Age at diagnosis of preinvasive and invasive cervical neoplasia in South Africa: HIV-positive versus HIV-negative women

High-grade cervical disease and cervical cancer in women aged 50 years and older compared with younger women: examining prevalence by HIV status in two large prospective cohorts in Botswana

OBJECTIVES

International guidelines recommend cervical screening cessation at age 50 following two consecutive negative screens. However, many women aged 50 and older in low-income and middle-income countries (LMICs) have not had prior opportunity to screen. We examine the prevalence of cervical dysplasia and cervical cancer stage in Botswana women aged 50+ compared with 30-49, stratified by HIV status.

DESIGN

Secondary analysis of data from two prospective cohort studies.

SETTING

The screening cohort was recruited at health facilities in South East District. The cancer cohort was recruited from the primary public tertiary referral hospital and a private hospital in Gaborone, Botswana.

PARTICIPANTS

The screening cohort included 2570 women aged 30 and older recruited from February 2021 to August 2022. Screening eligibility included anyone with a cervix and without a prior history of cervical cancer. The cancer cohort included 1520 patients diagnosed with cervical cancer who sought care at the facilities where recruitment took place from January 2015 to December 2022.

PRIMARY AND SECONDARY OUTCOME MEASURES

The prevalence of cervical intraepithelial neoplasia (CIN)2+ and cancer stage at diagnosis was compared across age groups, stratified by HIV status. Prevalence ratios were calculated for the association between age and CIN2+/CIN3+via log-binomial regression.

RESULTS

The prevalence of CIN2+ was similar between 30-49 years old and 50+, both among women with HIV (WWH, 15.9% and 19.3%, respectively) and without HIV (13.3% and 10.4%, respectively). Similar findings were found when CIN3+ was used as the outcome. There were no statistically significant differences in prevalence ratios (PRs) across age groups for CIN2+ (adjusted PR (aPR) WWH 1.1 (95% CI 0.80 to 1.6); aPR HIV- 0.78 (95% CI 0.45 to 1.4) nor CIN3+ (aPR WWH 1.1 (95% CI 0.70 to 1.6); aPR HIV- 0.81 (95% CI 0.40 to 1.7)). Nearly half of cervical cancer diagnoses were made in women 50+; three-quarters of cases in women without HIV were diagnosed at 50+ years.

CONCLUSIONS

Our findings demonstrate the prevalence of high-grade cervical dysplasia and cervical cancer remains high beyond age 50 in both women with and without HIV in an LMIC context with high HIV prevalence. Screening women 50+ will allow treatment for cervical dysplasia and may provide early diagnosis of curable cervical cancer. These findings support the rapid introduction of high-performance cervical screening to increase access for women 50+.

TRIAL REGISTRATION NUMBER

NCT04242823.

Cervical cancer screening in HIV-endemic countries: An urgent call for guideline change

Women living with HIV (WLWH) are at an increased risk of developing HPV-related high grade cervical dysplasia and cervical cancer. Prior World Health Organization (WHO) screening guidelines recommended starting screening at age 30. We assessed characteristics of women diagnosed with cervical cancer to further inform and refine screening guidelines. We prospectively enrolled women diagnosed with cervical cancer from January 2015 to March 2020 at two tertiary hospitals in Gaborone, Botswana. We performed chi-square and ANOVA analyses to evaluate the association between age upon diagnosis and HIV status, CD4 count, viral load, and other sociodemographic and clinical factors. Data were available for 1130 women who were diagnosed with cervical cancer and 69.3% were WLWH. The median age overall was 47.9 (IQR 41.2-59.1), 44.6 IQR: 39.8 - 50.9) among WLWH, and 61.2 (IQR 48.6-69.3) among women living without HIV. There were 1.3% of women aged <30 years old, 19.1% were 30-39 and 37.2% were 40-49. Overall, 20.4% (n = 231) of cancers were in women <40 years. Age of cervical cancer diagnosis is younger in countries with higher HIV prevalence, like Botswana. Approximately 20% of the patients presented with cancer at <40 years of age and would have likely benefited from screening 10 years prior to cancer diagnosis to provide an opportunity for detection and treatment of pre-invasive disease.

Cervical cancer in women living in South Africa: a record linkage study of the National Health Laboratory Service and the National Cancer Registry

INTRODUCTION

In countries with high HIV prevalence, it is important to understand the cervical cancer (CC) patterns by HIV status to ensure targeted prevention measures. We aimed to determine the factors associated with CC compared to non-infection related cancer in women living in South Africa.

METHODS

This was a cross-sectional study of women aged 15 years and older diagnosed with CC and non-infection related cancer in the South African public health sector from 2004 to 2014. The National Cancer Registry provided data on cancer, whilst HIV status was determined from routinely collected HIV related data from the National Health Laboratory Service. We explored the association of HIV infection, age, ethnicity and calendar period with CC compared to non-infection related cancer.

RESULTS

From 2004 to 2014, 49,599 women were diagnosed with CC, whilst 78,687 women had non-infection related cancer. About 40% (n = 20,063) of those with CC and 28% (n = 5,667) of those with non-infection related cancer had a known HIV status. The median age at CC diagnosis was 44 years (interquartile range (IQR): 37-52) and 54 years (IQR: 46-64) for HIV positive and negative women, respectively, and for non-infection related cancer, 45 years (IQR: 47-55) and 56 years (IQR: 47-66) for HIV negative and positive women, respectively. Diagnosis of CC was associated with HIV positivity, Black ethnicity, earlier calendar period (2004-2006) and the ages 30-49 years. In comparison with Black women, the odds of CC were 44% less in Coloured women, 50% less in Asian women and 51% less in White women.

CONCLUSIONS

HIV positive women presented a decade earlier with CC compared to HIV negative women. A large proportion of women with CC were unaware of their HIV status with a disproportionate burden of CC in Black women. We recommend women attending CC screening facilities to be offered HIV testing so that recommendations for their follow-up visits are given according to their HIV status.

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

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

Healthcare worker compliance with cervical cancer screening guidelines. An audit at district and regional level of care in the Pietermaritzburg Metropolitan area of KwaZulu-Natal

Background

In South Africa (SA) there are screening guidelines for cervical cancer in women living with HIV (WLWH). To our knowledge there is lack of data concerning the knowledge of health care workers (HCWs) about cervical cancer screening guidelines before the initiation of antiretroviral therapy (ART) in WLWH.

Objectives

To investigate the knowledge and familiarity of HCWs regarding cervical cancer screening guidelines in WLWH.

Methods

A cross-sectional questionnaire-based study exploring compliance with cervical cancer screening guidelines before initiating ART was conducted with 85 HCWs in the antiretroviral (ARV) clinics of a district and regional hospitals in KwaZulu-Natal, SA. Data were analysed using Stata V13 and a p-value of ≤ 0.05 was considered statistically significant.

Results

Eighty-five HCWs were included in the study. Health care workers’ responses to knowledge about cervical cancer screening in WLWH were suboptimal and revealed significant gaps. Most HCWs did not know the screening intervals of WLWH. Statistically significant associations were found between an HCW’s occupation and responses to the Likert scale questions.

Conclusion

Although the majority of HCWs were familiar with cervical cancer screening guidelines in WLWH, the study highlights that there are deficiencies in both knowledge and practice. Creating awareness among HCWs regarding the current methods of cervical cancer screening is a necessary to reduce morbidity and mortality from cervical cancer in WLWH.

Rural Zulu women's knowledge of and attitudes towards Pap smears and adherence to cervical screening

Background

Cervical cancer is the most common form of cancer in black women in South Africa and has almost a 60% mortality rate. However, adherence to cervical screening programmes of black women living in rural South Africa is not universal.

Aim

The aim of this study was to gain a better understanding of rural Zulu women’s knowledge of and attitudes towards Pap smear tests, and their reasons for participation or non-compliance with cervical screening.

Setting

This study was conducted at the gynaecology and antenatal clinics in a secondary referral hospital in rural KwaZulu-Natal.

Methods

A hospital-based cross-sectional study was undertaken in the form of a semi-structured patient questionnaire survey with open and closed questions. The responses to the open-ended questions were manually analysed by the authors using a thematic approach. Outcome measures included whether the woman had a previous Pap smear, her understanding of the cervical screening programme and causes of cervical cancer.

Results

This study included a total analysis of 234 responses. The mean age was 29 years (s.d. = 8.3 years). Overall, 32.5% of women had previously had a Pap smear. Among the responders, 33.3% were human immunodeficiency virus (HIV)-positive and 53.0% were HIV-negative. Only 19.2% of women understood that a Pap smear was related to screening for cervical cancer.

Conclusions

This study illustrated a poor understanding of cervical screening, which may result in the low level of uptake of Pap smear reported; this is particularly concerning in HIV-positive women, who are at higher risk of developing cervical cancer. Urgent and extensive public health campaigning is required within rural South Africa to improve cervical screening uptake and decrease cervical cancer mortality.

Association between secondhand smoke exposure and abnormal cervical cytology: A one-to-one matched case-control study

INTRODUCTION

The aim was to evaluate the association between secondhand smoke (SHS) exposure and abnormal cervical cytology among Chinese adult women.

METHODS

A one-to-one matched case-control study was conducted with outpatients of the First Hospital of Jilin University between October 2013 to September 2016. In all, 228 cytologic confirmed new cases of abnormal cervical cytology and the equivalent number of age and ethnic matched controls were interviewed about SHS exposure and related factors.

RESULTS

Although 78.3% of all the participants had been exposed to SHS (78.1% subjects vs 78.5% controls), there were no statistical significance of cervical cytological abnormalities and SHS exposure status (never, former, current exposure), exposure intensity in cigarettes per day (none, 1–9, 10–19, and ≥20), SHS exposure duration in years (none, 1–9, 10–19, and ≥20) and the Brinkman Index (BI) (none, 1–99, 100–399, ≥400) between the two groups. The univariate analysis results showed that there were statistical differences between subjects and controls in marital status, sexual frequency in past year, number of sexual partners, age at first intercourse, age at first delivery. The stratified Cox regression model only showed that the age at first sexual intercourse was associated with the cervical cytological abnormalities (OR=1.206, 95% CI: 1.104–1.319).

CONCLUSIONS

Studies on the association between SHS exposure and cervical lesions have been equivocal. In this study, the SHS exposure could not be detected as an independent risk factor of abnormal cervical cytology among Chinese adult women.

The global burden of women's cancers: a grand challenge in global health

Every year, more than 2 million women worldwide are diagnosed with breast or cervical cancer, yet where a woman lives, her socioeconomic status, and agency largely determines whether she will develop one of these cancers and will ultimately survive. In regions with scarce resources, fragile or fragmented health systems, cancer contributes to the cycle of poverty. Proven and cost-effective interventions are available for both these common cancers, yet for so many women access to these is beyond reach. These inequities highlight the urgent need in low-income and middle-income countries for sustainable investments in the entire continuum of cancer control, from prevention to palliative care, and in the development of high-quality population-based cancer registries. In this first paper of the Series on health, equity, and women's cancers, we describe the burden of breast and cervical cancer, with an emphasis on global and regional trends in incidence, mortality, and survival, and the consequences, especially in socioeconomically disadvantaged women in different settings.

Cervical cancer prevention and treatment research in Africa: a systematic review from a public health perspective

BACKGROUND

Women living in Africa experience the highest burden of cervical cancer. Research and investment to improve vaccination, screening, and treatment efforts are critically needed. We systematically reviewed and characterized recent research within a broader public health framework to organize and assess the range of cervical cancer research in Africa.

METHODS

We searched online databases and the Internet for published articles and cervical cancer reports in African countries. Inclusion criteria included publication between 2004 and 2014, cervical cancer-related content pertinent to one of the four public health categories (primary, secondary, tertiary prevention or quality of life), and conducted in or specifically relevant to countries or regions within the African continent. The study design, geographic region/country, focus of research, and key findings were documented for each eligible article and summarized to illustrate the weight and research coverage in each area. Publications with more than one focus (e.g. secondary and tertiary prevention) were categorized by the primary emphasis of the paper. Research specific to HIV-infected women or focused on feasibility issues was delineated within each of the four public health categories.

RESULTS

A total of 380 research articles/reports were included. The majority (54.6 %) of cervical cancer research in Africa focused on secondary prevention (i.e., screening). The number of publication focusing on primary prevention (23.4 %), particularly HPV vaccination, increased significantly in the past decade. Research regarding the treatment of precancerous lesions and invasive cervical cancer is emerging (17.6 %), but infrastructure and feasibility challenges in many countries have impeded efforts to provide and evaluate treatment. Studies assessing aspects of quality of life among women living with cervical cancer are severely limited (4.1 %). Across all categories, 11.3 % of publications focused on cervical cancer among HIV-infected women, while 17.1 % focused on aspects of feasibility for cervical cancer control efforts.

CONCLUSIONS

Cervical cancer research in African countries has increased steadily over the past decade, but more is needed. Tertiary prevention (i.e. treatment of disease with effective medicine) and quality of life of cervical cancer survivors are two severely under-researched areas. Similarly, there are several countries in Africa with little to no research ever conducted on cervical cancer.

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Unique human papillomavirus-type distribution in South African women with invasive cervical cancer and the effect of human immunodeficiency virus infection

OBJECTIVES

Cervical cancer is the most common cause of cancer-related deaths among South African women. Viral types associated with cervical cancer may differ not only between countries and regions, but possibly also between human immunodeficiency virus (HIV)-infected and noninfected women.

METHODS

In a population with high HIV prevalence, human papillomavirus (HPV)-type infections detected with DNA analyses were reported in a cohort of 299 women diagnosed with invasive cervical cancer.

RESULTS

One hundred fifty-four women tested HIV negative, 77 tested HIV positive, and HIV status was unknown for 68 women. The mean age for HIV-positive women was 41.3 years, and that for HIV-negative women was 55.8 years (P < 0.001). Ninety-two percent of women tested HPV-DNA positive. Human papillomavirus types 16 and/or 18 were present in 62% of HIV-negative women and 65% of HIV-positive women. The 5 most common HPV types in HIV-positive women were, in decreasing frequency, HPV 16, 18, 45, 33, and 58. In HIV-negative women, the most common HPV types were HPV 16, 18, 35, and 45, followed by HPV 33 and 52. Human papillomavirus type 45 was more likely in the HIV positive compared with the HIV negative (odds ratio, 3.07; 95% confidence interval, 1.07-8.77). The HIV-positive women had more multiple high-risk HPV-type infections than did the HIV-negative women (27% vs 8%, P = 0.001).

CONCLUSIONS

A high number of women in South Africa with cervical cancer are HIV positive. Without viral cross-protection, HPV vaccines should prevent around 65% of cervical cancers in this population. Human papillomavirus type 45 infection is significantly linked to HIV and important for future vaccine developments.

Implementation and Operational Research: Age Distribution and Determinants of Invasive Cervical Cancer in a "Screen-and-Treat" Program Integrated With HIV/AIDS Care in Zambia

BACKGROUND

Cervical cancer screening efforts linked to HIV/AIDS care programs are being expanded across sub-Saharan Africa. Evidence on the age distribution and determinants of invasive cervical cancer (ICC) cases detected in such programs is limited.

METHODS

We analyzed program operations data from the Cervical Cancer Prevention Program in Zambia, the largest public sector programs of its kind in sub-Saharan Africa. We examined age distribution patterns by HIV serostatus of histologically confirmed ICC cases and used multivariable logistic regression to evaluate independent risk factors for ICC among younger (≤35 years) and older (>35 years) women.

RESULTS

Between January 2006 and April 2010, of 48,626 women undergoing screening, 571 (1.2%) were diagnosed with ICC, including 262 (46%) HIV seropositive (median age: 35 years), 131 (23%) HIV seronegative (median age: 40 years), and 178 (31%) of unknown HIV serostatus (median age: 38 years). Among younger (≤35 years) women, being HIV seropositive was associated with a 4-fold higher risk of ICC [adjusted odds ratio = 4.1 (95% confidence interval: 2.8, 5.9)] than being HIV seronegative. The risk of ICC increased with increasing age among HIV-seronegative women and women with unknown HIV serostatus, but among HIV-seropositive women, the risk peaked around age 35 and nonsignificantly declined with increasing ages. Other factors related to ICC included being married (vs. being unmarried/widowed) in both younger and older women, and with having 2+ (vs. ≤1) lifetime sexual partners among younger women.

CONCLUSIONS

HIV infection seems to have increased the risk of cervical cancer among younger women in Zambia, pointing to the urgent need for expanding targeted screening interventions.

Characteristics and geographic distribution of HIV-positive women diagnosed with cervical cancer in Dar es Salaam, Tanzania

Cervical cancer is the leading incident cancer and the main cause of cancer-related mortality among women in sub-Saharan Africa. Furthermore, HIV-infected women are at a higher risk of developing cervical cancer than HIV-negative women. The purpose of this study was to distinguish differences in characteristics of HIV-positive and HIV-negative patients with cervical cancer in Dar es Salaam, Tanzania. The HIV status of cervical cancer patients diagnosed and/or treated at Ocean Road Cancer Institute in Dar es Salaam, Tanzania, during the period 2007-2011 was abstracted from the medical records. Additional abstracted information included patient's name, age, place of residence, occupation, education, marital status, age at marriage, gravidity, and screening clinic visit results. Ocean Road Cancer Institute patients came from two sources: the screening clinic followed by treatment clinic or the treatment clinic without prior screening. HIV-positive and HIV-negative patients were compared regarding the above-listed clinical and epidemiologic factors. Multivariable analysis was also performed to assess the risk factors associated with cervical cancer treatment without prior screening at Ocean Road Cancer Institute. HIV-positive cervical cancer patients tended to be younger, with higher education and lower parity. Patients screened for cervical cancer prior to treatment were more likely to be HIV-positive (OR: 2.09, 95% CI: 1.36, 3.21), less likely to have higher disease stages (OR: 0.64, 95% CI: 0.43, 0.94), and less likely to reside outside of Dar es Salaam (OR: 0.44, 95% CI: 0.30, 0.65). Screening for cervical cancer at Ocean Road Cancer Institute is utilised by more HIV-positive patients from Dar es Salaam. Future studies should focus on identifying the reasons for lower utilisation of screening by HIV-negative patients and patients from other distant rural regions in Tanzania.

High rates of cervical cancer among HIV-infected women at a referral hospital in Malawi

Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30-45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer). We extracted cervical Pap smear, biopsy, loop electrosurgical excision procedure and uterine specimen reports from a hospital pathology database from November 2012 to November 2013. We used logistic regression to estimate associations with CIN2+. We reviewed specimens from 824 women; we excluded 194 with unknown HIV status, leaving 630 in the analytic sample. Twelve percent had high-grade dysplasia and 109 women (17%) had cancer. Twenty-five percent of high-grade dysplasia cases and 35% of cancers occurred among women outside recommended screening ages. The odds of having CIN2+ were 6.55 times (95% CI 4.44-9.67) greater for HIV+ women. High-grade dysplasia and cervical cancer are very common among Malawian women, especially HIV+ women. HIV infection was strongly associated with CIN2+. Expanding screening to women not covered by current guidelines could avert a substantial proportion of cervical cancer cases in Malawi.

HIV testing and burden of HIV infection in black cancer patients in Johannesburg, South Africa: a cross-sectional study

BACKGROUND

HIV infection is a known risk factor for cancer but little is known about HIV testing patterns and the burden of HIV infection in cancer patients. We did a cross-sectional analysis to identify predictors of prior HIV testing and to quantify the burden of HIV in black cancer patients in Johannesburg, South Africa.

METHODS

The Johannesburg Cancer Case-control Study (JCCCS) recruits newly-diagnosed black cancer patients attending public referral hospitals for oncology and radiation therapy in Johannesburg . All adult cancer patients enrolled into the JCCCS from November 2004 to December 2009 and interviewed on previous HIV testing were included in the analysis. Patients were independently tested for HIV-1 using a single ELISA test . The prevalence of prior HIV testing, of HIV infection and of undiagnosed HIV infection was calculated. Multivariate logistic regression models were fitted to identify factors associated with prior HIV testing.

RESULTS

A total of 5436 cancer patients were tested for HIV of whom 1833[33.7% (95% CI=32.5-35.0)] were HIV-positive. Three-quarters of patients (4092 patients) had ever been tested for HIV. The total prevalence of undiagnosed HIV infection was 11.5% (10.7-12.4) with 34% (32.0-36.3) of the 1833 patients who tested HIV-positive unaware of their infection. Men >49 years [OR 0.49(0.39-0.63)] and those residing in rural areas [OR 0.61(0.39-0.97)] were less likely to have been previously tested for HIV. Men with at least a secondary education [OR 1.79(1.11-2.90)] and those interviewed in recent years [OR 4.13(2.62 - 6.52)] were likely to have prior testing. Women >49 years [OR 0.33(0.27-0.41)] were less likely to have been previously tested for HIV. In women, having children <5 years [OR 2.59(2.04-3.29)], hormonal contraceptive use [OR 1.33(1.09-1.62)], having at least a secondary education [OR:2.08(1.45-2.97)] and recent year of interview [OR 6.04(4.45-8.2)] were independently associated with previous HIV testing.

CONCLUSIONS

In a study of newly diagnosed black cancer patients in Johannesburg, over a third of HIV-positive patients were unaware of their HIV status. In South Africa black cancer patients should be targeted for opt-out HIV testing.

Cervical dysplasia and high-risk human papillomavirus infections among HIV-infected and HIV-uninfected adolescent females in South Africa

Background. HIV-infected adolescents may be at higher risk for high-grade cervical lesions than HIV-uninfected adolescents. The purpose of this study was to compare the prevalence of high-risk HPV (HR-HPV) infections and Pap smear abnormalities between these two groups. Methods. In this cross-sectional study, we compared the HPV DNA and Pap smear results between 35 HIV-infected and 50 HIV-uninfected adolescents in order to determine the prevalence of HR-HPV genotypes and cervical cytological abnormalities. Comparisons were made using Pearson χ² and independent-samples t-tests analyses, and associations between demographic and behavioral characteristics and HPV infections were examined. Results. HIV-infected participants were more likely to be infected with any HPV (88.6% versus 48.0%; P < 0.001) and with at least one HR-HPV (60.0% versus 24.0%; P = 0.001), and to have multiple concurrent HPV infections (68.6% versus 22.0%; P < 0.001). HPV 16 and 18 were relatively underrepresented among HR-HPV infections. Abnormal Pap test results were more common among HIV-infected participants (28.8% versus 12.0%; P = 0.054). A history of smoking was associated with HR-HPV infection. Conclusions. HIV-infected adolescents have an increased risk of infection with HR-HPV and of Pap test abnormalities. The majority of HR-HPV infections among our participants would not be prevented by the currently available vaccinations against HPV.

HIV, tuberculosis, and noncommunicable diseases: what is known about the costs, effects, and cost-effectiveness of integrated care?

Unprecedented investments in health systems in low- and middle-income countries (LMICs) have resulted in more than 8 million individuals on antiretroviral therapy. Such individuals experience dramatically increased survival but are increasingly at risk of developing common noncommunicable diseases (NCDs). Integrating clinical care for HIV, other infectious diseases, and NCDs could make health services more effective and provide greater value. Cost-effectiveness analysis is a method to evaluate the clinical benefits and costs associated with different health care interventions and offers guidance for prioritization of investments and scale-up, especially as resources are increasingly constrained. We first examine tuberculosis and HIV as 1 example of integrated care already successfully implemented in several LMICs; we then review the published literature regarding cervical cancer and depression as 2 examples of NCDs for which integrating care with HIV services could offer excellent value. Direct evidence of the benefits of integrated services generally remains scarce; however, data suggest that improved effectiveness and reduced costs may be attained by integrating additional services with existing HIV clinical care. Further investigation into clinical outcomes and costs of care for NCDs among people living with HIV in LMICs will help to prioritize specific health care services by contributing to an understanding of the affordability and implementation of an integrated approach.

Younger age distribution of cervical cancer incidence among survivors of pediatric and young adult cancers

BACKGROUND

Pediatric and young adult (PAYA) cancer survivors may have an earlier onset of chronic diseases compared with the general population. We compared the age at cervical cancer diagnosis between PAYA cancer survivors and females in the general US population.

METHODS

We used longitudinal data from 9 population-based registries of the Surveillance, Epidemiology, and End Results program collected between 1973 and 2010. PAYA cancer survivors were females diagnosed with any cancer before age 30 years, survived at least 5 years post-diagnosis, and were subsequently diagnosed with invasive cervical cancer (n=46). The general US population comprised females who were diagnosed with invasive cervical cancer as the primary malignancy (n=26,956). We estimated the difference in median age at diagnosis (ß₅₀) and bootstrap 95% confidence limits (CL) of invasive cervical cancer after adjustment for year of diagnosis and race.

RESULTS

The median age at diagnosis of invasive cervical cancer was 33 years for female PAYA cancer survivors and 40 years for females in the general US population (ß50=-7.0, 95% CL: -11, -3.2). Similar differences were observed across subgroups of stage and histologic subtype of invasive cervical cancer.

CONCLUSION

Our results suggest that PAYA cancer survivors are diagnosed with invasive cervical cancer at a substantially younger age compared with females without a prior cancer diagnosis in the general US population. This issue warrants further study, and could have implications for determining age at initiation or frequency of cervical cancer screening if younger age at diagnosis is attributable to an underlying biological phenomenon.

Effect of antiretroviral therapy on the incidence of cervical neoplasia among HIV-infected women: a population-based cohort study in Taiwan

OBJECTIVE

Cervical cancer has been recognized as one of the AIDS-defining cancers since 1993. Receipt of HAART has been shown to reduce the risk of opportunistic infection and AIDS-defining malignancies. However, findings concerning the effect of HAART on cervical neoplasia have been inconsistent.

DESIGN

A population-based cohort design was used, in which 1360 HIV-infected women were compared to the general population (HIV-negative women). The comparison population included 358 141 HIV-negative women randomly selected from among all insured persons in Taiwan in 2000. Data from HIV-infected and uninfected women were analyzed through 2008.

METHODS

The age and calendar year-standardized incidence ratio was calculated to estimate the relative risk of cervical neoplasia, and Cox proportional hazards models were used to assess the effect of HAART on the incidence of cervical neoplasia.

RESULTS

The incidence of cervical neoplasia was four times higher in the HIV-infected women than in the general population [standardized incidence ratio 4.0, 95% confidence interval (CI) 2.16-6.95]. The most increased risk was noted in HIV-infected women aged 40-59 years. Receipt of HAART was associated with a significantly reduced risk of cervical neoplasia (0.20, 0.05-0.77). The most evident protective effect was noted in adherent to HAART at least 85%, and those treated with HAART for more than 3 years (0.01, 0.00-0.47).

CONCLUSIONS

HIV-infected women have a substantially increased risk of cervical neoplasia. Adherent to HAART and prolonged HAART for more than 3 years may contribute to a reduction risk of cervical neoplasia.

Perinatally acquired HIV infection in adolescents from sub-Saharan Africa: a review of emerging challenges

Worldwide, more than three million children are infected with HIV, 90% of whom live in sub-Saharan Africa. As the HIV epidemic matures and antiretroviral treatment is scaled up, children with HIV are reaching adolescence in large numbers. The growing population of adolescents with perinatally acquired HIV infection living within this region presents not only unprecedented challenges but also opportunities to learn about the pathogenesis of HIV infection. In this Review, we discuss the changing epidemiology of paediatric HIV and the particular features of HIV infection in adolescents in sub-Saharan Africa. Longstanding HIV infection acquired when the immune system is not developed results in distinctive chronic clinical complications that cause severe morbidity. As well as dealing with chronic illness, HIV-infected adolescents have to confront psychosocial issues, maintain adherence to drugs, and learn to negotiate sexual relationships, while undergoing rapid physical and psychological development. Context-specific strategies for early identification of HIV infection in children and prompt linkage to care need to be developed. Clinical HIV care should integrate age-appropriate sexual and reproductive health and psychological, educational, and social services. Health-care workers will need to be trained to recognise and manage the needs of these young people so that the increasing numbers of children surviving to adolescence can access quality care beyond specialist services at low-level health-care facilities.

Completion of and early response to chemoradiation among human immunodeficiency virus (HIV)-positive and HIV-negative patients with locally advanced cervical carcinoma in South Africa

BACKGROUND

Very few published studies have dealt with the management of locally advanced cervix carcinoma among human immunodeficiency virus (HIV)-positive patients. The objective of this study was to compare the clinical characteristics, radiation and chemotherapy treatments, and outcomes in a cohort of HIV-positive and HIV-negative women with cervical cancer.

METHODS

The authors reviewed the charts of 59 HIV-positive patients and 324 HIV-negative patients who had stage IB1 to IIIB cervical carcinoma and who received radiation therapy. Demographic and clinical characteristics were compared at the time of diagnosis; and radiation doses, chemotherapy cycles, and responses were compared at the time of brachytherapy and at 6-week follow-up. Logistic regression models of response to treatment were developed.

RESULTS

Forty-nine HIV-positive patients (88.1%) but only 213 HIV-negative patients (65.7%) presented with stage IIIB disease (P = .009). Forty-seven HIV-positive patients (79.7%) and 291 HIV-negative patients (89.8%) completed the equivalent dose of 68 Grays (Gy) external-beam radiation and high-dose-rate brachytherapy. (P = .03). Of the 333 patients who commenced concurrent chemotherapy, 26 HIV-positive patients (53.1%) and 212 HIV-negative patients (74.6%) completed ≥4 weekly cycles of platinum-based treatment. Follow-up was censured at 6 weeks. In models that included age, disease stage, HIV status, and treatment, a poor response at 6 weeks was associated only with stage IIIB disease (odds ratio, 2.39; 95% confidence interval, 1.45-3.96) and receiving an equivalent radiation dose in 2-Gy fractions of <68 Gy (OR, 3.14; 95% CI, 1.24-7.94).

CONCLUSIONS

HIV-positive patients fared worse than HIV-negative patients because of later presentation and a decreased likelihood of completing treatment. The current findings emphasize the importance of completing irradiation therapy. Further studies will address the association of these variables with survival.

See-and-treat approaches to cervical cancer prevention for HIV-infected women

Cervical cancer remains the second commonest cancer among women worldwide, and more than 85% of the global burden of this disease occurs in the developing world. HIV-infected women have a higher likelihood of developing persistent high-risk human papillomavirus (HPV) infection, precancer, and invasive cervical cancer than seronegative women. Although highly effective primary and secondary prevention strategies are currently available, they remain inaccessible to the vast majority of women. Because of their simplicity and affordability, see-and-treat cervical cancer screening modalities have the potential to substantially improve women's access to cancer prevention, as well as to create much needed infrastructure for future molecular-based cervical screening and HPV vaccination programs. Additional data addressing the effectiveness of see-and-treat approaches for HIV-infected women are urgently needed. Studies informing best practice guidelines on when to start, when to stop, and how frequently to screen HIV-infected women within the see-and-treat paradigm would be of great value.