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Okunade KS, Badmos KB, Okoro A, Awolola NA, Nwaokorie FO, Adelabu H, Ademuyiwa IY, Adekanye TV, Akhenamen PO, Odoh E, Okoye C, Akanmu AS, Banjo AA, Anorlu RI, Berek JS. Prevalence and Associated Factors of High-Risk Human Papillomavirus Infections among Human Immunodeficiency Virus-Infected Women in Lagos, Nigeria. RESEARCH SQUARE 2024:rs.3.rs-4645178. [PMID: 39070626 PMCID: PMC11275992 DOI: 10.21203/rs.3.rs-4645178/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Background Given the synergistic relationship between human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections, knowledge of the genotypic prevalence and associated factors of high-risk HPV (HR-HPV) among HIV-infected women is crucial for developing targeted interventions such as appropriate screening tests and effective genotype-specific vaccination. Objectives We determined the prevalence of any HR-HPV and multiple HR-HPV infections and identified associated factors among a cohort of women living with HIV infections (WLHIV) in Lagos, Nigeria. Methods This descriptive cross-sectional study analysed the data of 516 WLHIV who underwent cervical cancer screening as part of the COMPASS-DUST study at the HIV treatment centre of Lagos University Teaching Hospital from July 2023 to March 2024. Multivariable binary logistic regression models were performed to explore factors associated with HR-HPV and multiple HR-HPV infections. Results Among the 516 WLHIV enrolled (mean age, 46.5±7.3 years), the overall HR-HPV prevalence was 13.4% (95% CI, 10.6-16.6), disaggregated as 3.3% for HPV16/18 (95% CI, 1.9-5.2) and 11.6% for other HR-HPV genotypes (95% CI, 9.0-14.7). Nineteen women (3.7%; 95% CI, 2.2-5.7)had multiple HR-HPV genotype infections. Having a recent serum CD4+ cell count ≤560 cells/μL (adjusted OR 3.32; 95% CI 1.06-10.38) and HPV 16/18 genotype infections (adjusted OR 38.98; 95% CI 11.93-127.37) were independently associated with an increased risk of multiple HR-HPV infections. Conclusion The findings of this study provide valuable insights into the epidemiology of HR-HPV infections and highlight the need for tailored interventions and continuous monitoring. By addressing these challenges through targeted screening, effective ART management, and vaccination programs, we can improve health outcomes and reduce the burden of cervical cancer in this vulnerable population.
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Mezei A, Trawin J, Payne B, Rawat A, Naguti P, Orem J, Murray MC, Nakisige C, Ogilvie G. Acceptability of Integrated Community-Based HIV and Cervical Cancer Screening in Mayuge District, Uganda. JCO Glob Oncol 2024; 10:e2200324. [PMID: 38237095 PMCID: PMC10805429 DOI: 10.1200/go.22.00324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 05/24/2023] [Accepted: 10/31/2023] [Indexed: 01/23/2024] Open
Abstract
PURPOSE To assess the acceptability of integrated screening for cervical cancer and HIV in the community setting. METHODS We developed surveys for patients and community health workers (CHWs) who participated in the Advances in Screening and Prevention in Reproductive Cancers (ASPIRE) Mayuge trial that compared self-collected human papillomavirus testing at home versus community health meetings in Mayuge district, Uganda. Quantitative data were summarized using descriptive statistics. Open-ended questions were analyzed using an inductive approach with thematic content analysis. RESULTS We conducted 102 patient surveys and 31 CHW surveys between June and August 2021. Ninety-nine percent of patients and 100% of CHWs indicated that they would find the addition of an HIV test to their self-collected cervical cancer test acceptable. The most frequently stated reasons in favor of adding an HIV test to the ASPIRE Mayuge cervical cancer screening pathways were time-saving, privacy, and support from other women and CHWs. The most frequently stated reasons against integrated screening were related to concerns about confidentiality, most often in reference to women's family members and other women in their village. CONCLUSION Integrated community-based cervical cancer and HIV testing would be highly acceptable to both women and CHWs.
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Affiliation(s)
- Alex Mezei
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jessica Trawin
- Women's Health Research Institute, British Columbia Women's Hospital + Health Centre, Vancouver, BC, Canada
| | - Beth Payne
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Angeli Rawat
- Women's Health Research Institute, British Columbia Women's Hospital + Health Centre, Vancouver, BC, Canada
| | - Priscilla Naguti
- Department of Reproductive Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Jackson Orem
- Department of Reproductive Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Melanie C.M. Murray
- Women's Health Research Institute, British Columbia Women's Hospital + Health Centre, Vancouver, BC, Canada
- Department of Medicine, Division of Infectious Diseases, University of British Columbia, Vancouver, BC, Canada
| | - Carolyn Nakisige
- Department of Reproductive Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Gina Ogilvie
- Women's Health Research Institute, British Columbia Women's Hospital + Health Centre, Vancouver, BC, Canada
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Gilles C, Konopnicki D, Rozenberg S. The recent natural history of human papillomavirus cervical infection in women living with HIV: A scoping review of meta-analyses and systematic reviews and the construction of a hypothetical model. HIV Med 2023; 24:877-892. [PMID: 37062862 DOI: 10.1111/hiv.13490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/14/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Women with HIV are more often infected with human papillomavirus (HPV) and are more prone to develop precancerous cervical lesions (squamous intraepithelial lesions, SIL) and invasive cervical cancer (ICC) than HIV-negative women. OBJECTIVE This scoping-review analyses the impact of HIV on HPV prevalence, incidence and evolution to SIL and ICC. METHODS We selected all PubMed systematic reviews and meta-analyses published between January 2000 and July 2021 reporting data about HPV, cervical intraepithelial neoplasia (CIN), SIL and ICC prevalence, incidence and evolution in women with HIV. A hypothetical model comparing the history of HPV infection in HIV-negative, combined antiretroviral therapy (cART)-treated and -untreated women with HIV was built. RESULTS Data from 11 meta-analyses and 10 systematic reviews were selected, which included between 770 and 236 127 women with HIV. Women with HIV have a 3 to 6 times higher risk of being infected by HPV, of progression to high-grade SIL (HSIL) and to ICC. These risks are exacerbated when the CD4 cell counts are low and when they are not using cART, whereas these risks are reduced by 20%-30% when they are optimally treated with cART and have had a suppressed HIV viral load for at least 2 years. In our model, we illustrated that optimal HIV treatment and preventing HIV reduce the number of ICC cases by 2.5 and 6 times, respectively. CONCLUSIONS Optimal treatment and care of HIV patients are essential to reduce their prevalence of ICC, as are preventive strategies which include HPV vaccination, cervical cancer screening strategies and treatment of HSIL.
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Affiliation(s)
- Christine Gilles
- Department of Obstetrics and Gynecology, Saint Pierre University Hospital 322, Belgium Université Libre de Bruxelles (ULB)-Free University of Brussels (ULB-VUB), Brussels, Belgium
| | - Déborah Konopnicki
- Infectious Disease Department Saint Pierre University Hospital 322, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Serge Rozenberg
- Department of Obstetrics and Gynecology, Saint Pierre University Hospital 322, Belgium Université Libre de Bruxelles (ULB)-Free University of Brussels (ULB-VUB), Brussels, Belgium
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Losada C, Samaha H, Scherer EM, Kazzi B, Khalil L, Ofotokun I, Rouphael N. Efficacy and Durability of Immune Response after Receipt of HPV Vaccines in People Living with HIV. Vaccines (Basel) 2023; 11:1067. [PMID: 37376456 DOI: 10.3390/vaccines11061067] [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: 04/10/2023] [Revised: 05/24/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Abstract
People living with HIV (PLH) experience higher rates of HPV infection as well as an increased risk of HPV-related disease, including malignancies. Although they are considered a high-priority group for HPV vaccination, there are limited data regarding the long-term immunogenicity and efficacy of HPV vaccines in this population. Seroconversion rates and geometric mean titers elicited by vaccination are lower in PLH compared to immunocompetent participants, especially in individuals with CD4 counts below 200 cells/mm3 and a detectable viral load. The significance of these differences is still unclear, as a correlate of protection has not been identified. Few studies have focused on demonstrating vaccine efficacy in PLH, with variable results depending on the age at vaccination and baseline seropositivity. Although waning humoral immunity for HPV seems to be more rapid in this population, there is evidence that suggests that seropositivity lasts at least 2-4 years following vaccination. Further research is needed to determine the differences between vaccine formulations and the impact of administrating additional doses on durability of immune protection.
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Affiliation(s)
- Cecilia Losada
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
| | - Hady Samaha
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
| | - Erin M Scherer
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
| | - Bahaa Kazzi
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
| | - Lana Khalil
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
| | - Ighovwerha Ofotokun
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA 30322, USA
| | - Nadine Rouphael
- The Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, Emory University, Decatur, GA 30030, USA
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Hewavisenti RV, Arena J, Ahlenstiel CL, Sasson SC. Human papillomavirus in the setting of immunodeficiency: Pathogenesis and the emergence of next-generation therapies to reduce the high associated cancer risk. Front Immunol 2023; 14:1112513. [PMID: 36960048 PMCID: PMC10027931 DOI: 10.3389/fimmu.2023.1112513] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 03/09/2023] Open
Abstract
Human papillomavirus (HPV), a common sexually transmitted virus infecting mucosal or cutaneous stratified epithelia, is implicated in the rising of associated cancers worldwide. While HPV infection can be cleared by an adequate immune response, immunocompromised individuals can develop persistent, treatment-refractory, and progressive disease. Primary immunodeficiencies (PIDs) associated with HPV-related disease include inborn errors of GATA, EVER1/2, and CXCR4 mutations, resulting in defective cellular function. People living with secondary immunodeficiency (e.g. solid-organ transplants recipients of immunosuppression) and acquired immunodeficiency (e.g. concurrent human immunodeficiency virus (HIV) infection) are also at significant risk of HPV-related disease. Immunocompromised people are highly susceptible to the development of cutaneous and mucosal warts, and cervical, anogenital and oropharyngeal carcinomas. The specific mechanisms underlying high-risk HPV-driven cancer development in immunocompromised hosts are not well understood. Current treatments for HPV-related cancers include surgery with adjuvant chemotherapy and/or radiotherapy, with clinical trials underway to investigate the use of anti-PD-1 therapy. In the setting of HIV co-infection, persistent high-grade anal intraepithelial neoplasia can occur despite suppressive antiretroviral therapy, resulting in an ongoing risk for transformation to overt malignancy. Although therapeutic vaccines against HPV are under development, the efficacy of these in the setting of PID, secondary- or acquired- immunodeficiencies remains unclear. RNA-based therapeutic targeting of the HPV genome or mRNA transcript has become a promising next-generation therapeutic avenue. In this review, we summarise the current understanding of HPV pathogenesis, immune evasion, and malignant transformation, with a focus on key PIDs, secondary immunodeficiencies, and HIV infection. Current management and vaccine regimes are outlined in relation to HPV-driven cancer, and specifically, the need for more effective therapeutic strategies for immunocompromised hosts. The recent advances in RNA-based gene targeting including CRISPR and short interfering RNA (siRNA), and the potential application to HPV infection are of great interest. An increased understanding of both the dysregulated immune responses in immunocompromised hosts and of viral persistence is essential for the design of next-generation therapies to eliminate HPV persistence and cancer development in the most at-risk populations.
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Affiliation(s)
- Rehana V. Hewavisenti
- Immunovirology and Pathogenesis Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Joshua Arena
- Immunovirology and Pathogenesis Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
- UNSW RNA Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Chantelle L. Ahlenstiel
- Immunovirology and Pathogenesis Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
- UNSW RNA Institute, The University of New South Wales, Sydney, NSW, Australia
| | - Sarah C. Sasson
- Immunovirology and Pathogenesis Program, The Kirby Institute, The University of New South Wales, Sydney, NSW, Australia
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Okunade KS, Badmos KB, Okoro AC, Ademuyiwa IY, Oshodi YA, Adejimi AA, Awolola NA, Ozonu O, Adelabu H, Olorunfemi G, Akanmu AS, Banjo AA, Anorlu RI, Berek JS. Comparative Assessment of p16/Ki-67 Dual Staining Technology for cervical cancer screening in women living with HIV (COMPASS-DUST)-Study protocol. PLoS One 2023; 18:e0278077. [PMID: 36701329 PMCID: PMC9879465 DOI: 10.1371/journal.pone.0278077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
The risk of progression of low-grade (CIN1) to high-grade cervical intraepithelial neoplasia (CIN2/3) is 3-5 times higher for women living with HIV (WLHIV) than for HIV-negative women. Evidence suggests that the current cervical cancer screening methods perform less effectively in WLHIV. An emerging screening method-p16/Ki-67 dual staining technology (DUST) is a safe and rapid assay that could be used to detect CIN2/3 with higher sensitivity and specificity. The study in this protocol will evaluate the performance of DUST in cervical cancer screening among WLHIV. We will conduct an intra-participant comparative study (Phase 1) to enrol n = 1,123 sexually active WLHIV aged 25-65 years at two accredited adult HIV treatment centres in Lagos, Nigeria to compare the performance of DUST to the currently used screening methods (Pap smear, hr-HPV DNA, or VIA testing) in detecting high-grade CIN and cancer (CIN2+). Subsequently, a prospective cohort study (Phase 2) will be conducted by enrolling all the WLHIV who are diagnosed as having low-grade CIN (CIN1) in Phase 1 for a 6-monthly follow-up for 2 years to detect the persistence and progression of CIN1 to CIN2+. The findings of this study may provide evidence of the existence of a better performance screening method for the primary and triage detection of CIN2+ in WLHIV. It may also demonstrate that this high-performance test can improve the long-term predictive accuracy of screening by extending the intervals between evaluations and thus decrease the overall cost and increase screening uptake and follow-up compliance in WLHIV.
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Affiliation(s)
- Kehinde S. Okunade
- Department of Obstetrics & Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
- Center for Clinical Trial, Research, and Implementation science (CCTRIS), College of Medicine, University of Lagos, Lagos, Nigeria
| | - Kabir B. Badmos
- Department of Anatomic and Molecular Pathology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Austin C. Okoro
- Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Iyabo Y. Ademuyiwa
- Department of Nursing Science, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Yusuf A. Oshodi
- Department of Obstetrics & Gynaecology, Lagos State University College of Medicine, Lagos, Nigeria
| | - Adebola A. Adejimi
- Department of Community Health & Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Nicholas A. Awolola
- Department of Anatomic and Molecular Pathology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Oluchi Ozonu
- Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Hameed Adelabu
- Center for Clinical Trial, Research, and Implementation science (CCTRIS), College of Medicine, University of Lagos, Lagos, Nigeria
| | - Gbenga Olorunfemi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Alani S. Akanmu
- Department of Haematology & Blood Transfusion, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Adekunbiola A. Banjo
- Department of Anatomic and Molecular Pathology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Rose I. Anorlu
- Department of Obstetrics & Gynaecology, College of Medicine, University of Lagos, Lagos, Nigeria
- Department of Obstetrics & Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Jonathan S. Berek
- Department of Obstetrics & Gynaecology, Stanford University School of Medicine, Stanford, United States of America
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7
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Ginindza TG, Forestier M, Almonte M. Cervical cancer screening by visual inspection and HPV testing in Eswatini. Prev Med 2022; 161:107144. [PMID: 35810934 PMCID: PMC9343965 DOI: 10.1016/j.ypmed.2022.107144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/23/2022] [Accepted: 07/02/2022] [Indexed: 11/24/2022]
Abstract
In 2009, visual inspection with acetic acid (VIA) followed by cryotherapy (VIA-and-cryotherapy), was introduced into the Eswatini cervical cancer prevention programme. We present screening results of 654 women attending VIA-and-cryotherapy who participated in a sexually transmitted infections prevalence study, at which samples for HPV DNA testing and liquid-based cytology (LBC) were also collected. VIA positives (VIA+) ineligible for cryotherapy, suspected cancers and women with high-grade squamous intraepithelial or worse lesions (HSIL+) on LBC were referred for diagnosis and treatment. Women with negative VIA who were HPV positive (HPV+) and those VIA+ treated with cryotherapy were recalled for another VIA one-year later. The positivity rates of VIA, HPV, atypical squamous cells of undetermined significance or worse cytology abnormalities (LBC ASCUS+) and low-grade squamous intraepithelial or worse lesions (LBC LSIL+) were 9.7%, 42.6%, 13.2% and 5.3%, respectively. HPV testing detected 29 of 31 LSIL+ (93.6%, 95%CI: 78.6-99.2) while VIA only detected 11 (35.6%, 95%CI: 19.2-54.6). The HIV prevalence was 43% (95%CI: 39.2-46.9). HIV positives were at increased risk of being VIA+ (age-adjusted odds ratio: 2.5, 95%CI: 1.5-4.3), HPV+ (3.7, 2.6-5.3) and having LSIL+ (16.3, 4.9-54.8). The ineligibility rates for cryotherapy were 38% (24 of 63 VIA+), and 46% among HIV positives (18 of 39 VIA+). HPV testing was substantially more sensitive than VIA, thus, HPV followed by ablative treatment may be more effective. However, the high ineligibility for cryotherapy highlights the need for improving the assessment of eligibility for ablative treatment and for strengthening colposcopy, particularly in populations with high HIV prevalence.
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Affiliation(s)
- Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; Cancer and Infectious Disease Epidemiology Research Unit (CIDERU), Durban, South Africa
| | | | - Maribel Almonte
- International Agency for Research on Cancer (IARC), Lyon, France.
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Vink FJ, Steenbergen RD, Kremer WW, Lissenberg-Witte BI, Heideman DA, Bleeker MC, van Zummeren M, Breytenbach E, Visser C, Lukhwareni A, Meijer CJ, Dreyer G. Posttreatment monitoring by ASCL1/LHX8 methylation analysis in women with HIV treated for cervical intraepithelial neoplasia grade 2/3. AIDS 2022; 36:953-961. [PMID: 35152224 DOI: 10.1097/qad.0000000000003197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Women with HIV (WWH) have an increased risk to develop recurrent cervical intraepithelial neoplasia grade 2/3 (rCIN2/3) after treatment compared with HIV-negative women. Therefore, appropriate posttreatment monitoring of WWH is important. This study evaluates the performance of ASCL1 and LHX8 methylation analysis as posttreatment monitoring test in WWH treated for CIN2/3, as alternative to cytology or human papillomavirus (HPV) as follow-up test. DESIGN Prospective observational cohort study. METHODS WWH treated for CIN2/3 by large loop excision of the transformation zone (LLETZ) (n = 61) were invited for follow-up study visits at 1, 2.5 and 4 years after baseline. Baseline and follow-up cervical scrapes were tested for cytology, HPV and DNA methylation of ASCL1 and LHX8 genes. The performance of these strategies for the detection of rCIN2/3 was evaluated in the first follow-up cervical scrape. RESULTS Thirteen (21.3%) rCIN2/3 lesions were detected within 4 years of follow-up. In women without rCIN2/3 in follow-up, methylation levels of ASCL1 and LHX8 decreased significantly after LLETZ treatment (P = 0.02 and 0.007, respectively). In women with rCIN2/3, methylation levels remained high after LLETZ treatment. The 4-year rCIN2/3 risk was 4.9% (95% CI: 0.6-16.5) for ASCL1/LHX8-negative women, 8.1% (95% CI: 1.7-21.9) for HPV-negative women and 7.7% (95% CI: 2.1-18.5) for cytology-negative women. CONCLUSION A negative ASCL1/LHX8 methylation test in follow-up is associated with a low rCIN2/3 risk and could serve as an objective test of cure and well tolerated alternative for HPV and/or cytology screening in the posttreatment monitoring of WWH.
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Chinula L, McGue S, Smith JS, Saidi F, Mkochi T, Msowoya L, Varela A, Lee F, Gopal S, Chagomerana M, Tomoka T, Mwapasa V, Tang J. A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial. Contemp Clin Trials Commun 2022; 26:100903. [PMID: 35243124 PMCID: PMC8857441 DOI: 10.1016/j.conctc.2022.100903] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 01/25/2023] Open
Abstract
Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.
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Affiliation(s)
- Lameck Chinula
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
| | - Shannon McGue
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Jennifer S. Smith
- University of North Carolina, Department of Epidemiology, McGavran-Greenberg Hall, Chapel Hill, 2103, NC, USA
| | - Friday Saidi
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Tawonga Mkochi
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Lizzie Msowoya
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Amanda Varela
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Fan Lee
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
| | | | - Maganizo Chagomerana
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Tamiwe Tomoka
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | | | - Jennifer Tang
- University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- University of North Carolina, Department of OB-GYN, Division of Global Women's Health, 3009 Old Clinic Building, CB 7570, Chapel Hill, NC, USA
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Trejo MJ, Soliman AS, Chen Y, Kalima M, Chuba A, Chama E, Mwaba CK, Banda L, Lishimpi K. Effects of HIV infection on metastatic cervical cancer and age at diagnosis among patients in Lusaka, Zambia. Int J Gynaecol Obstet 2022; 156:521-528. [PMID: 34121186 PMCID: PMC8669036 DOI: 10.1002/ijgo.13784] [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: 02/18/2021] [Revised: 05/12/2021] [Accepted: 06/11/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To examine the association between the duration of HIV infection and the stage of cervical cancer in Lusaka, Zambia. METHODS This retrospective case-case study included 1583 cervical cancer patients from the Cancer Diseases Hospital in Lusaka, Zambia. A sub-population of HIV-positive patients with additional clinical HIV information was identified following linkage of cancer and HIV databases. Logistic regression models examined the relationship between HIV status and early-onset cervical cancer diagnosis, and between HIV infection duration and initial diagnosis of metastatic cervical cancer. RESULTS The study population had an average age of 49 years and 40.9% had an initial diagnosis of metastatic cancer. HIV-positive women were more than twice as likely to be diagnosed at early-onset cervical cancer compared with HIV-negative women. Among the sub-population of HIV-positive patients, a longer duration of HIV infection was associated with 20% lowered odds of initial metastatic cancer diagnosis. CONCLUSION The availability, accessibility, and impact of the cervical screening program in this population should be further examined to elucidate the relationship between cervical screening, age, and duration of HIV infection and the the stage of diagnosis of cervical cancer.
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Affiliation(s)
- Mario Jesus Trejo
- Department of Epidemiology and Biostatistics, Mel & Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ, USA
| | - Amr S. Soliman
- Department of Community Health and Social Medicine, School of Medicine, The City College of New York, New York, NY, USA,Correspondence Amr S. Soliman, City University of New York School of Medicine, New York, NY, USA.
| | - Yuli Chen
- Department of Epidemiology, Colorado School of Public Health, University of Colorado
| | - Mulele Kalima
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
| | - Alick Chuba
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
| | - Eslone Chama
- University Teaching Hospital – HIV/AIDS Program, Lusaka, Zambia
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Pimple SA, Pahwa V, Mishra GA, Anand KV, Pathuthara S, Biswas SK. Screening for Early Detection of Cervical Cancer in Women Living with HIV in Mumbai, India - Retrospective Cohort Study from a Tertiary Cancer Center. Indian J Med Paediatr Oncol 2022. [DOI: 10.1055/s-0042-1742662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
Introduction Women living with human immunodeficiency virus (HIV) have an increased risk of persistent human papillomavirus infection (HPV) of developing cervical cancer precursors and are, therefore, considered at higher risk for cervical cancer. Despite the higher risk, screening for cervical cancer is extremely low among HIV-positive women in India.
Objectives Given the limited usefulness of cytology-based screening programs, the current study retrospectively evaluated the comparative performance of visual inspection with 5% acetic acid (VIA), conventional cytology, and human papillomavirus (HPV) testing among HIV-positive women attending the cancer screening clinic at the tertiary cancer center.
Materials and Methods Retrospective analysis of 291 HIV-positive women attending cervical cancer screening services in a tertiary cancer center in Mumbai was undertaken. All underwent simultaneous screening with VIA, Pap cytology, and HPV DNA testing, followed by diagnostic colposcopy and histopathology. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to detect cervical intraepithelial neoplasia (CIN) 2/3 on histology were estimated.
Results The screen positivity rate for cervical cancer screening by VIA, high-risk HPV DNA, and Pap cytology was 35.7, 34.4, and 6.2% respectively. At the CIN2+ disease threshold, the sensitivity, specificity, PPV, and NPV estimates were 80.00% (59.30–93.17), 68.42% (62.46–73.96), 19.23% (15.46–23.67), 97.33% (94.30–98.77) for VIA; 80.00% (68.78–97.45), 70.68% (64.81–76.08), 22.00% (18.22–26.32), 98.43% (95.58–99.45) for HPV DNA; and 64.00% (42.52–82.03), 98.12% (95.67–99.39), 76.19% (56.13–88.89), 96.67% (94.50–98.00) for cytology (HSIL cutoff).
Conclusion The diagnostic performance of VIA and HPV DNA was comparable and better than cytology indicating that VIA as a cost-effective cervical cancer screening test can be incorporated within the services under sexually transmitted diseases /HIV testing and counseling centers within the country.
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Affiliation(s)
- Sharmila A. Pimple
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Vandita Pahwa
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gauravi A. Mishra
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Kavita V. Anand
- Department of Preventive Oncology, Centre for Cancer Epidemiology (CCE), Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Saleem Pathuthara
- Department of Microbiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sanjay K. Biswas
- Department of Microbiology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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12
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Mondatore D, Bai F, Augello M, Giovenzana M, Pisani Ceretti A, Bono V, Opocher E, d’Arminio Monforte A, Marchetti GC, Tincati C. Persistence of High Peripheral Activated CD8+ T-cells and Not a Low CD4:CD8 Ratio Predict cytologic HPV-Related Dysplasia in cART-Treated, HIV-Positive Subjects. Open Forum Infect Dis 2022; 9:ofac046. [PMID: 35291446 PMCID: PMC8918388 DOI: 10.1093/ofid/ofac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/27/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
People with HIV are at increased risk of HPV-disease progression, given the persistence of immune activation and residual inflammation despite effective cART. Whether a low CD4:CD8 T-cell ratio, known to mirror peripheral immune dysfunction, associates with Squamous Intraepithelial Lesions (SIL) is unknown.
Methods
Retrospective cohort study on cART-treated HIV-positive subjects undergoing screening for HPV-related dysplasia (anal/cervical cytology and HPV genotyping). SIL was defined as the presence of either atypical squamous cells of undetermined significance (ASCUS), Low-grade SIL or High-grade SIL. Demographic and viro-immunological parameters (T-cell count, CD4:CD8 T-cell ratio, CD8+CD38+ T-cells percentage) at the time of screening were analyzed by Chi square, Mann Whitney test and multivariate logistic regression analysis.
Results
419 cART-treated subjects were included. Half of the patients had cervical/anal SIL. Individuals with SIL were more commonly males, MSM, co-infected with Treponema pallidum, treated with Integrase Inhibitors (INSTI)-based cART regimens and with a shorter time since HIV diagnosis and cART initiation than subjects with normal cytology. CD38+CD8+ T-cells percentage, but not the CD4:CD8 T-cell ratio, correlated with SIL. HPV infection, especially with multiple and high-risk genotypes, was confirmed associated with SIL. In multivariate analysis, the only factors independently associated with cervical/anal dysplasia were HPV infection and harbouring higher percentages of peripheral activated CD38+CD8+ T-cells.
Conclusions
HPV infection is the major driver of dysplasia in the setting of HIV infection. CD8+CD38+ T-cells also resulted an independent predictor of dysplasia in cART-treated subjects, while the CD4:CD8 T-cell ratio did not. In the setting of HIV-HPV co-infection, the CD4:CD8 T-cell ratio may not fully capture the alterations of HPV-specific immunity.
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Affiliation(s)
- D Mondatore
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - F Bai
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - M Augello
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - M Giovenzana
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - A Pisani Ceretti
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - V Bono
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - E Opocher
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - A d’Arminio Monforte
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - G C Marchetti
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - C Tincati
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
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13
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Carlander C, Lagheden C, Eklund C, Nordqvist Kleppe S, Dzabic M, Wagner P, Sparén P, Dillner J. Nonvaccine human papillomavirus genotype common in women with HIV failing cervical precancer treatment. AIDS 2021; 35:2367-2374. [PMID: 34723851 DOI: 10.1097/qad.0000000000003026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess failure after treatment of high-grade cervical intraepithelial neoplasia (CIN2+) by HIV status and human papillomavirus (HPV) type. DESIGN A population-based register study. METHODS The Swedish National HIV Registry, the Swedish Population Registry and the Swedish National Cervical Screening Registry were linked to identify all women in Stockholm and Gothenburg counties (Sweden) living with HIV and diagnosed with CIN2+ sometime between 1983 and 2014 (n = 179). HIV-negative controls with CIN2+, were matched (2 : 1) for country of birth. CIN2+ biopsies were retrieved from biobanks and genotyped. Absolute risk and adjusted odds ratios (adjOR) of treatment failure by HIV status given HPV type (HPV16/18 vs. non-HPV16/18) were calculated. RESULTS HPV16 (32%) and HPV35 (24%) dominated in women living with HIV (WLWH) with failure, HPV35 mainly in women born in sub-Saharan Africa (67%). The absolute risk of failure in women with HPV16/18 was 26% [95% confidence interval (95% CI) 14-44] in WLWH and 12% in HIV-negative (95% CI 7-19). The absolute risk of failure in women with non-HPV16/18 was 20% (95% CI 12-31) in WLWH and 5% in HIV-negative (95% CI 2-11). WLWH with non-HPV16/18 were six times more likely to fail than HIV-negative (adjOR 6.1, 95% CI 2.0-18.6). CONCLUSION HPV35, not included in current HPV vaccines, was the second most common type in WLWH with failure. WLWH with non-HPV16/18 were six times more likely to fail than HIV-negative. This could have implications for surveillance and vaccination post CIN2+ treatment, particularly in WLWH from sub-Saharan Africa.
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Affiliation(s)
- Christina Carlander
- Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm
- Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Uppsala
| | - Camilla Lagheden
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carina Eklund
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sara Nordqvist Kleppe
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mensur Dzabic
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Philippe Wagner
- Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Uppsala
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics
| | - Joakim Dillner
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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14
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Crusz SM, El-Shakankery K, Miller RE. Targeting HPV in gynaecological cancers - Current status, ongoing challenges and future directions. ACTA ACUST UNITED AC 2021; 16:1745506520961709. [PMID: 33296284 PMCID: PMC7731692 DOI: 10.1177/1745506520961709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite the success of preventive vaccination, the Human Papilloma Virus still accounts for 266,000 deaths annually, as the main causative factor of cervical, vaginal, anal, penile and oropharyngeal cancers. Human Papilloma Virus infects epithelial cells, driving tumourigenesis primarily from incorporation of DNA into the host cellular genome. Translation of two particular Human Papilloma Virus-specific oncoproteins, E6 and E7, are the key drivers of malignancy. If diagnosed early cervical, vaginal and vulval cancers have good prognosis and are treated with curative intent. However, metastatic disease carries a poor prognosis, with first-line systemic treatment providing only modest increase in outcome. Having shown promise in other solid malignancies, immune checkpoint inhibition and therapeutic cancer vaccines have been directed towards Human Papilloma Virus-associated gynaecological cancers, mindful that persistent Human Papilloma Virus infection drives malignancy and is associated with immunosuppression and lack of T-cell immunity. In this review, we discuss novel therapeutic approaches for targeting Human Papilloma Virus-driven gynaecological malignancies including vaccination strategies, use of immunomodulation, immune checkpoint inhibitors and agents targeting Human Papilloma Virus-specific oncoproteins. We also highlight the evolving focus on exciting new treatments including adoptive T-cell therapies.
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Affiliation(s)
- Shanthini M Crusz
- Department of Medical Oncology, St Bartholomew's Hospital, London, UK
| | | | - Rowan E Miller
- Department of Medical Oncology, St Bartholomew's Hospital, London, UK.,Department of Medical Oncology, University College London Hospital, London, UK
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Abstract
Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.
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16
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Willis JA, Cheburkanov V, Kassab G, Soares JM, Blanco KC, Bagnato VS, Yakovlev VV. Photodynamic viral inactivation: Recent advances and potential applications. APPLIED PHYSICS REVIEWS 2021; 8:021315. [PMID: 34084253 PMCID: PMC8132927 DOI: 10.1063/5.0044713] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/13/2021] [Indexed: 05/04/2023]
Abstract
Antibiotic-resistant bacteria, which are growing at a frightening rate worldwide, has put the world on a long-standing alert. The COVID-19 health crisis reinforced the pressing need to address a fast-developing pandemic. To mitigate these health emergencies and prevent economic collapse, cheap, practical, and easily applicable infection control techniques are essential worldwide. Application of light in the form of photodynamic action on microorganisms and viruses has been growing and is now successfully applied in several areas. The efficacy of this approach has been demonstrated in the fight against viruses, prompting additional efforts to advance the technique, including safety use protocols. In particular, its application to suppress respiratory tract infections and to provide decontamination of fluids, such as blood plasma and others, can become an inexpensive alternative strategy in the fight against viral and bacterial infections. Diverse early treatment methods based on photodynamic action enable an accelerated response to emerging threats prior to the availability of preventative drugs. In this review, we evaluate a vast number of photodynamic demonstrations and first-principle proofs carried out on viral control, revealing its potential and encouraging its rapid development toward safe clinical practice. This review highlights the main research trends and, as a futuristic exercise, anticipates potential situations where photodynamic treatment can provide a readily available solution.
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Affiliation(s)
- Jace A. Willis
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Vsevolod Cheburkanov
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Giulia Kassab
- São Carlos Institute of Physics, University of São Paulo, São Carlos, São Paulo, Brazil
| | - Jennifer M. Soares
- São Carlos Institute of Physics, University of São Paulo, São Carlos, São Paulo, Brazil
| | - Kate C. Blanco
- São Carlos Institute of Physics, University of São Paulo, São Carlos, São Paulo, Brazil
| | | | - Vladislav V. Yakovlev
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
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17
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Sando D, Kintu A, Okello S, Kawungezi PC, Guwatudde D, Mutungi G, Muyindike W, Menzies NA, Danaei G, Verguet S. Cost-effectiveness analysis of integrating screening and treatment of selected non-communicable diseases into HIV/AIDS treatment in Uganda. J Int AIDS Soc 2021; 23 Suppl 1:e25507. [PMID: 32562364 PMCID: PMC7305460 DOI: 10.1002/jia2.25507] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/04/2020] [Accepted: 04/09/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Despite growing enthusiasm for integrating treatment of non-communicable diseases (NCDs) into human immunodeficiency virus (HIV) care and treatment services in sub-Saharan Africa, there is little evidence on the potential health and financial consequences of such integration. We aim to study the cost-effectiveness of basic NCD-HIV integration in a Ugandan setting. METHODS We developed an epidemiologic-cost model to analyze, from the provider perspective, the cost-effectiveness of integrating hypertension, diabetes mellitus (DM) and high cholesterol screening and treatment for people living with HIV (PLWH) receiving antiretroviral therapy (ART) in Uganda. We utilized cardiovascular disease (CVD) risk estimations drawing from the previously established Globorisk model and systematic reviews; HIV and NCD risk factor prevalence from the World Health Organization's STEPwise approach to Surveillance survey and global databases; and cost data from national drug price lists, expert consultation and the literature. Averted CVD cases and corresponding disability-adjusted life years were estimated over 10 subsequent years along with incremental cost-effectiveness of the integration. RESULTS Integrating services for hypertension, DM, and high cholesterol among ART patients in Uganda was associated with a mean decrease of the 10-year risk of a CVD event: from 8.2 to 6.6% in older PLWH women (absolute risk reduction of 1.6%), and from 10.7 to 9.5% in older PLWH men (absolute risk reduction of 1.2%), respectively. Integration would yield estimated net costs between $1,400 and $3,250 per disability-adjusted life year averted among older ART patients. CONCLUSIONS Providing services for hypertension, DM and high cholesterol for Ugandan ART patients would reduce the overall CVD risk among these patients; it would amount to about 2.4% of national HIV/AIDS expenditure, and would present a cost-effectiveness comparable to other standalone interventions to address NCDs in low- and middle-income country settings.
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Affiliation(s)
- David Sando
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alexander Kintu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Samson Okello
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Peter Chris Kawungezi
- Department of Community Health, Mbarara University of Science and Technology, Mbarara, Uganda
| | - David Guwatudde
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gerald Mutungi
- Department of Non-Communicable Diseases Prevention and Control, Ministry of Health, Kampala, Uganda
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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18
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Kremer WW, Vink FJ, van Zummeren M, Dreyer G, Rozendaal L, Doorbar J, Bleeker MCG, Meijer CJLM. Characterization of cervical biopsies of women with HIV and HPV co-infection using p16 ink4a, ki-67 and HPV E4 immunohistochemistry and DNA methylation. Mod Pathol 2020; 33:1968-1978. [PMID: 32249820 DOI: 10.1038/s41379-020-0528-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 12/23/2022]
Abstract
This study aims to characterize cervical intraepithelial neoplasia (CIN) in women living with HIV using biomarkers. Immunohistochemical (IHC) staining for human papillomavirus (HPV) E4 protein indicates CIN with productive HPV infection, whereas Ki-67 and p16ink4a indicate CIN with transforming characteristics, which may be further characterized using DNA hypermethylation, indicative for advanced transforming CIN. Cervical biopsies (n = 175) from 102 HPV positive women living with HIV were independently reviewed by three expert pathologists. The consensus CIN grade was used as reference standard. IHC staining patterns were scored for Ki-67 (0-3), p16ink4a (0-3), and E4 (0-2) and correlated to methylation levels of four cellular genes in corresponding cervical scrapes. Reference standards and immunoscores were obtained from 165 biopsies:15 no dysplasia, 91 CIN1, 31 CIN2, and 28 CIN3. Ki-67 and p16ink4a scores increased with increasing CIN grade, while E4 positivity was highest in CIN1 and CIN2 lesions. E4 positive CIN1 lesions had higher Ki-67 and p16ink4a scores and higher methylation levels compared with E4 negative CIN1 lesions. E4 positive biopsies with low cumulative Ki-67/p16 ink4a immunoscores (0-3) had significantly higher methylation levels compared with E4 negative biopsies. No significant differences in Ki-67 and p16ink4a scores and methylation levels were observed between E4 negative and positive CIN2 or CIN3 lesions. The presence of high methylation levels in scrapes of CIN lesions with IHC characteristics of both productive (E4 positive) and transforming infections (increased Ki-67/p16ink4a expression) in women living with HIV might indicate a rapid aggressive course of HPV infections towards cancer in these women.
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Affiliation(s)
- Wieke W Kremer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Frederique J Vink
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Marjolein van Zummeren
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Greta Dreyer
- Department of Obstetrics and Gynecology, University of Pretoria, Pretoria, South Africa
| | - Lawrence Rozendaal
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - John Doorbar
- Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, CB2 1QP, UK
| | - Maaike C G Bleeker
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Chris J L M Meijer
- Amsterdam UMC, Vrije Universiteit Amsterdam, Pathology, Cancer Center Amsterdam, de Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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19
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Kardani K, Basimi P, Fekri M, Bolhassani A. Antiviral therapy for the sexually transmitted viruses: recent updates on vaccine development. Expert Rev Clin Pharmacol 2020; 13:1001-1046. [PMID: 32838584 DOI: 10.1080/17512433.2020.1814743] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION The sexually transmitted infections (STIs) caused by viruses including human T cell leukemia virus type-1 (HTLV-1), human immunodeficiency virus-1 (HIV-1), human simplex virus-2 (HSV-2), hepatitis C virus (HCV), hepatitis B virus (HBV), and human papillomavirus (HPV) are major public health issues. These infections can cause cancer or result in long-term health problems. Due to high prevalence of STIs, a safe and effective vaccine is required to overcome these fatal viruses. AREAS COVERED This review includes a comprehensive overview of the literatures relevant to vaccine development against the sexually transmitted viruses (STVs) using PubMed and Sciencedirect electronic search engines. Herein, we discuss the efforts directed toward development of effective vaccines using different laboratory animal models including mice, guinea pig or non-human primates in preclinical trials, and human in clinical trials with different phases. EXPERT OPINION There is no effective FDA approved vaccine against the sexually transmitted viruses (STVs) except for HBV and HPV as prophylactic vaccines. Many attempts are underway to develop vaccines against these viruses. There are several approaches for improving prophylactic or therapeutic vaccines such as heterologous prime/boost immunization, delivery system, administration route, adjuvants, etc. In this line, further studies can be helpful for understanding the immunobiology of STVs in human. Moreover, development of more relevant animal models is a worthy goal to induce effective immune responses in humans.
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Affiliation(s)
- Kimia Kardani
- Department of Hepatitis and AIDS, Pasteur Institute of Iran , Tehran, Iran
| | - Parya Basimi
- Department of Hepatitis and AIDS, Pasteur Institute of Iran , Tehran, Iran
| | - Mehrshad Fekri
- Department of Hepatitis and AIDS, Pasteur Institute of Iran , Tehran, Iran
| | - Azam Bolhassani
- Department of Hepatitis and AIDS, Pasteur Institute of Iran , Tehran, Iran
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20
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Kremer WW, Steenbergen R, Heideman D, Kenter GG, Meijer C. The use of host cell DNA methylation analysis in the detection and management of women with advanced cervical intraepithelial neoplasia: a review. BJOG 2020; 128:504-514. [PMID: 32619334 PMCID: PMC7818489 DOI: 10.1111/1471-0528.16395] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 12/24/2022]
Abstract
This paper briefly reviews the role of hypermethylation of host cell genes in cervical carcinogenesis and discusses potential clinical applications of methylation analysis in the management of high-risk HPV (hrHPV) -positive women. We argue that methylation assays can be used: 1. for primary triage of hrHPV-positive women to detect cervical cancer and advanced cervical intraepithelial neoplasia (CIN); 2. as secondary triage for women with minor cytological abnormalities to identify those with the highest risk of CIN3 or worse; 3. as exit test for women leaving the screening programme to identify cervical cancer and advanced CIN; and 4. to support management of CIN. TWEETABLE ABSTRACT: This paper discusses potential clinical applications of DNA methylation analysis in the management of women with a high-risk HPV infection.
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Affiliation(s)
- W W Kremer
- Department of Pathology, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rdm Steenbergen
- Department of Pathology, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dam Heideman
- Department of Pathology, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G G Kenter
- Obstetrics and Gynaecology, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Centre for Gynaecological Oncology Amsterdam, Antoni van Leeuwenhoek-Netherlands Cancer Institute and Amsterdam UMC, Amsterdam, The Netherlands
| | - Cjlm Meijer
- Department of Pathology, Cancer Centre Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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21
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Prevalence of High-risk Nonavalent Vaccine-type Human Papillomavirus Infection Among Unvaccinated, Sexually Active Asian Female Adolescents With and Without Perinatally Acquired HIV Infection. Pediatr Infect Dis J 2020; 39:615-619. [PMID: 32282527 DOI: 10.1097/inf.0000000000002659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND We studied the prevalence of 7, high-risk human papillomavirus (HPV) types in the nonavalent vaccine (HRVT-7: HPV 16, 18, 31, 33, 45, 52, 58) among vaccine-naïve, sexually active Asian female adolescents with and without perinatally acquired HIV infection (PHIV). METHODS PHIV female adolescents 12-24 years of age and HIV-uninfected controls matched by age and number of lifetime sex partners were enrolled in a 3-year observational cohort study in Thailand and Vietnam. Samples from the oral cavity, anus, cervix and vagina were collected for HRVT-7 HPV genotyping, and serum collected for HPV 16 and 18 antibody testing. Baseline data were analyzed using multivariable logistic regression. RESULTS We included 93 PHIV (median CD4 593 cells/mm, 62% with HIV RNA suppression) and 99 HIV-uninfected adolescents (median lifetime sex partners 2). The overall prevalence of HRVT-7 infection was 53% in PHIV and 49% in HIV-uninfected adolescents (P = 0.66). Cervical HRVT-7 DNA was detected more frequently in PHIV than HIV-uninfected adolescents (37% vs. 23%, P = 0.04). Overall, more lifetime partners [≥3 vs. 1; odds ratio (OR) 2.99 (1.38-6.51), P = 0.02] and having other sexually transmitted infections [OR 3.30 (1.51-7.21), P = 0.003] increased the risk of HRVT-7 infection and/or positive HPV 16/18 antibodies; while detectable HIV RNA [OR 2.78 (1.05-7.36), P = 0.04] increased the risk among PHIV adolescents. CONCLUSIONS Half of sexually active Asian female adolescents, regardless of HIV infection, had already acquired HRVT-7 infection. This underscores the need for earlier access to HPV vaccine in the region.
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Aina IO, Raul SM, Padilla LA, Mthethwa-Hleta S, Preko PO, Jolly PE. Sociodemographic factors, health seeking behaviors, reproductive history, and knowledge of cervical screening among women in Swaziland. Infect Agent Cancer 2020; 15:16. [PMID: 32165914 PMCID: PMC7059331 DOI: 10.1186/s13027-020-00282-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/20/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cervical cancer is the leading cause of cancer among women in Swaziland; however, a low rate of cervical screening in this population has led to high rates of morbidity and mortality from cervical cancer. OBJECTIVE To identify factors associated with lack of cervical screening among women in Swaziland. METHODS A cross-sectional study was conducted among 300 women aged 18-69 years attending clinics in three regions of Swaziland from May to August of 2014. An investigator-administered questionnaire was used to collect data on socioeconomic factors, health-seeking behaviors, reproductive history, and cervical screening history and knowledge from the women. RESULTS Adjusted multivariable logistic regression analysis revealed that women < 30 years of age were less likely to receive a cervical exam compared to women ≥30 years of age (Odds Ratio 0.06, 95% Confidence Interval 0.01-0.67). Women who had a tertiary education were almost 6 times more likely to receive a cervical screening (OR 5.83, 95% CI 1.11-30.50). Women who said that they did not know when to receive cervical screening were 73% less likely to have a cervical exam (OR 0.27, 95% CI 0.01-0.74). CONCLUSIONS Younger age, lower educational level, and lack of knowledge about when to receive a cervical screening affected whether women obtained a cervical screening. This indicates the need for educating women, particularly younger women, about the importance of cervical examinations. Addressing these barriers to screening should lead to a decrease in cervical lesions and cancer, especially in this high HIV-positive population.
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Affiliation(s)
- Ibironke O. Aina
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1655 University Boulevard, Birmingham, AL 35294-0022 USA
| | - Smruti M. Raul
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1655 University Boulevard, Birmingham, AL 35294-0022 USA
| | - Luz A. Padilla
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1655 University Boulevard, Birmingham, AL 35294-0022 USA
| | - Simangele Mthethwa-Hleta
- Ministry of Health and Social Welfare, 2nd Floor Ministry of Justice & Constitutional Affairs Building, Mhalambanyatsi Road, Mbabane, Swaziland
| | - Peter O. Preko
- Care and Treatment Lead for the President’s Emergency Plan for AIDS Relief (PEPFAR), Jubela Street; Kent Rock, Mbabane, Swaziland
| | - Pauline E. Jolly
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, 1655 University Boulevard, Birmingham, AL 35294-0022 USA
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Curty G, de Carvalho PS, Soares MA. The Role of the Cervicovaginal Microbiome on the Genesis and as a Biomarker of Premalignant Cervical Intraepithelial Neoplasia and Invasive Cervical Cancer. Int J Mol Sci 2019; 21:ijms21010222. [PMID: 31905652 PMCID: PMC6981542 DOI: 10.3390/ijms21010222] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/24/2019] [Accepted: 12/25/2019] [Indexed: 12/24/2022] Open
Abstract
The microbiome is able to modulate immune responses, alter the physiology of the human organism, and increase the risk of viral infections and development of diseases such as cancer. In this review, we address changes in the cervical microbiota as potential biomarkers to identify the risk of cervical intraepithelial neoplasia (CIN) development and invasive cervical cancer in the context of human papillomavirus (HPV) infection. Current approaches for clinical diagnostics and the manipulation of microbiota with the use of probiotics and through microbiota transplantation are also discussed.
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Bandara HMHN, Samaranayake LP. Viral, bacterial, and fungal infections of the oral mucosa: Types, incidence, predisposing factors, diagnostic algorithms, and management. Periodontol 2000 2019; 80:148-176. [PMID: 31090135 DOI: 10.1111/prd.12273] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
For millions of years, microbiota residing within us, including those in the oral cavity, coexisted in a harmonious symbiotic fashion that provided a quintessential foundation for human health. It is now clear that disruption of such a healthy relationship leading to microbial dysbiosis causes a wide array of infections, ranging from localized, mild, superficial infections to deep, disseminated life-threatening diseases. With recent advances in research, diagnostics, and improved surveillance we are witnessing an array of emerging and re-emerging oral infections and orofacial manifestations of systemic infections. Orofacial infections may cause significant discomfort to the patients and unnecessary economic burden. Thus, the early recognition of such infections is paramount for holistic patient management, and oral clinicians have a critical role in recognizing, diagnosing, managing, and preventing either new or old orofacial infections. This paper aims to provide an update on current understanding of well-established and emerging viral, bacterial, and fungal infections manifesting in the human oral cavity.
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Affiliation(s)
| | - Lakshman P Samaranayake
- Department of Oral and Craniofacial Health Sciences, College of Dental Medicine, University of Sharjah, Sharjah, UAE
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Begoihn M, Mathewos A, Aynalem A, Wondemagegnehu T, Moelle U, Gizaw M, Wienke A, Thomssen C, Worku D, Addissie A, Jemal A, Kantelhardt EJ. Cervical cancer in Ethiopia - predictors of advanced stage and prolonged time to diagnosis. Infect Agent Cancer 2019; 14:36. [PMID: 31737087 PMCID: PMC6849163 DOI: 10.1186/s13027-019-0255-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/05/2019] [Indexed: 01/20/2023] Open
Abstract
Introduction In Ethiopia, most cervical cancer patients present at advanced cancer stages, long time after they experience first symptoms. We investigated possible predictors of long time spans between symptom onset and pathologic diagnosis (patient intervals). We also aimed to seek out predictors for advanced cancer stage diagnosis. Methods We conducted a retrospective cohort study among 1575 cervical cancer patients who were registered at Tikur Anbessa Specialized Hospital (TASH), Addis Ababa, Ethiopia between September 2008 and September 2012. Cox proportional hazards regression was used to find predictors of long patient intervals. Cumulative odds ordinal logistic regression was used to identify predictors of cancer stage at diagnosis. Results Median patient interval was 30 weeks, with the interval substantially longer in patients residing in rural than urban areas. Longer patient intervals were associated with more advanced cancer stages at pathologic diagnosis. HIV-positive women had an almost 1.5 times increased risk of diagnosis at a more advanced stage. Conclusion Cervical cancer patients are diagnosed after long time periods leading to advanced stages at diagnosis. Measures to raise awareness about cervical cancer, to increase screening and to shorten the time interval from recognition of symptoms to diagnosis are urgently needed.
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Affiliation(s)
- Matthias Begoihn
- 1Department of Gynecology, Martin-Luther-University, Halle (Saale), Germany
| | - Assefa Mathewos
- 2Radiotherapy Center, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abreha Aynalem
- 2Radiotherapy Center, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Ulrike Moelle
- 1Department of Gynecology, Martin-Luther-University, Halle (Saale), Germany
| | - Muluken Gizaw
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle (Saale), Germany.,4Department of Preventive Medicine School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Andreas Wienke
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle (Saale), Germany
| | - Christoph Thomssen
- 1Department of Gynecology, Martin-Luther-University, Halle (Saale), Germany
| | - Dawit Worku
- 5Department of Gynecology, School of Medicine Addis Ababa University, Addis Ababa, Ethiopia
| | - Adamu Addissie
- 3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle (Saale), Germany.,4Department of Preventive Medicine School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ahmedin Jemal
- Department of Intramural Research, American Cancer Society, Atlanta, Georgia
| | - Eva Johanna Kantelhardt
- 1Department of Gynecology, Martin-Luther-University, Halle (Saale), Germany.,3Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University, Halle (Saale), Germany
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Gabaza C, Chonzi P, Chadambuka A, Shambira G, Juru TP, Gombe NT, Nsubuga P, Tshimanga M. Utilization and outcomes of cervical cancer screening services in Harare City, 2012-2016: a secondary data analysis. BMC Health Serv Res 2019; 19:454. [PMID: 31277655 PMCID: PMC6612142 DOI: 10.1186/s12913-019-4314-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 07/01/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Visual inspection with acetic acid and cervicography (VIAC) is a method used to screen for cervical cancer. VIAC can be used as part of a "see and treat" strategy. Nine Harare city council health facilities offer VIAC free of charge with the aim of reducing morbidity and mortality from cervical cancer. Between 2014 and 2016, the number of women utilising VIAC dropped by 35%. We analysed records of clients who utilise VIAC at Harare city health facilities to characterise women accessing VIAC and their outcomes to make recommendations for improving the services. METHODS We conducted a descriptive cross-sectional study using data collected for the Harare city VIAC program. We analysed all records of clients who utilised VIAC services at nine Harare city health facilities from 1 May 2012 to 31 December 2016. RESULTS We analysed 46,217 records, the median age of the clients was 34 years [Q1 = 27: Q3 = 42]. Of the 46,217 clients screened, 3001 (6.5%) were VIAC positive, and 512 (1.1%) had suspicious of cancer lesions. The prevalence of VIAC positive ranged from 58 to 74 per 1000-screened clients over the 5 years. The prevalence of suspected cancer ranged from 9 to 14 per 1000-screened clients, and there was a general decrease in the prevalence between 2012 and 2016. Of the 3513 clients with VIAC positive or had suspicious of cancer lesions, 2090 (74.1%) did not receive treatment at the site where the screening took place. CONCLUSION The majority of women who are accessing VIAC services in Harare are middle-aged, multiparous and married women. There is a treatment gap at most of the VIAC centres such that clients are referred to other centres for management. The objective of "see and treat" is not being realised.
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Affiliation(s)
- Christine Gabaza
- Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - Prosper Chonzi
- Department of Health, Harare city Council, Harare, Zimbabwe
| | - Addmore Chadambuka
- Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
| | - Gerald Shambira
- Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
| | | | | | - Peter Nsubuga
- African Field Epidemiolog, Network ( AFENET), Kampala, Uganda
| | - Mufuta Tshimanga
- Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe
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Krings A, Dunyo P, Pesic A, Tetteh S, Hansen B, Gedzah I, Wormenor CM, Amuah JE, Behnke AL, Höfler D, Pawlita M, Kaufmann AM. Characterization of Human Papillomavirus prevalence and risk factors to guide cervical cancer screening in the North Tongu District, Ghana. PLoS One 2019; 14:e0218762. [PMID: 31246997 PMCID: PMC6597158 DOI: 10.1371/journal.pone.0218762] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 06/07/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This population-based study aimed to fill the knowledge gap on Human Papillomavirus (HPV) prevalence and associated sociodemographic risk factors of the general population in the North Tongu District, Ghana. These results are needed to guide cervical cancer prevention efforts, as the leading type of female cancers. METHODS A cross-sectional study including 2002 women in the North Tongu District, Ghana investigated HPV prevalence and associated sociodemographic risk factors. Women were recruited by geographical distribution through the local community-based health system and samples collected using a self-sampling device. For HPV genotyping BSGP5+/6+-PCR with Luminex-MPG readout was used. Multivariate logistic regression analyzed sociodemographic risk factors for HPV positivity. RESULTS Of 2002 self-collected samples, 1943 were eligible, contained sufficient DNA and provided valid HPV genotyping results. Prevalence of single high risk HPV types was 32.3% and of multiple high risk types 9.7%. The five most common detected HPV types were HPV16 (7.4%; 95%CI: 6.3-8.7), HPV52 (7.2%; 95%CI: 6.1-8.5), HPV35 (4.8%; 95%CI: 3.9-5.8), HPV59 (4.7%; 95%CI: 3.8-5.8), HPV56 (3.9%; 95%CI: 3.1-4.8). Highest prevalence was observed among women aged 18-24 years, while age 25-54 years was inversely associated with high risk HPV positivity in multivariate analysis. Sociodemographic risk factors identified were i) having any sexual partner, ii) more partners increased the odds for high risk HPV positivity, iii) independently from this marital status, in particular not being married. DISCUSSION & CONCLUSION Most importantly, the high risk HPV prevalence detected from this study is higher than estimates reported for Western Africa. This needs be considered, when deciding on the cervical cancer screening algorithms introduced on a wider scale. Follow-up and triage, depending on the methods chosen, can easily overburden the health system. Self-sampling worked well and provided adequate samples for HPV-based screening. Women with increasing number of sexual partners and not being married were found to have higher odds of being high risk HPV positive, therefore could be a higher prioritized screening target group.
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Affiliation(s)
- Amrei Krings
- Clinic for Gynecology, Laboratory for Gynecologic Tumor Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany
| | | | - Aleksandra Pesic
- Clinic for Gynecology, Laboratory for Gynecologic Tumor Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany
| | | | | | - Isaac Gedzah
- Catholic Hospital Battor, Battor, Volta Region, Ghana
| | | | - Joseph E. Amuah
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Anna-Lisa Behnke
- Clinic for Gynecology, Laboratory for Gynecologic Tumor Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany
| | - Daniela Höfler
- Division of Molecular Diagnostics of Oncogenic Infections, Research Program Infection, Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Pawlita
- Division of Molecular Diagnostics of Oncogenic Infections, Research Program Infection, Inflammation and Cancer, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Andreas M. Kaufmann
- Clinic for Gynecology, Laboratory for Gynecologic Tumor Immunology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Campus Benjamin Franklin, Berlin, Germany
- * E-mail:
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Predictors of Locally Advanced Disease at Presentation and Clinical Outcomes Among Cervical Cancer Patients Admitted at a Tertiary Hospital in Botswana. Int J Gynecol Cancer 2019; 28:1218-1225. [PMID: 29794500 DOI: 10.1097/igc.0000000000001284] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES The aim of this study was to determine predictors of locally advanced disease at presentation and clinical outcomes among cervical cancer patients in Botswana to inform interventional strategies. METHODS Retrospective review of 149 medical records of new cervical cancer patients was conducted between August 2016 and February 2017 at the Princess Marina Hospital. Data collected included sociodemographics, presenting symptoms, stage of disease, comorbidities, interventions, and clinical outcomes. STATA 12 was used for data analysis. Frequencies were used to describe patient demographics and clinical variables. Bivariate and multivariate binary logistic regression analyses were used to determine association between stage of disease at presentation and patient characteristics. P ≤ 0.05 was considered significant. RESULTS Mean age was 49.5 years. Nine (89.2%) in 10 patients had locally advanced cervical cancer (stage IB1-IVB). Two thirds (65.1%) were human immunodeficiency virus positive. Previous cervical cancer screening was low at 38.3%. Common symptoms were abnormal vaginal bleeding, low abdominal pain, and malodorous vaginal discharge reported among 75.8%, 66.4%, and 39.6% of cases, respectively. Overall, 32 (21.5%) were declared cured, 52 (34.9%) improved, and 11 (7.4%) opted for home-based care. Hospital deaths were 41 (27.5%). Major causes of death were renal failure (48.7%) and severe anemia (39%). Thirteen (8.7%) were lost to follow-up. Being unmarried (odds ratio [OR], 3.9), lack of cervical cancer screening (OR, 6.68), presentation with vaginal bleeding (OR, 7.69), and low abdominal pain (OR, 4.69) were associated with advanced disease at presentation. CONCLUSIONS Lack of cervical cancer screening, vaginal bleeding, low abdominal pain, and unmarried status were associated with advanced disease at presentation. We recommend scale-up of cervical cancer screening and its integration into routine human immunodeficiency virus care. Capacity building in gynecologic oncology and palliative care services is currently critical.
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Nakalembe M, Makanga P, Mubiru F, Swanson M, Martin J, Huchko M. Prevalence, correlates, and predictive value of high-risk human papillomavirus mRNA detection in a community-based cervical cancer screening program in western Uganda. Infect Agent Cancer 2019; 14:14. [PMID: 31114629 PMCID: PMC6515623 DOI: 10.1186/s13027-019-0230-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/07/2019] [Indexed: 12/26/2022] Open
Abstract
Background New strategies are needed to combat the high incidence of cervical cancer in resource-limited settings such as sub-Saharan Africa. Screening for high-risk human papillomavirus (hrHPV) DNA is sensitive for pre-cancer, but its lack of specificity results in substantial overtreatment in low resource settings where additional testing (e.g., colposcopy) is rarely available. Testing for hrHPV E6/E7 mRNA may enhance specificity, but little is known about its performance characteristics in resource-limited settings. Methods In a series of community health fairs in rural Uganda, women aged 25 to 49 years provided self-collected vaginal samples, which were tested for hrHPV (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) E6/E7 mRNA with the Aptima® assay. Positive specimens underwent testing for HPV-16 and 18/45. After excluding pregnant women, all women testing positive for any hrHPV subsequently were offered cervical biopsy to determine pathology. Results A total of 1892 women provided a vaginal sample for hrHPV testing during 24 health fairs. The median age was 34 years, HIV prevalence was 10, and 95% had not been previously screened. Prevalence of any hrHPV E6/E7 mRNA was 21% (95% confidence interval (CI): 19 to 23%); the prevalence of HPV-16 was 2.6%, HPV-18/45 1.9%, and HPV 16 and 18/45 were jointly found in 0.1% of the study population. Younger age, pregnancy and HIV-positivity were independently associated with any hrHPV infection. Of the 255 evaluable cervical biopsies, the positive predictive value of detecting any hrHPV E6/E7 mRNA for presence of cervical intraepithelial neoplasia grade 2 or higher ("CIN 2+") was 8.2% (95% CI: 5.1 to 12%). The positive predictive value associated with detection of HPV-16 mRNA (15%) or HPV-18/45 mRNA (15%) was only slightly higher. Conclusion Among community-based women in Uganda, the prevalence of any hrHPV E6/E7 mRNA in vaginal samples was high, but the prevalence of the most oncogenic HPV types (16, 18, or 45) was substantially lower. Positive predictive value of hrHPV mRNA-positivity for CIN 2+ was also low, including when restricting to HPV 16/18/45-positivity. The findings emphasize the need to identify more specific screening approaches for cervical cancer.
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Affiliation(s)
- Miriam Nakalembe
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Philippa Makanga
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Frank Mubiru
- 1Department of Obstetrics and Gynecology, Infectious Diseases Institute, Makerere University Kampala, Kampala, Uganda
| | - Megan Swanson
- Department of Obstetrics and Gynecology, University of California, San Francisco, Uganda
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, Uganda
| | - Megan Huchko
- 4Department of Obstetrics and Gynecology, Global Health Institute, Duke University, Durham, North Carolina USA
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Kassa LS, Dile WM, Zenebe GK, Berta AM. Precancerous lesions of cervix among women infected with HIV in Referral Hospitals of Amhara Region, Northwest Ethiopia: a cross sectional study. Afr Health Sci 2019; 19:1695-1704. [PMID: 31149000 PMCID: PMC6531982 DOI: 10.4314/ahs.v19i1.46] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The risk of death from complications related to cancer of the cervix is a main health problem over the course of a woman's life in low income countries. It commonly affects women infected with HIV. Therefore, screening women infected with HIV should start in low income countries, including Ethiopia. METHODS We conducted an institution based cross-sectional study from September 1st, 2015 to December 30th, 2015. During the study, 435 women were included in the study. The data were collected through face to face interviews and patient chart review using pre-tested and structured questionnaires. Data was also collected through visual inspection with acetic acid applied for screening and treatment. Data was entered into Epi-info version 7, cleaned and analyzed using SPSS version 20. Logistic regression analysis fitted and odds ratio with 95% confidence interval were computed. RESULTS The overall prevalence of pre-cancerous lesions of the cervix was 20.2% (95%CI: 13%, 29%). Having more than one lifetime sexual partner (AOR=2.91, 95%CI:1.13, 7.52), a history of sexually transmitted disease (AOR=4.04, 95%CI: 2.19, 7.44), age at first birth less than 18 years (AOR=3.36, 95%CI: 1.79, 5.01) and baseline CD4 count less than 200 cells/mm3 (AOR=7.51, 95%CI: 3.58, 15.68) were significantly associated with pre-cancerous lesion of the cervix. CONCLUSION This study points out the prevalence of pre-cancerous lesions of the cervix is high. Thus, the findings recommend raising of a screening strategy for cervical intraepithelial neoplasia for all women living with HIV should be undertaken. In addition, awareness creation about the impact of multiple sexual partner, promotion of early HIV diagnosis and timely baseline CD4 cell count is important.
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Affiliation(s)
| | | | | | - Abadi Marta Berta
- Department of Midwifery, College of Medicine and Health Sciences, University of Gondar
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Joshi S, Muwonge R, Kulkarni V, Deodhar K, Mandolkar M, Lucas E, Sankaranarayanan R. Incidence of cervical intraepithelial neoplasia in women infected with human immunodeficiency virus (HIV) with no evidence of disease at baseline: Results of a prospective cohort study with up to 6.4 years of follow-up from India. Int J Cancer 2019; 144:1082-1091. [PMID: 30132840 DOI: 10.1002/ijc.31826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/28/2018] [Accepted: 07/13/2018] [Indexed: 11/12/2022]
Abstract
We report the incidence of cervical intraepithelial neoplasia (CIN) among HIV-infected women who did not have any colposcopic or histopathological evidence of CIN at baseline. Of the 1,023 women without any CIN at baseline, 855 (83.6%) have been followed up to a maximum of 6.4 years contributing 2,875 person years of observation (PYO). Among these 855 women, 54 cases of any CIN were observed resulting in incidence rate of any CIN of 1.9 per 100 PYO. The median time for follow-up for women with any CIN was 3.0 (IQR 1.6-3.7) years. The cumulative incidence rate per 100 PYO of CIN 2 or worse lesion in women with HPV-18 infection at baseline was 13.3% (95% CI 5.1-26.8); in women with HPV-16 infection was 10.8% (95% CI 4.4-20.9); in women with HPV-31 infection was 4.2% (95% CI 0.9-11.7); and in women with other high-risk HPV infections was 5.4% (95% CI 2.6-9.7). HPV-18 infection at baseline contributed highest frequency of incident CIN 2 or worse lesions followed by HPV-16 infection; however, other high-risk HPV types were also responsible for substantial number of incident CIN. The elevated risk of CIN2+ disease in the study cohort was non-significant in women with CD4 count <200, possibly because of the small number of cases. Our results emphasize the need for regular cervical cancer screening of HIV-infected women and urgent implementation of cervical cancer screening services in HIV programs in India and other low and middle-income countries.
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Affiliation(s)
- Smita Joshi
- Department of Preventive Oncology, Prayas and HCJMRI, Pune, India
| | - Richard Muwonge
- Screening Group, International Agency for Research on Cancer, Lyon, France
| | | | - Kedar Deodhar
- Department of Pathology, Tata Memorial Centre, Mumbai, India
| | | | - Eric Lucas
- Screening Group, International Agency for Research on Cancer, Lyon, France
| | - Rengaswamy Sankaranarayanan
- Screening Group, International Agency for Research on Cancer, Lyon, France
- Research Triangle Institute International-India, Commercial Tower, New Delhi, India
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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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Davies G, Firnhaber C, Pantanowitz L, Michelow P. The relationship between menopausal women infected with the human immunodeficiency virus and cervical atrophy: A cytologic study. Diagn Cytopathol 2018; 47:302-306. [PMID: 30588777 DOI: 10.1002/dc.24092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 07/18/2018] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the advent of combined antiretroviral therapy (cART), HIV positive women are expected to live longer. The effect of chronic HIV infection and cART on cervical epithelial maturation has not been well studied in postmenopausal woman. The objective of this study was to determine whether HIV positive postmenopausal women on cART show expected atrophic changes in cervical Pap tests. METHODS The maturation index (MI) was performed on routine cervical smears from HIV-infected, postmenopausal women attending an HIV clinic in a tertiary hospital in Johannesburg, over a 4-year period from January 2009 to December 2012. RESULTS In Pap smears of 111 patients on cART, 58 (52%) showed an unexpected predominantly mature squamous epithelial pattern whereas 53 (48%) were predominantly immature or atrophic (P = .0001). There was no significant statistical difference in maturation according to cART use. CONCLUSION HIV-infected, postmenopausal women in this study had reduced rates of cervical atrophy than expected, irrespective of cART use and CD4 count. Initiation of cART before menopause was associated with greater cervical epithelium maturation than those women who started cART after menopause. Additional, larger studies are required to confirm this novel finding and to investigate the reason for this phenomenon.
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Affiliation(s)
- Gillian Davies
- National Health Laboratory Services and Department of Anatomical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Cynthia Firnhaber
- Department of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Liron Pantanowitz
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pamela Michelow
- National Health Laboratory Services and Department of Anatomical Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
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Ginindza TG, Almonte M, Dlamini X, Sartorius B. Distribution of cervical abnormalities detected by visual inspection with acetic acid in Swaziland, 2011-2014: A retrospective study. Afr J Prim Health Care Fam Med 2018; 10:e1-e7. [PMID: 30456977 PMCID: PMC6244366 DOI: 10.4102/phcfm.v10i1.1773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/12/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Cervical cancer is the fourth most common cancer worldwide among women, with the number of new cases increasing from 493 243 in 2002 to 527 000 in 2012. These numbers are likely to be underestimated because given the lack of registration resources, cervical cancer deaths are usually under-reported in low-income countries. AIM To describe the distribution of and trends in visual inspection with acetic acid (VIA) to detected cervical abnormalities in Swaziland by reviewing records of VIA examinations performed at two main hospitals in Swaziland between 2011 and 2014. SETTING Mbabane Government Hospital and Realign Fitkin Memorial (RFM). METHODS Records of cervical screening using VIA at the Mbabane government hospital and RFM hospital between 2011 and 2014 were retrieved. Positivity rates (PRs) of VIA with 95% confidence intervals (95% CI) were calculated and used as proxies of cervical abnormalities. Odds ratios of the association between VIA-detected cervical abnormalities and human immunodeficiency virus (HIV) status were estimated using logistic regressions. RESULTS VIA was positive in 1828 of 12 151 VIA records used for analysis (15%, 95% CI: 14.4-15.7). VIA was positive in 9% (36 of 403) women under the age of 20, in 15.5% (1714 of 11 046) of women aged 20-49 years and in 11.1% (78 of 624) of women aged 50-64 years. A decreasing trend of VIA positivity was observed over time at both screening centres (p for trend < 0.001). Of 2697 records with Papanicolaou results, 20% (67 of 331) VIA-positives and only 5% (114 of 2366) VIA negatives had high-grade squamous intraepithelial lesion. Among 4578 women with reported HIV status, 1702 were HIV-positive (37.2%, 95% CI: 35.8-38.6). The prevalence of HIV in VIA-positive women was 62.5% (95% CI: 58.7-66.2), almost double that among VIA-negative women (33.0%, 95% CI: 31.6-34.5) and that among all women screened (p < 0.001). HIV-positive women were 3.4 times more likely to have cervical abnormalities on VIA than HIV-negative women (OR: 3.4, 95% CI: 2.8-4.0, p < 0.01). CONCLUSION The high VIA PRs observed over four years in this study may reflect the prevalence of cervical abnormalities, in particular, in HIV-positive women. VIA is not a robust screening test, but it can play a major role in strengthening and expanding cervical cancer screening prevention programmes in resource-limited countries.
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Affiliation(s)
- Themba G Ginindza
- Discipline of Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal.
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D'Alessandro P, Arduino B, Borgo M, Saccone G, Venturella R, Di Cello A, Zullo F. Loop Electrosurgical Excision Procedure versus Cryotherapy in the Treatment of Cervical Intraepithelial Neoplasia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Gynecol Minim Invasive Ther 2018; 7:145-151. [PMID: 30306032 PMCID: PMC6172872 DOI: 10.4103/gmit.gmit_56_18] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 07/19/2018] [Accepted: 08/13/2018] [Indexed: 01/03/2023] Open
Abstract
Aim: Invasive cervical cancer is proceeded by a phase of preinvasive disease that is slow to progress and can be detected, treated, and collectively referred to as cervical intraepithelial neoplasia (CIN). Several excisional and ablative treatments for CIN have been studied, with loop electrosurgical excision procedure (LEEP) and cryotherapy being the two most commonly utilized. The objective of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to compare the compare harms and benefits of LEEP versus cryotherapy in women with CIN. Methods: Electronic databases were searched from their inception until May 2018. We included all RCTs comparing cryotherapy versus LEEP in women with CIN. We included trials evaluating both HIV-seropositive and HIV-seronegative women. The primary outcome was the persistence of the disease at 6-month follow-up. Meta-analysis was performed using the random-effects model to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). Results: Four trials, including 1035 women with CIN, were identified as relevant and included in the meta-analysis. Women who received LEEP for CIN had a significantly lower persistence at 6-month follow-up biopsy (RR: 0.87, 95% CI: 0.76–0.99) and significantly lower recurrence at 12-month follow-up biopsy (RR: 0.91, 95% CI: 0.84–0.99) compared to those who received cryotherapy. No between-group differences were found in the complications rate, but the analyses were not powered for these outcomes. Conclusions: In women with CIN, treatment with LEEP was associated with a significantly lower risk of persistence disease at 6 months and recurrence disease at 12 months compared to treatment with cryotherapy.
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Affiliation(s)
- Pietro D'Alessandro
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Bruno Arduino
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maria Borgo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Roberta Venturella
- Department of Obstetrics and Gynaecology, School of Medicine, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Annalisa Di Cello
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Belglaiaa E, Souho T, Badaoui L, Segondy M, Prétet JL, Guenat D, Mougin C. Awareness of cervical cancer among women attending an HIV treatment centre: a cross-sectional study from Morocco. BMJ Open 2018; 8:e020343. [PMID: 30139893 PMCID: PMC6112383 DOI: 10.1136/bmjopen-2017-020343] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To explore awareness about cervical cancer among Moroccan women attending an HIV treatment centre in Laâyoune city, Morocco. DESIGN A cross-sectional study was conducted from April to June 2017 using a knowledge test regarding cervical cancer, its risk factors and its prevention. SETTING HIV treatment centre at the Hospital of Moulay Hassan Ben Elmehdi in Laâyoune city, Morocco. PARTICIPANTS One hundred and twenty-three HIV-positive women aged 19 years and older were recruited to this study. RESULTS A total of 115 women were eligible to participate in the study. The average age was 34.9±10.2 years. Few women (20%) had heard about cervical cancer and its screening, the majority (17.4%) having received information from mass media. The vast majority (79.1%) of respondents had no knowledge of cervical cancer risk factors, and 80.8% did not know any symptoms of cervical cancer. Only 13% had undergone a Pap smear test. The main reason for not seeking Pap smear was the absence of symptoms (47%). CONCLUSION Our study documents poor awareness of cervical cancer. Given that the HIV-positive population is at increased risk of cervical cancer, health education programmes should be promoted to increase awareness of cervical cancer as well as access and participation in cervical cancer screening.
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Affiliation(s)
- Essaada Belglaiaa
- Service des soins infirmiers, Institut Supérieur des Professions Infirmières et Techniques de Santé, Laâyoune, Morocco
- EA 3181, LabEx LipSTIC ANR-11-LABX-0021, Université Bourgogne Franche-Comté, Besançon, France
| | - Tiatou Souho
- Faculté des Sciences et Techniques, Université de Kara, Kara, Togo
| | - Latifa Badaoui
- Service de Médecine, Hôpital Moulay Hassan ibn Mehdi, Laâyoune, Morocco
| | - Michel Segondy
- INSERM UMR1058 Pathogenèse et contrôle des infections chroniques, Université de Montpellier, Montpellier, France
| | - Jean-Luc Prétet
- EA 3181, LabEx LipSTIC ANR-11-LABX-0021, Université Bourgogne Franche-Comté, Besançon, France
- Centre National de Référence Papillomavirus, CHU de Besançon, Besançon, France
| | - David Guenat
- EA 3181, LabEx LipSTIC ANR-11-LABX-0021, Université Bourgogne Franche-Comté, Besançon, France
- Centre National de Référence Papillomavirus, CHU de Besançon, Besançon, France
| | - Christiane Mougin
- EA 3181, LabEx LipSTIC ANR-11-LABX-0021, Université Bourgogne Franche-Comté, Besançon, France
- Centre National de Référence Papillomavirus, CHU de Besançon, Besançon, France
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Suppressive antiretroviral therapy associates with effective treatment of high-grade cervical intraepithelial neoplasia. AIDS 2018; 32:1475-1484. [PMID: 29746299 DOI: 10.1097/qad.0000000000001853] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess if women living with HIV (WLWH) have poorer outcome after treatment of cervical intraepithelial neoplasia grade 2, grade 3, adenocarcinoma in situ or cervical cancer (CIN2+) than HIV-negative women (HNW) and to identify predictors of CIN2+ treatment failure and recurrence in WLWH. DESIGN Population-based cohort study with follow-up between 1983 and 2015. METHODS The Swedish National HIV Registry, the Swedish Population Registry and the Swedish National Cervical Screening Registry were linked to identify all women in Stockholm and Gothenburg counties (Sweden) living with HIV and diagnosed with CIN2+ (n = 179) sometime between 1983 and 2014. For each WLWH, two HNW resident in the same counties and matched for country of birth, diagnosed with CIN2+, were chosen as controls. Treatment failure was defined as the presence of CIN2+ at initial follow-up. Recurrence was defined as the presence of CIN1+ subsequent to an initial normal follow-up. RESULTS WLWH were three times more likely to have treatment failure (odds ratio (OR) 3.7 [95% confidence interval (CI) 2.0-6.8]) and five times more likely to recur (hazard ratio 5.0 [95% CI 2.1-11.6]) than HNW. Suppressive antiretroviral therapy (ART) at time of treatment of CIN2+ was associated with reduced OR of treatment failure (OR 0.3 [95% CI 0.1-0.8]). Immunosuppression (CD4 cell count <200 cells/μl) associated strongly with treatment failure (OR compared with CD4 cell count ≥500: 8.5 [95% CI 2.3-30.7]). CONCLUSION Suppressive ART is associated with effective treatment of CIN2+. Early HIV diagnosis and ART are essential for successful CIN2+ treatment.
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Bateman LB, Blakemore S, Koneru A, Mtesigwa T, McCree R, Lisovicz NF, Aris EA, Yuma S, Mwaiselage JD, Jolly PE. Barriers and Facilitators to Cervical Cancer Screening, Diagnosis, Follow-Up Care and Treatment: Perspectives of Human Immunodeficiency Virus-Positive Women and Health Care Practitioners in Tanzania. Oncologist 2018; 24:69-75. [PMID: 29934410 PMCID: PMC6324638 DOI: 10.1634/theoncologist.2017-0444] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 04/10/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study was conducted to identify barriers and facilitators to cervical cancer screening, diagnosis, follow-up care, and treatment among human immunodeficiency virus (HIV)-infected women and clinicians and to explore the acceptability of patient navigators in Tanzania. MATERIALS AND METHODS In 2012, we conducted four focus groups, two with HIV-positive women and two with clinicians who perform cervical cancer screening, diagnosis, follow-up care, and treatment. Transcriptions were analyzed using thematic analysis. RESULTS Findings from the patient focus groups indicate the prevalence of fear and stigma surrounding cervical cancer as well as a lack of information and access to screening and treatment. The clinician focus groups identified numerous barriers to screening, diagnosis, follow-up care, and treatment. Participants in both types of groups agreed that a patient navigation program would be an effective way to help women navigate across the cancer continuum of care including screening, diagnosis, follow-up care, and treatment. CONCLUSION Given the fear, stigma, misinformation, and lack of resources surrounding cervical cancer, it is not surprising that patient navigation would be welcomed by patients and providers. IMPLICATIONS FOR PRACTICE This article identifies specific barriers to cervical cancer screening and treatment from the perspectives of both clinicians and patients in Tanzania and describes the acceptability of the concept of patient navigation.
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Affiliation(s)
| | - Shaundra Blakemore
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | - Alaya Koneru
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Renicha McCree
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA
| | | | - Eric A Aris
- Management and Development for Health, Dar es Salaam, Tanzania
| | - Safina Yuma
- Reproductive Health Cancer Unit, The United Republic of Tanzania, Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Julius D Mwaiselage
- Division for Cancer Prevention and Research, Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Pauline E Jolly
- School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Looker KJ, Rönn MM, Brock PM, Brisson M, Drolet M, Mayaud P, Boily M. Evidence of synergistic relationships between HIV and Human Papillomavirus (HPV): systematic reviews and meta-analyses of longitudinal studies of HPV acquisition and clearance by HIV status, and of HIV acquisition by HPV status. J Int AIDS Soc 2018; 21:e25110. [PMID: 29873885 PMCID: PMC5989783 DOI: 10.1002/jia2.25110] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 03/27/2018] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Observational studies suggest HIV and human papillomavirus (HPV) infections may have multiple interactions. We reviewed the strength of the evidence for the influence of HIV on HPV acquisition and clearance, and the influence of HPV on HIV acquisition. METHODS We performed meta-analytic systematic reviews of longitudinal studies of HPV incidence and clearance rate by HIV status (review 1) and of HIV incidence by HPV status (review 2). We pooled relative risk (RR) estimates across studies using random-effect models. I2 statistics and subgroup analyses were used to quantify heterogeneity across estimates and explore the influence of participant and study characteristics including study quality. Publication bias was examined quantitatively with funnel plots and subgroup analysis, as well as qualitatively. RESULTS AND DISCUSSION In review 1, 37 publications (25 independent studies) were included in the meta-analysis. HPV incidence (pooled RR = 1.55, 95% CI: 1.29 to 1.88; heterosexual males: pooled RR = 1.95, 95% CI: 1.62, 2.34; females: pooled RR = 1.63, 95% CI: 1.26 to 2.11; men who have sex with men: pooled RR = 1.36, 95% CI: 1.01 to 1.82) and high-risk HPV incidence (pooled RR = 2.20, 95% CI: 1.90 to 2.54) was approximately doubled among people living with HIV (PLHIV) whereas HPV clearance rate (pooled RR = 0.53, 95% CI: 0.42 to 0.67) was approximately halved. In review 2, 14 publications (11 independent studies) were included in the meta-analysis. HIV incidence was almost doubled (pooled RR = 1.91, 95% CI 1.38 to 2.65) in the presence of prevalent HPV infection. There was more evidence of publication bias in review 2, and somewhat greater risk of confounding in studies included in review 1. There was some evidence that adjustment for key confounders strengthened the associations for review 2. Misclassification bias by HIV/HPV exposure status could also have biased estimates toward the null. CONCLUSIONS These results provide evidence for synergistic HIV and HPV interactions of clinical and public health relevance. HPV vaccination may directly benefit PLHIV, and help control both HPV and HIV at the population level in high prevalence settings. Our estimates of association are useful for mathematical modelling. Although observational studies can never perfectly control for residual confounding, the evidence presented here lends further support for the presence of biological interactions between HIV and HPV that have a strong plausibility.
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Affiliation(s)
- Katharine J Looker
- Population Health SciencesBristol Medical SchoolUniversity of BristolBristolUK
| | - Minttu M Rönn
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
- Department of Global Health and PopulationHarvard T.H Chan School of Public HealthBostonUSA
| | - Patrick M Brock
- Institute of Biodiversity, Animal Health and Comparative MedicineCollege of Medical, Veterinary and Life SciencesUniversity of GlasgowGlasgowUK
| | - Marc Brisson
- Centre de recherche du CHU de Québec‐Université LavalAxe santé des populations et pratiques optimales en santéQuébecCanada
| | - Melanie Drolet
- Centre de recherche du CHU de Québec‐Université LavalAxe santé des populations et pratiques optimales en santéQuébecCanada
| | - Philippe Mayaud
- Department of Clinical ResearchFaculty of Infectious and Tropical DiseasesLondon School of Hygiene and Tropical MedicineLondonUK
| | - Marie‐Claude Boily
- Department of Infectious Disease EpidemiologyImperial College LondonLondonUK
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Hazenberg HMJL, de Boer NKH, Mulder CJJ, Mom SH, van Bodegraven AA, Tack Md PhD GJ. Neoplasia and Precursor Lesions of the Female Genital Tract in IBD: Epidemiology, Role of Immunosuppressants, and Clinical Implications. Inflamm Bowel Dis 2018; 24:510-531. [PMID: 29462389 DOI: 10.1093/ibd/izx062] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Indexed: 12/13/2022]
Abstract
In this review the risk of breast, ovarian, and endometrial cancer and cervical and vulvovaginal (pre)malignant abnormalities in patients with inflammatory bowel disease (IBD) with or without immune suppressive treatment will be discussed. So far, this has not been studied thoroughly and large studies taking into account diverse potential confounding factors are lacking. IBD per se has not been associated with development of cervical cancer, yet patients with Crohn's disease who smoke, have a younger age at diagnosis or who use(d) thiopurines might be more at risk. Other immunosuppressive medication seems not to increase this risk, however, as evidence at this point is incomplete, physician awareness and prevention by lifestyle counseling, HPV vaccination and (intensified) screening are warranted. The risk for breast, endometrial, ovarian, and vulvovaginal cancer in IBD patients appears to be comparable to the background population, although for breast cancer this may even be decreasedin Crohn's disease specifically. Immunosuppressive medication in general does not seem to alter this risk. Earlier and more frequent screening for breast cancer than currently conducted in general nationwide screening programs is not recommended at this moment. Current literature suggests a much lower overall malignancy recurrence rate in IBD patients than has been observed previously. More importantly, immune suppressive medication does not appear to increase the recurrence risk. Robust epidemiologic data on female genital tract cancer are needed.
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Affiliation(s)
- Hanna M J L Hazenberg
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Nanne K H de Boer
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Chris J J Mulder
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam
| | - Stijn H Mom
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam
| | - Ad A van Bodegraven
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology, Geriatrics, Internal and Intensive Care Medicine (Co-MIK), Zuyderland Medical Center, Heerlen-Sittard-Geleen
| | - Greetje J Tack Md PhD
- Department of Gastroenterology and Hepatology, VU University Medical Center, Amsterdam.,Department of Gastroenterology and Hepatology, Medical Center Leeuwarden, Leeuwarden
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Hancock G, Hellner K, Dorrell L. Therapeutic HPV vaccines. Best Pract Res Clin Obstet Gynaecol 2018; 47:59-72. [PMID: 29108943 DOI: 10.1016/j.bpobgyn.2017.09.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/20/2017] [Indexed: 12/22/2022]
Abstract
High-risk human papillomavirus (HPV) infection is known to be a necessary factor for cervical and anogenital malignancies. Cervical cancers account for over a quarter of a million deaths annually. Despite the availability of prophylactic vaccines, HPV infections remain extremely common worldwide. Furthermore, these vaccines are ineffective at clearing pre-existing infections and associated preinvasive lesions. As cervical dysplasia can regress spontaneously, a therapeutic HPV vaccine that boosts host immunity could have a significant impact on the morbidity and mortality associated with HPV. Therapeutic vaccines differ from prophylactic vaccines in that they are aimed at generating cell-mediated immunity rather than neutralising antibodies. This review will cover various therapeutic vaccine strategies in development for the treatment of HPV-associated lesions and cancers.
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Affiliation(s)
- Gemma Hancock
- Nuffield Department of Medicine, University of Oxford and Oxford NIHR Biomedical Research Centre, NDM Research Building, Old Road Campus, Headington, Oxford, UK.
| | - Karin Hellner
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK.
| | - Lucy Dorrell
- Nuffield Department of Medicine, University of Oxford and Oxford NIHR Biomedical Research Centre, NDM Research Building, Old Road Campus, Headington, Oxford, UK; Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Women's Centre, John Radcliffe Hospital, Oxford, UK.
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Segondy M, Ngou J, Kelly H, Omar T, Goumbri-Lompo O, Doutre S, Mayaud P, Didelot MN. Diagnostic value of human papillomavirus (HPV) 16 and HPV18 viral loads for the detection of high-grade cervical intraepithelial neoplasia (CIN2+) in a cohort of African women living with HIV. J Clin Virol 2018; 99-100:79-83. [PMID: 29353074 DOI: 10.1016/j.jcv.2018.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/10/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND African women living with HIV (WLHIV) are at high risk of cervical cancer but rarely adequately screened. Better strategies enabling identification of WLHIV with high-grade cervical intraepithelial lesions (CIN2+) are required. OBJECTIVES To investigate the diagnostic value of HPV16 and HPV18 viral loads in a cohort of African WLHIV. DESIGN HPV16 and HPV18 viral loads were determined by quantitation of the E6 gene DNA by real-time PCR in cervical specimens collected at baseline and endline (16 months) from 245 African WLHIV positive for HPV16 or/and HPV18. Cervical biopsies were graded using the histopathological CIN classification. RESULTS Women with CIN2+ had higher viral load for HPV16 (p < 0.0001) or HPV18 (p = 0.03) than those without CIN2+. HPV16 viral load ≥3.59 log copies/1000 cells detected CIN2+ with sensitivity and specificity of 93.5% (95%CI: 81.7-98.3%) and 74.1% (95%CI: 66.3-80.6%), respectively, whereas HPV18 viral load ≥1.63 log copies/1000 cells detected CIN2+ with sensitivity and specificity of 59.1% (95%CI: 38.7-76.7%) and 66.9% (95%CI: 58.8-74.1%), respectively. A high baseline HPV16 viral load was significantly associated with persistence of, or progression to CIN2+ at endline; these findings were not observed for HPV18. CONCLUSIONS HPV16 viral load is a powerful marker of CIN2+ in African WLHIV. HPV18 viral load is of lower diagnostic value in this population.
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Affiliation(s)
- Michel Segondy
- INSERM, EFS, University of Montpellier, Montpellier, France; Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France.
| | - Jean Ngou
- INSERM, EFS, University of Montpellier, Montpellier, France
| | - Helen Kelly
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanvier Omar
- Department of Pathology, National Health Laboratory Services, Johannesburg, South Africa
| | - Olga Goumbri-Lompo
- Department of Pathology, University Teaching Hospital Yalgado, Ouagadougou, Burkina Faso
| | - Sylviane Doutre
- Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France
| | - Philippe Mayaud
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Marie-Noelle Didelot
- INSERM, EFS, University of Montpellier, Montpellier, France; Department of Biology and Pathology, University of Montpellier Hospital, Montpellier, France
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Xiang C, Zha Y, Chen Q. Effect of radiotherapy and chemotherapy on levels of serum S100B, IL-6, and IL-17 in patients with malignant glioma. EUR J INFLAMM 2018. [DOI: 10.1177/2058739218804329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
From February 2014 to 2016, we recruited 80 patients with malignant glioma in the Renmin Hospital of Wuhan University. To study the effect of radiotherapy and chemotherapy on the levels of serum S100 calcium-binding protein B (S100B), interleukin 6 (IL-6), and interleukin 17 (IL-17), all patients were divided into two groups randomly and evenly. In one group, all 40 patients received the three-dimensional conformal radiotherapy (3D-CRT). In another group, all patients received combinatorial treatment of 3D-CRT and temozolomide (TMZ). The therapeutic effect, immune function index before and after the treatment, change of serum S100B, IL-6, and IL-17 levels as well as adverse reactions were analyzed and compared between those two groups. We found that the effective rate of the combination group was 82.5%, which is significantly higher than 52.5% in the control group. After treatment, the number of CD3+, CD4+, and NK cells in the combination group was higher. But, CD8+ cells were lower compared with those before treatment. The levels of serum S100B, IL-6, and IL-17 in both groups were lower than those before treatment. In conclusion, radiotherapy combined with chemotherapy is more effective than radiotherapy alone in the treatment of malignant cerebral gliomas and is worthy of clinical spreading.
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Affiliation(s)
- Chao Xiang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yunfei Zha
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
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McGrath CJ, Garcia R, Trinh TT, Richardson BA, John-Stewart GC, Nyongesa-Malava E, Mugo NR, Glynn EH, Sakr SR, De Vuyst H, Chung MH. Role of p16 testing in cervical cancer screening among HIV-infected women. PLoS One 2017; 12:e0185597. [PMID: 29023464 PMCID: PMC5638250 DOI: 10.1371/journal.pone.0185597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 09/15/2017] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND p16 immunohistochemistry is used to evaluate for HPV-associated cervical intraepithelial neoplasia. The diagnostic performance of p16 in HIV infection is unclear. METHODS Between June-December 2009, HIV-infected women underwent Papanicolaou (Pap) smear, human papillomavirus (HPV) testing, visual inspection with acetic acid (VIA), and colposcopy-directed biopsy as the disease gold standard at a HIV clinic in Kenya. Pap smears were evaluated for p16 expression. Sensitivity, specificity, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) of p16 to detect CIN2/3 on histology and the impact of immunosuppression and ART was assessed. RESULTS Of 331 cervical samples with p16 expression, p16 sensitivity and specificity to detect CIN2/3 was 54.1% and 72.4% respectively, which was lower than Pap and HPV in sensitivity, but higher in specificity than Pap, HPV, and VIA. Combining tests and p16 reduced sensitivity and increased specificity of Pap from 90.5% to 48.7% and 51.4% to 81.7%; of VIA from 59.5% to 37.8% and 67.6% to 89.9%; and of HPV from 82.4% to 50.0% and 55.3% to 84.8%. Combination p16 increased the PPV of Pap from 34.9% to 43.4%; of HPV from 34.7% to 48.7%; and VIA from 34.9% to 51.9%. Adjunctive p16 did not change AUC (P>0.05). P16 performance was not altered by immunosuppression or ART use. Combining p16 with HPV and VIA reduced the variation in HPV and VIA performance associated with CD4 and ART. CONCLUSION As an adjunctive test in HIV-infected women, p16 immunohistochemistry increased specificity and PPV of HPV and VIA for CIN2/3, and was not altered in performance by immunosuppression, ART, or age.
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Affiliation(s)
- Christine J. McGrath
- Department of Global Health, University of Washington, Seattle, Washington United States of America
| | - Rochelle Garcia
- Department of Pathology, University of Washington, Seattle, Washington, United States of America
| | - Trong T. Trinh
- Department of Global Health, University of Washington, Seattle, Washington United States of America
| | - Barbra A. Richardson
- Department of Global Health, University of Washington, Seattle, Washington United States of America
- Department of Biostatistics, University of Washington, Seattle, Washington, United States of America
- Division of Vaccine and Infectious Diseases, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | - Grace C. John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
| | | | | | - Emily H. Glynn
- Department of Pathology, University of Washington, Seattle, Washington, United States of America
| | | | - Hugo De Vuyst
- International Agency for Research on Cancer, Lyon, France
| | - Michael H. Chung
- Department of Global Health, University of Washington, Seattle, Washington United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
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Aho I, Kivelä P, Haukka J, Sutinen J, Heikinheimo O. Declining prevalence of cytological squamous intraepithelial lesions of the cervix among women living with well-controlled HIV - Most women living with HIV do not need annual PAP smear screening. Acta Obstet Gynecol Scand 2017; 96:1330-1337. [PMID: 28832899 DOI: 10.1111/aogs.13207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Cervical screening by means of annual Papanicolaou (PAP) smears has been recommended for all women living with HIV. We analysed the results of our annual PAP smear screening program to identify low-risk subgroups for less rigorous screening. MATERIAL AND METHODS The study comprised 369 women followed at the Helsinki University Hospital 2002-2013, with a total of 2033 PAP smear results. We analyzed the temporal changes in PAP smear findings. Logistic regression analysis for binominal dependent variables was used for assessing risk factors for ever having cytological squamous intraepithelial lesions (hereafter referred as SIL) using generalized estimating equations taking into account multiple observations of each patient. RESULTS Most women had well-controlled HIV, especially towards the end of the study. PAP smear results improved substantially. At the time of each individual's last PAP smear, 90.0% of the findings displayed normal results. Conversely, the rate of SIL decreased from 16.8% to 4.6% from 2002 to 2013. In multivariate analysis the risk of SIL was significantly lower in women with consecutive normal PAP smear findings during the first two years of follow up [odds ratio (OR) 0.21, 95% confidence interval (CI) 0.10-0.45, p < 0.001] and with CD4 counts >500 cells/μL (OR 0.11, 95% CI 0.05-0.26, p < 0.001). CONCLUSIONS Widespread use of combination antiretroviral therapy (cART) and systematic cervical screening has reduced the rate of abnormal PAP smears. It seems feasible to identify low-risk women by combining HIV-related information and PAP smear results. Screening low-risk women living with HIV at three-year intervals similar to HIV-negative women appears justified.
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Affiliation(s)
- Inka Aho
- Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pia Kivelä
- Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Haukka
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Jussi Sutinen
- Infectious Diseases, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Oskari Heikinheimo
- Obstetrics and Gynecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Dreyer G. Clinical implications of the interaction between HPV and HIV infections. Best Pract Res Clin Obstet Gynaecol 2017; 47:95-106. [PMID: 28958633 DOI: 10.1016/j.bpobgyn.2017.08.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 08/27/2017] [Indexed: 01/01/2023]
Abstract
HIV-related immunodeficiency has complex effects on female genital HPV, which include increased risks of infection, multiple types, persistence, reactivation and the risk to develop pre-invasive and invasive disease. Reconstitution of immunity with anti-viral drugs improves cellular immunity, but the risk of HPV-related malignancy remains higher than background incidences and presents at younger ages. Early initiation of antiretroviral therapy (ART) allows improved retention of immune memory through existing antibodies and T-cell clones and improves long-term outcomes. Suggestions of a higher risk to contract HIV if there is existing genital HPV infection are supported and explained by pathophysiological cervical changes, including inflammation. HIV-HPV interactions should influence public health decisions towards prioritising large-scale prepubertal HPV-vaccine roll-out, secondary cervical cancer prevention and early detection programmes for HIV-infected women and early initiation of ART. This chapter will also focus on special considerations for the management of women with co-infection with these two viruses and genital HPV-related diseases.
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Affiliation(s)
- Greta Dreyer
- Department Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa.
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Smith JS, Sanusi B, Swarts A, Faesen M, Levin S, Goeieman B, Ramotshela S, Rakhombe N, Williamson AL, Michelow P, Omar T, Hudgens MG, Firnhaber C. A randomized clinical trial comparing cervical dysplasia treatment with cryotherapy vs loop electrosurgical excision procedure in HIV-seropositive women from Johannesburg, South Africa. Am J Obstet Gynecol 2017; 217:183.e1-183.e11. [PMID: 28366730 DOI: 10.1016/j.ajog.2017.03.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 03/19/2017] [Accepted: 03/23/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mortality associated with cervical cancer is a public health concern for women, particularly in HIV-seropositive women in resource-limited countries. HIV-seropositive women are at a higher risk of high-grade cervical precancer, which can eventually progress to invasive carcinoma as compared to HIV-seronegative women. It is imperative to identify effective treatment methods for high-grade cervical precursors among HIV-seropositive women. OBJECTIVE Randomized controlled trial data are needed comparing cryotherapy vs loop electrosurgical excision procedure treatment efficacy in HIV-seropositive women. Our primary aim was to compare the difference in the efficacy of loop electrosurgical excision procedure vs cryotherapy for the treatment of high-grade cervical intraepithelial neoplasia (grade ≥2) among HIV-seropositive women by conducting a randomized clinical trial. STUDY DESIGN HIV-seropositive women (n = 166) aged 18-65 years with histology-proven cervical intraepithelial neoplasia grade ≥2 were randomized (1:1) to cryotherapy or loop electrosurgical excision procedure treatment at a government hospital in Johannesburg. Treatment efficacy was compared using 6- and 12-month cumulative incidence posttreatment of: (1) cervical intraepithelial neoplasia grade ≥2; (2) secondary endpoints of histologic cervical intraepithelial neoplasia grade ≥3 and grade ≥1; and (3) high-grade and low-grade cervical cytology. The study was registered (ClinicalTrials.govNCT01723956). RESULTS From January 2010 through August 2014, 166 participants were randomized (86 loop electrosurgical excision procedure; 80 cryotherapy). Cumulative cervical intraepithelial neoplasia grade ≥2 incidence was higher for cryotherapy (24.3%; 95% confidence interval, 16.1-35.8) than loop electrosurgical excision procedure at 6 months (10.8%; 95% confidence interval, 5.7-19.8) (P = .02), although by 12 months, the difference was not significant (27.2%; 95% confidence interval, 18.5-38.9 vs 18.5%; 95% confidence interval, 11.6-28.8, P = .21). Cumulative cervical intraepithelial neoplasia grade ≥1 incidence for cryotherapy (89.2%; 95% confidence interval, 80.9-94.9) did not differ from loop electrosurgical excision procedure (78.3%; 95% confidence interval, 68.9-86.4) at 6 months (P = .06); cumulative cervical intraepithelial neoplasia grade ≥1 incidence by 12 months was higher for cryotherapy (98.5%; 95% confidence interval, 92.7-99.8) than loop electrosurgical excision procedure (89.8%; 95% confidence interval, 82.1-95.2) (P = .02). Cumulative high-grade cytology incidence was higher for cryotherapy (41.9%) than loop electrosurgical excision procedure at 6 months (18.1%, P < .01) and 12 months (44.8% vs 19.4%, P < .001). Cumulative incidence of low-grade cytology or greater in cryotherapy (90.5%) did not differ from loop electrosurgical excision procedure at 6 months (80.7%, P = .08); by 12 months, cumulative incidence of low-grade cytology or greater was higher in cryotherapy (100%) than loop electrosurgical excision procedure (94.8%, P = .03). No serious adverse effects were recorded. CONCLUSION Although rates of cumulative cervical intraepithelial neoplasia grade ≥2 were lower after loop electrosurgical excision procedure than cryotherapy treatment at 6 months, both treatments appeared effective in reducing cervical intraepithelial neoplasia grade ≥2 by >70% by 12 months. The difference in cumulative cervical intraepithelial neoplasia grade ≥2 incidence between the 2 treatment methods by 12 months was not statistically significant. Relatively high cervical intraepithelial neoplasia grade ≥2 recurrence rates, indicating treatment failure, were observed in both treatment arms by 12 months. A different treatment protocol should be considered to optimally treat cervical intraepithelial neoplasia grade ≥2 in HIV-seropositive women.
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Whitham HK, Hawes SE, Chu H, Oakes JM, Lifson AR, Kiviat NB, Sow PS, Gottlieb GS, Ba S, Sy MP, Kulasingam SL. A Comparison of the Natural History of HPV Infection and Cervical Abnormalities among HIV-Positive and HIV-Negative Women in Senegal, Africa. Cancer Epidemiol Biomarkers Prev 2017; 26:886-894. [PMID: 28515108 DOI: 10.1158/1055-9965.epi-16-0700] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/05/2017] [Accepted: 01/18/2017] [Indexed: 11/16/2022] Open
Abstract
Background: There is evidence of an interaction between HIV and human papillomavirus (HPV) resulting in increased HPV-associated morbidity and cancer mortality among HIV-positive women. This study aims to determine how the natural history of cervical HPV infection differs by HIV status.Methods: A total of 1,320 women (47% were positive for HIV-1 and/or HIV-2) were followed for an average of two years in Senegal, West Africa between 1994 and 2010. Cytology (with a sub-sample of histology) and HPV DNA testing were performed at approximately 4-month intervals yielding data from over 7,900 clinic visits. Competing risk modeling was used to estimate rates for transitioning between three clinically relevant natural history stages: Normal, HPV, and HSIL (high-grade squamous intraepithelial lesions). Among HIV-positive women, exploratory univariate analyses were conducted examining the impact of HPV type, infection with multiple HPV types, HIV type, CD4+ count, and age.Results: HIV-positive women had higher rates of progression and lower rates of regression compared with HIV-negative women (i.e., adverse transitions). HIV-positive women had a 2.55 [95% confidence interval (CI), 1.69-3.86; P < 0.0001] times higher rate of progression from HPV to HSIL than HIV-negative women (with 24-month absolute risks of 0.18 and 0.07, respectively). Among HIV-positive women, HPV-16/18 infection and CD4+ count <200/mm3 were associated with adverse transitions.Conclusions: Adverse HIV effects persist throughout HPV natural history stages.Impact: In the limited-resource setting of sub-Saharan Africa where cervical cancer screening is not widely available, the high-risk population of HIV-positive women may be ideal for targeted screening. Cancer Epidemiol Biomarkers Prev; 26(6); 886-94. ©2017 AACR.
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Affiliation(s)
- Hilary K Whitham
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota.
| | - Stephen E Hawes
- Department of Epidemiology, University of Washington, Seattle, Washington
| | - Haitao Chu
- Division of Biostatistics, University of Minnesota, Minneapolis, Minnesota
| | - J Michael Oakes
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Alan R Lifson
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Nancy B Kiviat
- Department of Pathology, University of Washington, Seattle, Washington
| | - Papa Salif Sow
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Geoffrey S Gottlieb
- Department of Medicine, Division of Allergy and Infectious Diseases/CERID and Department of Global Health, University of Washington, Seattle, Washington
| | - Selly Ba
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Marie P Sy
- Service des Maladies Infectieuses, University of Dakar, Dakar, Senegal
| | - Shalini L Kulasingam
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
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Mboumba Bouassa RS, Prazuck T, Lethu T, Jenabian MA, Meye JF, Bélec L. Cervical cancer in sub-Saharan Africa: a preventable noncommunicable disease. Expert Rev Anti Infect Ther 2017; 15:613-627. [PMID: 28440679 DOI: 10.1080/14787210.2017.1322902] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Infections caused by high-risk human papillomavirus (HPV) are responsible for 7.7% of cancers in developing countries, mainly cervical cancer. This disease is steadily increasing in sub-Saharan Africa, with more than 75,000 new cases and 50,000 deaths yearly, further increased by HIV infection. Areas covered: The current status of cervical cancer associated with HPV in sub-Saharan Africa has been systematically revised. The main issues discussed here are related to the public health burden of cervical cancer in sub-Saharan Africa and predictions for the coming decades, including molecular epidemiology and determinants of HPV infection in Africa, and promising prevention measures currently being evaluated in Africa. Expert commentary: By the year 2030, cervical cancer will kill more than 443,000 women yearly worldwide, most of them in sub-Saharan Africa. The increase in the incidence of cervical cancer in Africa could counteract the progress made by African women in reducing maternal mortality and longevity. Nevertheless, cervical cancer is a potentially preventable noncommunicable disease, and intervention strategies to eliminate cervical cancer as a public health concern should be urgently implemented.
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Affiliation(s)
- Ralph-Sydney Mboumba Bouassa
- a Laboratoire de virologie, hôpital Européen Georges Pompidou , Assistance Publique-Hôpitaux de Paris , France.,b Department of Immunology, INSERM U970 , Université Paris Descartes, Sorbonne Paris-Cité , Paris , France
| | - Thierry Prazuck
- c Service des Maladies Infectieuses et Tropicales , Centre Hospitalier Régional Orléans La Source , Orléans , France
| | - Thérèse Lethu
- d Department of health and well-being , Global Health Objectives , Geneva , Switzerland
| | - Mohammad-Ali Jenabian
- e Departement des Sciences Biologiques et Centre de recherche BioMed , Universite du Quebec a Montreal (UQAM) , Montreal , QC , Canada
| | - Jean-François Meye
- f Service de Gynécologie Obstétrique, Centre Hospitalo-Universitaire d'Angondjé, Libreville et Faculté de Médecine de Libreville , Université des Sciences de la Santé , Libreville , Gabon
| | - Laurent Bélec
- a Laboratoire de virologie, hôpital Européen Georges Pompidou , Assistance Publique-Hôpitaux de Paris , France.,b Department of Immunology, INSERM U970 , Université Paris Descartes, Sorbonne Paris-Cité , Paris , France
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Delory T, Ngo-Giang-Huong N, Rangdaeng S, Chotivanich N, Limtrakul A, Putiyanun C, Suriyachai P, Matanasarawut W, Jarupanich T, Liampongsabuddhi P, Heard I, Jourdain G, Lallemant M, Le Coeur S. Human Papillomavirus infection and cervical lesions in HIV infected women on antiretroviral treatment in Thailand. J Infect 2017; 74:501-511. [PMID: 28254419 DOI: 10.1016/j.jinf.2017.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 02/19/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To estimate the prevalence and factors associated with Human Papillomavirus (HPV) infection, HPV genotypes and cytological/histological high-grade (HSIL+/CIN2+) lesions. METHODS We conducted a cross-sectional study within a prospective cohort of HIV-infected women on combination antiretroviral therapy (cART). Cervical specimens were collected for cytology and HPV genotyping (Papillocheck®). Any women with High-Risk-HPV (HR-HPV), and/or potentially HR-HPV (pHR-HPV) and/or ASC-US or higher (ASC-US+) lesions were referred for colposcopy. Factors associated with HR-HPV infection and with HSIL+/CIN2+ lesions were investigated using mixed-effects logistic regression models. RESULTS 829 women were enrolled: median age 40.4 years, on cART for a median of 6.9 years, median CD4 cell-count 536 cells/mm3, and 788 (96%) with HIV-viral load<50copies/mL. Of 214 (26%) infected with HPV: 159 (19%) had ≥1 HR-HPV, of whom 38 (5%) HPV52, 22 (3%) HPV16, 9 (1%) HPV18; 21 (3%) had pHR-HPV, 34 (4%) low risk-HPV infection, and 56 (26%) had multiple genotypes. Younger age, low CD4 cell-counts and low education were independently associated with HR-HPV infection. 72 women (9%) had ASC-US+ and 28 (3%) HSIL+/CIN2+ lesions. HR-HPV infection was independently associated with HSIL+/CIN2+ lesions. CONCLUSION The prevalence of HPV infection and of cervical lesions was low. The HPV genotype distribution supports the use of 9-valent vaccine in Thailand.
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Affiliation(s)
- Tristan Delory
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France; Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; APHP, Service de maladies infectieuses et tropicales, hôpital Saint Louis, F-75010, Paris, France; Institut National d'Etudes Démographiques (Ined), UR-5, Paris, France.
| | - Nicole Ngo-Giang-Huong
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France; Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Samreung Rangdaeng
- Faculty of Medicine, Department of Pathology, Chiang Mai University, Chiang Mai, Thailand
| | | | - Aram Limtrakul
- Ministry of Public Health, Nakornping Hospital, Chiang Mai, Thailand
| | - Chaiwat Putiyanun
- Ministry of Public Health, Chiang Kham Hospital, Chiang Kham, Thailand
| | | | | | | | | | - Isabelle Heard
- HPV National Reference Center, Pasteur Institute, Paris, France; APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Gonzague Jourdain
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France; Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Marc Lallemant
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France; Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Sophie Le Coeur
- Institut de recherche pour le développement (IRD) UMI 174-PHPT, Marseille, France; Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand; Institut National d'Etudes Démographiques (Ined), UR-5, Paris, France; Harvard T.H. Chan School of Public Health, Boston, MA, United States
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