18 months are independently and significantly associated with a decreased risk of persistent cervical HR-HPV infection.
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Affiliation(s)
- Deborah Konopnicki
- Department of Infectious Diseases and AIDS Reference Center, Saint-Pierre University Hospital, rue Haute 322, Brussels 1000, Belgium.
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Coutlée F, de Pokomandy A, Franco EL. Epidemiology, natural history and risk factors for anal intraepithelial neoplasia. Sex Health 2013; 9:547-55. [PMID: 22954036 DOI: 10.1071/sh11167] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/07/2012] [Indexed: 01/02/2023]
Abstract
Studies conducted in HIV-seropositive individuals have enhanced our understanding of the natural history of anal intraepithelial neoplasia (AIN) and of factors predictive of progression to high-grade AIN, the immediate precursor to anal cancer. AIN is frequently detected in HIV-seropositive individuals. Factors that increase the risk for AIN include HIV infection, low current or nadir blood CD4+ cell counts, receptive anal intercourse, oncogenic human papillomavirus (HPV) infection, persistent anal HPV infection, multiple HPV type infections and high anal HPV viral load. This review confirms the importance of high-grade AIN in HIV-seropositive individuals and HIV-seronegative men having sex with men.
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Affiliation(s)
- François Coutlée
- Départements de Microbiologie et Infectiologie, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
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High-risk human papillomavirus infection in HIV-positive African women living in Europe. J Int AIDS Soc 2013; 16:18023. [PMID: 23406965 PMCID: PMC3574170 DOI: 10.7448/ias.16.1.18023] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 12/12/2012] [Accepted: 01/10/2013] [Indexed: 11/21/2022] Open
Abstract
Introduction Cervical infection with high-risk human papillomavirus (HRHPV) induces cervical cancer and is present in 14% of women in Europe. We assessed the prevalence and incidence of cervical HRHPV in a cohort of HIV-positive women living in Belgium. Methods Prospective observational program of screening and follow up of HRHPV cervical infection performed by Hybrid Capture in 825 HIV-positive women between 2002 and 2011. Women without normal cervix at baseline were excluded. Results The final analysis included 652 women: median age 38 years, African origin (81%), median HIV follow-up (66 months), median CD4 count (426 cells/μL) and 79% on antiretroviral therapy (cART). At baseline, HRHPV prevalence was 43% and decreased significantly as both age and CD4 cell count increased: highest prevalence (100%) in women <30 years and <200 CD4/μL and lowest (19%) in women >40 years and >500 CD4/μL (p<0.0001, multivariate analysis). The relative risk (RR) to carry HRHPV at baseline decreases proportionally by 11% for each 5 years-age increase and by 11% for each 100 CD4 cells/μL rise (RR=0.89, 95% CI: 0.85-0.93; p<0.0001, Poisson regression for both). During follow-up, incidence rate of HRHPV was 13.4 per 100 women-years. Conclusions We found a high HRHPV prevalence of 43% and an incidence rate of 13 per 100 women-years in this cohort of HIV-positive women living in Europe and on cART. Women under 40 years-age had the highest prevalence even with CD4 count >350 cells/μL. The magnitude of HRHPV epidemiology should prompt to evaluate the clinical efficacy of vaccines against HPV in HIV-infected women.
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Rositch AF, Gravitt PE, Tobian AAR, Newell K, Quinn TC, Serwadda D, Ssebbowa P, Kiggundu V, Gray RH, Reynolds SJ. Frequent detection of HPV before and after initiation of antiretroviral therapy among HIV/HSV-2 co-infected women in Uganda. PLoS One 2013; 8:e55383. [PMID: 23383171 PMCID: PMC3558485 DOI: 10.1371/journal.pone.0055383] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/21/2012] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Most data on HPV and antiretroviral therapy (ART) come from high-resource countries with infrequent sampling for HPV pre- and post-ART initiation. Therefore, we examined the frequency of cervical HPV DNA detection among HIV/HSV-2 co-infected women followed monthly for 6 months both before and after initiation of ART in Rakai, Uganda. METHODS Linear Array was used to detect 37 HPV genotypes in self-collected cervicovaginal swabs from 96 women who initiated ART. Random-effects log-binomial regression was used to compare the prevalence of HPV detection in the pre- and post-ART periods and determine other potential risk factors, including CD4 counts and HIV viral load. RESULTS Nearly all women had detectable HPV in the 6 months preceding ART initiation (92%) and the cumulative prevalence remained high following initiation of therapy (90%). We found no effect of ART on monthly HPV DNA detection (prevalence ratio: 1.0; 95% confidence interval: 0.96, 1.08), regardless of immune reconstitution or HIV viral suppression. Older age and higher pre-ART CD4 counts were associated with a significantly lower risk of HPV DNA detection. CONCLUSIONS ART did not impact HPV detection within 6 months of therapy initiation, highlighting the importance of continued and consistent screening, even after ART-initiation and immune reconstitution.
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Affiliation(s)
- Anne F Rositch
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
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Couture MC, Page K, Stein ES, Sansothy N, Sichan K, Kaldor J, Evans JL, Maher L, Palefsky J. Cervical human papillomavirus infection among young women engaged in sex work in Phnom Penh, Cambodia: prevalence, genotypes, risk factors and association with HIV infection. BMC Infect Dis 2012; 12:166. [PMID: 22839728 PMCID: PMC3436768 DOI: 10.1186/1471-2334-12-166] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 06/29/2012] [Indexed: 01/09/2023] Open
Abstract
Background Although cervical cancer is the leading cancer in Cambodia, most women receive no routine screening for cervical cancer and few treatment options exist. Moreover, nothing is known regarding the prevalence of cervical HPV or the genotypes present among women in the country. Young sexually active women, especially those with multiple sex partners are at highest risk of HPV infection. We examine the prevalence and genotypes of cervical HPV, as well as the associated risk factors among young women engaged in sex work in Phnom Penh, Cambodia. Methods We conducted a cross-sectional study among 220 young women (15–29 years) engaged in sex work in different venues including brothels or entertainment establishments, and on a freelance basis in streets, parks and private apartments. Cervical specimens were collected using standard cytobrush technique. HPV DNA was tested for by polymerase chain reaction (PCR) and genotyping using type-specific probes for 29 individual HPV types, as well as for a mixture of 10 less common HPV types. All participants were also screened for HIV status using blood samples. Multivariate logistic regression analyses were conducted to assess risk factors for any or multiple HPV infection. Results The prevalence of cervical HPV 41.1%. HPV 51 and 70 were the most common (5.0%), followed by 16 (4.6%), 71 (4.1%) and 81 (3.7%). Thirty-six women (16.4%) were infected with multiple genotypes and 23.3% were infected with at least one oncogenic HPV type. In multivariate analyses, having HIV infection and a higher number of sexual partners were associated with cervical HPV infection. Risk factors for infection with multiple genotypes included working as freelance female sex workers (FSW) or in brothels, recent binge use of drugs, high number of sexual partners, and HIV infection. Conclusions This is the first Cambodian study on cervical HPV prevalence and genotypes. We found that HPV infection was common among young FSW, especially among women infected with HIV. These results underscore the urgent need for accessible cervical cancer screening and treatment, as well as for a prophylactic vaccine that covers the HPV subtypes present in Cambodia.
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Affiliation(s)
- Marie-Claude Couture
- University of California San Francisco, Global Health Sciences, 50 Beale street, Suite 1200, San Francisco, CA 94105, USA.
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Luz PM, Velasque L, Friedman RK, Russomano F, Andrade AC, Moreira RI, Chicarino-Coelho J, Pires E, Veloso VG, Grinsztejn B. Cervical cytological abnormalities and factors associated with high-grade squamous intraepithelial lesions among HIV-infected women from Rio de Janeiro, Brazil. Int J STD AIDS 2012; 23:12-7. [PMID: 22362681 DOI: 10.1258/ijsa.2009.009409] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although cervical cancer remains a major public health problem in Brazil, knowledge of cervical cytological abnormalities among HIV-infected women remains scarce. At baseline evaluation of a cohort followed in Rio de Janeiro, Brazil, 703 HIV-infected women underwent cytology-based cervical cancer screening and human papillomavirus (HPV) DNA testing. Poisson regression analysis was used to evaluate the association of factors with the presence of high-grade squamous intraepithelial lesions (HSIL). Cervical cytology was abnormal in 24.3% of the women; 4.1% had HSIL. Beyond HPV infection, factors independently associated with the presence of HSIL was age (≥25 and ≤40 years, prevalence ratio [PR] 2.60, 95% confidence interval [CI] 1.11-6.10), and more than three pregnancies was protective (PR 0.33, 95% CI 0.11-0.94). High coverage of cervical cancer screening is warranted to prevent morbidity and mortality from cervical cancer in this population.
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Affiliation(s)
- P M Luz
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
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White HL, Mulambia C, Sinkala M, Mwanahamuntu MH, Parham GP, Kapambwe S, Moneyham L, Kempf MC, Chamot E. Motivations and experiences of women who accessed "see and treat" cervical cancer prevention services in Zambia. J Psychosom Obstet Gynaecol 2012; 33:91-8. [PMID: 22369192 PMCID: PMC4140087 DOI: 10.3109/0167482x.2012.656161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In Zambia, a country with a generalized HIV epidemic, age-adjusted cervical cancer incidence is among the highest worldwide. In 2006, the University of Alabama at Birmingham-Center for Infectious Disease Research in Zambia and the Zambian Ministry of Health launched a visual inspection with acetic acid (VIA) -based "see and treat" cervical cancer prevention program in Lusaka. All services were integrated within existing government-operated primary health care facilities. OBJECTIVE Study aims were to (i) identify women's motivations for cervical screening, (ii) document women's experiences with screening and (iii) describe the potentially reciprocal influences between women undergoing cervical screening and their social networks. DESIGN AND METHODS Focus group discussions (FGD) and in-depth interviews (IDI) were conducted with women who accepted screening and with care providers. Low-level content analysis was performed to identify themes evoked by participants. Between September 2009 and July 2010, 60 women and 21 care providers participated in 8 FGD and 10 IDI. RESULTS Women presented for screening with varying needs and expectations. A majority discussed their screening decisions and experiences with members of their social networks. Key reinforcing factors and obstacles to VIA screening were identified. CONCLUSIONS Interventions are needed to gain support for the screening process from influential family members and peers.
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Affiliation(s)
- Heather L. White
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA
| | - Chishimba Mulambia
- Institute of Economic and Social Sciences, University of Zambia, Lusaka, Zambia
| | | | - Mulindi H. Mwanahamuntu
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Groesbeck P. Parham
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, University Teaching Hospital, Lusaka, Zambia, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, USA
| | - Sharon Kapambwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia, University Teaching Hospital, Lusaka, Zambia
| | - Linda Moneyham
- School of Nursing, University of Alabama at Birmingham, Birmingham, USA
| | - Mirjam C. Kempf
- School of Nursing, University of Alabama at Birmingham, Birmingham, USA
| | - Eric Chamot
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, USA,Corresponding author: Eric Chamot, Department of Epidemiology, University of Alabama at Birmingham School of Public Health. 1530 3 Ave. S. Birmingham AL 35294-0022. USA. Tel. +1 205 934 7176
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Prevalence and Risk Factors Associated with Precancerous Cervical Cancer Lesions among HIV-Infected Women in Resource-Limited Settings. AIDS Res Treat 2012; 2012:953743. [PMID: 22548156 PMCID: PMC3324885 DOI: 10.1155/2012/953743] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 01/26/2012] [Accepted: 01/27/2012] [Indexed: 11/18/2022] Open
Abstract
Objective. To assess the prevalence and identified associated risk factors for precancerous cervical cancer lesions among HIV-infected women in resource-limited settings in Kenya. Methods. HIV-infected women attending the ART clinic at the Nazareth Hospital ART clinic between June 2009 and September 2010. Multivariate logistic regression model with odds ratios and 95% confidence intervals (CI) were estimated after controlling for important covariates. Result. A total of 715 women were screened for cervical cancer. The median age of the participants was 40 years (range 18-69 years). The prevalence of precancerous lesions (CINI, CINII, CIN III, ICC) was 191 (26.7%). After controlling for other variables in logistic regression analysis, cervical precancerous lesions were associated with not being on ART therapy; whereby non-ART were 2.21 times more likely to have precancerous lesions than ART patients [(aOR) = 2.21, 95% CI (1.28-3.83)]. Conclusion. The prevalence of precancerous cervical lesions was lower than other similar settings. It is recommended that cancer screening of HIV-infected women should be an established practice. Availability and accessibility of these services can be done through their integration into HIV. Prompt initiation of HAART through an early enrollment into care has an impact on reducing the prevalence and progression of cervical precancerous lesions.
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Vanni T, Luz PM, Grinsztejn B, Veloso VG, Foss A, Mesa-Frias M, Legood R. Cervical cancer screening among HIV-infected women: an economic evaluation in a middle-income country. Int J Cancer 2011; 131:E96-104. [PMID: 21964797 DOI: 10.1002/ijc.26472] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 09/22/2011] [Indexed: 11/10/2022]
Abstract
Due to the recent widespread availability of highly active antiretroviral therapy (HAART) in middle-income countries, there has been an increase in life expectancy for women on HAART, but no corresponding decrease in cervical cancer incidence. This study evaluates the optimal cervical cancer screening strategy for HIV-infected women in a middle-income country. We developed a mathematical model, which simulates the natural history of the HPV infection, as well as the HIV-mediated immunosupression among women in Brazil. Our model was calibrated using data from the IPEC/FIOCRUZ Women's HIV-infected cohort. The model compares the lifetime effects, costs and cost-effectiveness of strategies combining cytology, HPV DNA test and colposcopy at different screening intervals for different CD4 count strata (27 strategies in total). We found that the strategy with the best cost-effectiveness profile (cost-effectiveness ratio-U$4,911/year of life saved [YLS] and probability of being cost-effective-86%) was HPV testing followed by cytology triage every year for all HIV infected women, considering a very cost-effective threshold given by Brazil's GDP per capita (US$8,625/YLS). The results were robust to changes in the input parameters as demonstrated in one-way, scenario, threshold and probabilistic sensitivity analysis. Our study indicates that annual HPV testing followed by cytology triage for all HIV-infected women is likely to be very cost-effective in a middle-income country like Brazil. The results reflect the synergic effect of using a highly sensitive screening test (HPV DNA test) in sequence with a highly specific test (cytology).
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Affiliation(s)
- Tazio Vanni
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Adler DH. The impact of HAART on HPV-related cervical disease. Curr HIV Res 2011; 8:493-7. [PMID: 20946095 DOI: 10.2174/157016210793499240] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 10/24/2010] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW highly active antiretroviral therapy (HAART) has had an unequivocally positive impact on morbidity and mortality in HIV-infected individuals. These benefits have clearly extended to some HIV-related malignancies, including Kaposi's sarcoma and non-Hodgkin's lymphoma. The impact of HAART on cervical cancer, however, remains uncertain. The objective of this review is to summarize the last ten years of registry-based and clinical research into the impact of HAART on human papillomavirus (HPV) related cervical disease. RELEVANT FINDINGS compared to their HIV-uninfected counterparts, HIV-infected women have an increased prevalence of HPV infection, increased risk of progression of HPV-related cervical disease, and an increased risk of invasive cervical cancer. While the partial immune reconstitution afforded by HAART might be expected to decrease susceptibility to HPV infection and cervical disease, the local effects of improved immunosurveillance on the cervix are uncertain and the increased longevity of patients on HAART may increase risk of exposure to HPV and provide the time required for progression of cervical disease. Registry-based evidence has been consistent in identifying the lack of decrease in cervical cancer incidence in the HAART era. Clinical research on the subject, however, has produced conflicting evidence with regards to both the effect of HAART on HPV infection and its impact on cervical disease progression/regression. SUMMARY the incidence of cervical cancer has not decreased in the HAART-era. Furthermore, clinical research has not shown a clear benefit of HAART in decreasing HPV-related cervical disease in HIV-infected women. A better understanding of this subject will have an impact on cervical disease surveillance practices.
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Affiliation(s)
- David H Adler
- University of Rochester, 601 Elmwood Avenue, Box 655, Rochester, NY 14642, USA.
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Age at diagnosis of preinvasive and invasive cervical neoplasia in South Africa: HIV-positive versus HIV-negative women. Int J Gynecol Cancer 2011; 21:363-6. [PMID: 21270617 DOI: 10.1097/igc.0b013e3182094d78] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
HYPOTHESIS Human immunodeficiency virus-positive women develop invasive cervical cancer at a significantly earlier age than seronegative women. It is hypothesized that this might result from shorter preinvasive stages. METHODS Prospective observational study of histologically diagnosed 398 low-grade (LGSIL), 738 high-grade intraepithelial lesions (HGSIL), and 1048 invasive cancers (IC) in a black South African population. The study comprised of 493 (22.6%) seropositive women and 1691 (77.4%) seronegative women who served as the controls. All were subdivided into 5-years age bands. RESULTS The mean age at diagnosis of LGSIL and HGSIL was similar in the cases (t = 0.7; P = 0.49) and the controls (t = 1.2; P = 0.22). The mean age at diagnosis of IC was significantly younger in the HIV-seropositive women than in the HIV-seronegative women (t = 14.0; P < 0.0001). The relative age distribution curves of LGSIL, HGSIL, and IC evolved close to each other in the cases. In the seronegative women, there was an 18-year lag between the peak age distribution of HGSIL and IC. CONCLUSION Our data support the hypothesis of a shorter preinvasive stage in HIV-positive women.
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Raposo LM, Velasque L, Luz PM, Friedman RK, Cytryn A, Andrade ACVD, Vanni T, Brasil PEAA, Russomano F, Veloso VG, Grinsztejn B, Struchiner CJ. Desempenho do exame citológico e da captura híbrida II no rastreamento de lesões intraepiteliais escamosas de alto grau em mulheres HIV+. CAD SAUDE PUBLICA 2011; 27:1281-91. [DOI: 10.1590/s0102-311x2011000700004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 04/26/2011] [Indexed: 11/21/2022] Open
Abstract
As lesões intraepiteliais escamosas de alto grau (HSIL) são precursoras do câncer do colo do útero, com maior risco de ocorrência e desenvolvimento em mulheres HIV+. Neste trabalho, estimamos e comparamos o desempenho do exame citológico e da captura híbrida II no rastreamento das lesões precursoras em mulheres HIV+. A população de estudo compreendeu mulheres acompanhadas na coorte prospectiva aberta do Instituto de Pesquisa Clínica Evandro Chagas da Fundação Oswaldo Cruz (IPEC/Fiocruz). A colposcopia e histologia foram consideradas conjuntamente na definição do teste de referência. O exame citológico apresentou sensibilidade de 31,8% e especificidade de 95,5%, enquanto a captura híbrida II apresentou maior sensibilidade (100%) e menor especificidade (52%). As razões de verossimilhança para o teste positivo e negativo foram estimadas em 7,1 e 0,7 para o exame citológico e em 2,1 e 0,0 para a captura híbrida II, respectivamente.
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Affiliation(s)
| | - Luciane Velasque
- Universidade Federal do Estado do Rio de Janeiro, Brasil; Fundação Oswaldo Cruz, Brasil
| | | | | | | | | | - Tazio Vanni
- London School of Hygiene and Tropical Medicine
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Nowak RG, Gravitt PE, Morrison CS, Gange SJ, Kwok C, Oliver AE, Howard R, Van der Pol B, Salata RA, Padian NS, Chipato T, Munjoma M, Celentano DD. Increases in human papillomavirus detection during early HIV infection among women in Zimbabwe. J Infect Dis 2011; 203:1182-91. [PMID: 21451006 DOI: 10.1093/infdis/jiq172] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Individuals who acquire human immunodeficiency virus (HIV) may experience an immediate disruption of genital tract immunity, altering the ability to mount a local and effective immune response. This study examined the impact of early HIV infection on new detection of human papillomavirus (HPV). METHODS One hundred fifty-five Zimbabwean women with observation periods before and after HIV acquisition and 486 HIV-uninfected women were selected from a cohort study evaluating hormonal contraceptive use and risk of HIV acquisition. Study visits occurred at 3-month intervals. Cervical swab samples available from up to 6 months before, at, and up to 6 months after the visit when HIV was first detected were typed for 37 HPV genotypes or subtypes. RESULTS We observed ∼5-fold higher odds of multiple (≥2) new HPV detections only after HIV acquisition, relative to HIV-negative women after adjusting for sexual behavior and concurrent genital tract infections. We also observed ∼2.5-fold higher odds of single new HPV detections at visits before and after HIV acquisition, relative to HIV-uninfected women in multivariable models. CONCLUSIONS These findings suggest that HIV infection has an immediate impact on genital tract immunity, as evidenced by the high risk of multiple new HPV detections immediately after HIV acquisition.
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Affiliation(s)
- Rebecca G Nowak
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland 21205, USA
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Lang TU, Khalbuss WE, Monaco SE, Michelow P, Pantanowitz L. Review of HIV-Related Cytopathology. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2011:256083. [PMID: 21559199 PMCID: PMC3090088 DOI: 10.4061/2011/256083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 02/15/2011] [Indexed: 11/28/2022]
Abstract
Exfoliative and aspiration cytologies play a major role in the management of patients with human immunodeficiency virus infection. Common cytology samples include cervicovaginal and anal Papanicolaou tests, fine needle aspirations, respiratory specimens, body fluids, Tzanck preparations, and touch preparations from brain specimens. While the cytopathologists need to be aware of specific infections and neoplasms likely to be encountered in this setting, they should be aware of the current shift in the pattern of human immunodeficiency virus-related diseases, as human immunodeficiency virus patients are living longer with highly active antiretroviral therapy and suffering fewer opportunistic infections with better antimicrobial prophylaxis. There is a rise in nonhuman immunodeficiency virus-defining cancers (e.g., anal cancer, Hodgkin's lymphoma) and entities (e.g., gynecomastia) from drug-related side effects. Given that fine needle aspiration is a valuable, noninvasive, and cost-effective tool, it is frequently employed in the evaluation and diagnosis of human immunodeficiency virus-related diseases. Anal Papanicolaou tests are also increasing as a result of enhanced screening of human immunodeficiency virus-positive patients for cancer. This paper covers the broad spectrum of disease entities likely to be encountered with human immunodeficiency virus-related cytopathology.
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Affiliation(s)
- Tee U. Lang
- Department of Pathology, University of Pittsburgh Medical Center Cancer Pavilion, 5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
| | - Walid E. Khalbuss
- Department of Pathology, University of Pittsburgh Medical Center Cancer Pavilion, 5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
| | - Sara E. Monaco
- Department of Pathology, University of Pittsburgh Medical Center Cancer Pavilion, 5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
| | - Pam Michelow
- Cytology Unit, Department of Anatomical Pathology, Faculty of Health Sciences, University of the Witwatersrand and National Health Laboratory Service, Johannesburg 2192, South Africa
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center Cancer Pavilion, 5150 Centre Avenue, Suite 201, Pittsburgh, PA 15232, USA
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Potential impact of antiretroviral therapy and screening on cervical cancer mortality in HIV-positive women in sub-Saharan Africa: a simulation. PLoS One 2011; 6:e18527. [PMID: 21483701 PMCID: PMC3070738 DOI: 10.1371/journal.pone.0018527] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2009] [Accepted: 03/10/2011] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite having high cervical cancer incidence and mortality rates, screening for cervical precancerous lesions remains infrequent in sub-Saharan Africa. The need to screen HIV-positive women because of the higher prevalence and faster progression of cervical precancerous lesions may be heightened by the increased access to highly-active antiretroviral therapy (HAART). Policymakers need quantitative data on the effect of HAART and screening to better allocate limited resources. Our aim was to quantify the potential effect of these interventions on cervical cancer mortality. METHODS AND FINDINGS We constructed a Markov state-transition model of a cohort of HIV-positive women in Cameroon. Published data on the prevalence, progression and regression of lesions as well as mortality rates from HIV, cervical cancer and other causes were incorporated into the model. We examined the potential impact, on cumulative cervical cancer mortality, of four possible scenarios: no HAART and no screening (NHNS), HAART and no screening (HNS), HAART and screening once on HAART initiation (HSHI), and HAART and screening once at age 35 (HS35). Our model projected that, compared to NHNS, lifetime cumulative cervical cancer mortality approximately doubled with HNS. It will require 262 women being screened at HAART initiation to prevent one cervical cancer death amongst women on HAART. The magnitudes of these effects were most sensitive to the rate of progression of precancerous lesions. CONCLUSIONS Screening, even when done once, has the potential of reducing cervical cancer mortality among HIV-positive women in Africa. The most feasible and cost-effective screening strategy needs to be determined in each setting.
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de Andrade ACV, Luz PM, Velasque L, Veloso VG, Moreira RI, Russomano F, Chicarino-Coelho J, Pires E, Levi JE, Grinsztejn B, Friedman RK. Factors associated with colposcopy-histopathology confirmed cervical intraepithelial neoplasia among HIV-infected women from Rio De Janeiro, Brazil. PLoS One 2011; 6:e18297. [PMID: 21479179 PMCID: PMC3068170 DOI: 10.1371/journal.pone.0018297] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/25/2011] [Indexed: 12/25/2022] Open
Abstract
Introduction Despite the availability of preventive strategies (screening tests and vaccines), cervical cancer continues to impose a significant health burden in low- and medium-resourced countries. HIV-infected women are at increased risk for infection with human papillomavirus (HPV) and thus development of cervical squamous intraepithelial neoplasia (CIN). Methods Study participants included HIV-infected women enrolling the prospective open cohort of Evandro Chagas Clinical Research Institute, Oswaldo Cruz Foundation (IPEC/FIOCRUZ). At cohort entry, women were subjected to conventional Papanicolaou test, HPV-DNA test and colposcopy; lesions suspicious for CIN were biopsied. Histopathology report was based on directed biopsy or on specimens obtained by excision of the transformation zone or cervical conization. Poisson regression modeling was used to assess factors associated with CIN2+ diagnosis. Results The median age of the 366 HIV-infected women included in the study was 34 years (interquartile range: 28–41 years). The prevalence of CIN1, CIN2 and CIN3 were 20.0%, 3.5%, and 2.2%, respectively. One woman was found to have cervical cancer. The prevalence of CIN2+ was 6.0%. Factors associated with CIN2+ diagnosis in the multivariate model were age < years compared to ≥35 years (aPR = 3.22 95%CI 1.23–8.39), current tobacco use (aPR = 3.69 95%CI 1.54–8.78), nadir CD4 T-cell count <350 cells/mm3 when compared to ≥ 350 cells/mm3 (aPR = 6.03 95%CI 1.50–24.3) and concomitant diagnosis of vulvar and/or vaginal intraepithelial lesion (aPR = 2.68 95%CI 0.99–7.24). Discussion Increased survival through wide-spread use of highly active antiretroviral therapy might allow for the development of cervical cancer. In Brazil, limited cytology screening and gynecological care adds further complexity to the HIV-HPV co-infection problem. Integrated HIV care and cervical cancer prevention programs are needed for the prevention of cervical cancer mortality in this group of women.
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Affiliation(s)
| | - Paula Mendes Luz
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Luciane Velasque
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- Departamento de Matemática e Estatística, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brasil
| | | | - Ronaldo I. Moreira
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Fabio Russomano
- Instituto Fernandes Figueira, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | | | - Elaine Pires
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
| | - José Eduardo Levi
- Laboratório de Virologia, Instituto de Medicina Tropical, Universidade de São Paulo, São Paulo, Brasil
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
- * E-mail:
| | - Ruth Khalili Friedman
- Instituto de Pesquisa Clínica Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil
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Logan JL, Khambaty MQ, D'Souza KM, Menezes LJ. Cervical cancer screening among HIV-infected women in a health department setting. AIDS Patient Care STDS 2010; 24:471-5. [PMID: 20653483 DOI: 10.1089/apc.2009.0295] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
HIV-infected women are at increased risk of developing invasive cervical cancer and present for care at a later stage of disease. Because of this susceptibility, the US Preventive Services Task Force and Centers for Disease Control and Prevention recommend that HIV-infected women receive two Pap smears during their first year after diagnosis, then annually thereafter. The aim of this study was to determine adherence to these screening guidelines and associations between demographic factors and receipt of Pap smears at a local health department in Florida. Demographic and Pap smear data were extracted from randomly selected medical records of 200 HIV-infected women receiving care between January 2000 and May 2006. Descriptive statistics and chi(2) associations were determined. Overall, 83% of women received at least one Pap smear in their first year after enrollment; 24.5% received the recommended two Pap smears. The women were predominantly minorities (57.4% African Americans; 22.8% Hispanics) and economically disadvantaged (mean income $8,180). First year Pap smear rate was significantly associated with type of insurance (p = 0.0185) and Pap smear facility (p < 0.0001), with a trend toward association with HIV risk behavior (p = 0.0593). First-year Pap smear rate was not associated with age, income, ethnicity, or incarceration history. Although this health department provided similar cervical cancer screening levels to those reported elsewhere, rates fall short of evidence-based guidelines. Future research must address low second Pap smear rates in the context of patient and provider barriers to improve early detection and prevention of cervical cancer in HIV-infected women.
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Affiliation(s)
- Jennifer L. Logan
- University of South Florida, Division of Infectious Disease and International Medicine, Tampa, Florida
| | - Maria Q. Khambaty
- University of South Florida, Division of Infectious Disease and International Medicine, Tampa, Florida
| | - Karina M. D'Souza
- University of South Florida, Division of Infectious Disease and International Medicine, Tampa, Florida
| | - Lynette J. Menezes
- University of South Florida, Division of Infectious Disease and International Medicine, Tampa, Florida
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Human papillomavirus HPV-16, 18, 52 and 58 integration in cervical cells of HIV-1-infected women. J Clin Virol 2010; 48:198-201. [DOI: 10.1016/j.jcv.2010.03.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 03/24/2010] [Accepted: 03/28/2010] [Indexed: 11/17/2022]
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Minkoff H, Zhong Y, Burk RD, Palefsky JM, Xue X, Watts DH, Levine AM, Wright RL, Colie C, D'Souza G, Massad LS, Strickler HD. Influence of adherent and effective antiretroviral therapy use on human papillomavirus infection and squamous intraepithelial lesions in human immunodeficiency virus-positive women. J Infect Dis 2010; 201:681-90. [PMID: 20105077 DOI: 10.1086/650467] [Citation(s) in RCA: 118] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The impact of highly active antiretroviral therapy (HAART) on the natural history of human papillomavirus (HPV) remains uncertain following conflicting reports. Prior studies, however, did not consider patients' adherence to their regimens or HAART effectiveness (viral suppression). METHODS Human immunodeficiency virus (HIV)-positive women (N = 286) who initiated HAART during follow-up in a prospective cohort were assessed semiannually for HPV infection (by polymerase chain reaction) and squamous intraepithelial lesions (SILs). Adherence was defined as use of HAART as prescribed > or = 95% of the time, and effective HAART was defined as suppression of HIV replication. The prevalence, incident detection, and clearance of HPV infection and/or SILs before versus after HAART initiation were compared (using women as their own comparison group). RESULTS HAART initiation among adherent women was associated with a significant reduction in prevalence (odds ratio, 0.60 [95% confidence interval {CI}, 0.44-0.81]; P = .001), incident detection of oncogenic HPV infection (hazard ratio [HR], 0.49 [95% CI, 0.30-0.82]; P = .006), and decreased prevalence and more rapid clearance of oncogenic HPV-positive SILs (HR, 2.35 [95% CI, 1.07-5.18]; P = .03). Effects were smaller among nonadherent women. The associations of HPV infection and/or SILs with HAART effectiveness were fairly similar to those with HAART adherence. CONCLUSION Effective and adherent HAART use is associated with a significantly reduced burden of HPV infection and SILs; this may help explain why rates of cervical cancer have not increased during the HAART era, despite greater longevity.
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Affiliation(s)
- Howard Minkoff
- Department of Obstetrics and Gynecology, Maimonides Medical Center and State University of New York Downstate, Brooklyn, NY 11219, USA.
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