A longitudinal study of HPV detection and cervical pathology in HIV infected women

Geographic Variation in Human Papillomavirus Vaccination Initiation and Completion Among Young Adults in the U.S

INTRODUCTION

This study explores how human papillomavirus vaccination initiation and completion among men and women aged 18-34 years varies by geographic region.

METHODS

Data from the 2015-2017 Behavioral Risk Factor Surveillance System were analyzed. Geographic regions for the selected states were defined as South, Northeast, and Midwest/West. Human papillomavirus vaccination initiation was defined as receipt of ≥1 dose, and completion was defined as receipt of ≥3 doses. Weighted, multivariable logistic regression models estimated the association between geographic region and vaccine uptake, adjusting for sociodemographic, health, and healthcare factors. Analyses were performed in November 2019.

RESULTS

A total of 18,078 adults were included in the study, 80% of whom resided in the South. The overall vaccination initiation rate was 23.4%, and the completion rate was 11.0%. Initiation was higher among those who resided in the Northeast (38.6%), followed by Midwest/West (23.8%), and lowest for those in the South (21.8%) (p<0.0001). Completion rates followed the same trend as initiation. In the adjusted models, compared with the adults residing in the Northeast, those living in the South were less likely to initiate (AOR=0.47, 95% CI=0.40, 0.55) and complete (AOR=0.56, 95% CI=0.46, 0.68) human papillomavirus vaccination.

CONCLUSIONS

Human papillomavirus vaccine uptake was low for all regions, but vaccine uptake was significantly lower in the South region. This demonstrates the need to identify barriers specifically associated with the Southern population, which may include differing levels of education and insurance. Such work is especially pertinent because many Southern states face increased risk of human papillomavirus-associated cancers such as cervix and oral cavity and pharynx cancers.

Differences in Sociodemographic Correlates of Human Papillomavirus-Associated Cancer Survival in the United States

OBJECTIVES

Human papillomavirus (HPV)-associated cancers account for about 9% of the cancer mortality burden in the United States; however, survival differs among sociodemographic factors. We determine sociodemographic and clinical variables associated with HPV-associated cancer survival.

METHODS

Data derived from the Surveillance, Epidemiology, and End Results 18 cancer registry were analyzed for a cohort of adult patients diagnosed with a first primary HPV-associated cancer (anal, cervical, oropharyngeal, penile, vaginal, and vulvar cancers), between 2007 and 2015. Multivariable Fine and Gray proportional hazards regression models stratified by anatomic site estimated the association of sociodemographic and clinical variables and cancer-specific survival.

RESULTS

A total of 77 774 adults were included (11 216 anal, 27 098 cervical, 30 451 oropharyngeal, 2221 penile, 1176 vaginal, 5612 vulvar; average age = 57.2 years). The most common HPV-associated cancer was cervical carcinoma (58%) for females and oropharyngeal (81%) for male. Among patients diagnosed with anal/rectal squamous cell carcinoma (SCC), males had a higher risk of death than females. NonHispanic (NH) blacks had a higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma; and Hispanics had a higher risk of death from oropharyngeal SCC than NH whites. Marital status was associated with risk of death for all anatomic sites except vulvar. Compared to nonMedicaid insurance, patients with Medicaid and uninsured had higher risk of death from anal/rectal SCC, oropharyngeal SCC, and cervical carcinoma.

CONCLUSIONS

There exists gender (anal) and racial and insurance (anal, cervical, and oropharyngeal) disparities in relative survival. Concerted efforts are needed to increase and sustain progress made in HPV vaccine uptake among these specific patient subgroups, to reduce cancer incidence.

Human papillomavirus and cervical cancer

Cervical cancer is by far the most common HPV-related disease. About 99.7% of cervical cancer cases are caused by persistent genital high-risk human papillomavirus (HPV) infection. Worldwide, cervical cancer is one of the most common cancer in women with an estimated 528,000 new cases reported in 2012. Most HPV infections clear spontaneously but persistent infection with the oncogenic or high-risk types may cause cancer of the oropharynx and anogenital regions. The virus usually infects the mucocutaneous epithelium and produces viral particles in matured epithelial cells and then causes a disruption in normal cell-cycle control and the promotion of uncontrolled cell division leading to the accumulation of genetic damage. There are currently two effective prophylactic vaccines against HPV infection, and these comprise of HPV types 16 and 18, and HPV types 6, 11, 16 and 18 virus-like particles. HPV testing in the secondary prevention of cervical cancer is clinically valuable in triaging low-grade cytological abnormalities and is also more sensitive than cytology as a primary screening. If these prevention strategies can be implemented in both developed and developing countries, many thousands of lives could be saved.

Human papillomavirus and cervical cancer

Cervical cancer is by far the most common HPV-related disease. About 99.7% of cervical cancer cases are caused by persistent genital high-risk human papillomavirus (HPV) infection. Worldwide, cervical cancer is one of the most common cancers in women with an estimated 528,000 new cases reported in 2012. Most HPV infections clear spontaneously but persistent infection with the oncogenic or high-risk types may cause cancer of the oropharynx and anogenital regions. The virus usually infects the mucocutaneous epithelium and produces viral particles in matured epithelial cells and then causes a disruption in normal cell-cycle control and the promotion of uncontrolled cell division leading to the accumulation of genetic damage. There are currently two effective prophylactic vaccines against HPV infection, and these comprise of HPV types 16 and 18, and HPV types 6, 11, 16 and 18 virus-like particles. HPV testing in the secondary prevention of cervical cancer is clinically valuable in triaging low-grade cytological abnormalities and is also more sensitive than cytology as a primary screening. If these prevention strategies can be implemented in both developed and developing countries, many thousands of lives could be saved.

Molecular mechanisms in progression of HPV-associated cervical carcinogenesis

Cervical cancer is the fourth most frequent cancer in women worldwide and a major cause of mortality in developing countries. Persistent infection with high-risk human papillomavirus (HPV) is a necessary cause for the development of cervical cancer. In addition, genetic and epigenetic alterations in host cell genes are crucial for progression of cervical precancerous lesions to invasive cancer. Although much progress has been made in understanding the life cycle of HPV and it’s role in the development of cervical cancer, there is still a critical need for accurate surveillance strategies and targeted therapeutic options to eradicate these cancers in patients. Given the widespread nature of HPV infection and the type specificity of currently available HPV vaccines, it is crucial that molecular details of the natural history of HPV infection as well as the biological activities of viral oncoproteins be elucidated. A better understanding of the mechanisms involved in oncogenesis can provide novel insights and opportunities for designing effective therapeutic approaches against HPV-associated malignancies. In this review, we briefly summarize epigenetic alterations and events that cause alterations in host genomes inducing cell cycle deregulation, aberrant proliferation and genomic instability contributing to tumorigenesis.

Risk Factors Associated with Genital Warts in Hiv-Positive Brazilian Women

Aims and Background

In Brazil, the female population has been increasingly infected with human immunodeficiency virus (HIV), and uterine cervix carcinoma now represents the second highest cause of mortality. Although HIV infection among women is associated with an increased prevalence of cervical cancer precursors, the co-infection with human papillomavirus (HPV) is considered to be a necessary but not sufficient factor to induce genital lesions. This study was conducted to identify risk factors associated with the history of genital warts among HIV-positive women.

Methods

A comparative cross-sectional evaluation was applied to 141 HIV-positive women. All patients were submitted to colposcopy, smear cytology, directed biopsy, and HPV-DNA detection. The chi-square, Fisher's exact test, and the odds ratio (OR, 95%; confidence interval, CI) were used to evaluate associations between history of genital warts and risk factors.

Results

A history of genital warts presented associations with: a) age at first sexual intercourse ≤17 years (OR, 0.42; CI, 0.16-1.11); b) history of genital warts in sex partners (OR, 11.39; CI, 4.21–30.76), especially with recurrent episodes (OR, 6.60; CI, 2.69–16.12); c) drug addiction (OR, 2.38; CI, 1.09–5.19), especially in crack users (OR, 5.34; CI, 1.64–17.41); d) cervical HPV infection (OR, 2.75; CI 1.09–6.90); e) cervical infection caused by only one HPV type (OR, 2.77; CI 1.06–7.20); f) perianal HPV infection (OR, 2.30; CI, 0.70–7.56), associated with negative results for undetermined risk HPV (OR, 8.41; P = 0.04); and g) no antiretroviral therapy (OR, 3.41; P = 0.07).

Conclusions

Evaluation of behavioral risk factors associated with a genital wart history is an important tool to prevent and reduce persistent HPV infection, and consequently genital cancer precursors in HIV infected women.

Cervical screening in HIV-positive women in the East of England: recent CD4 as the predictive risk factor

This study examines the relationship between CD4 count and cervical cytological abnormality in HIV-positive women attending two district general hospital genitourinary medicine clinics in the East of England. It aims to determine whether the rate of cervical cytological abnormalities differs in HIV-positive women with CD4 count >350 cells/µl and those with CD4 count ≤350 cells/µl; and to compare the rates of abnormalities with that of the general population. We retrospectively reviewed data from a cross-sectional audit undertaken between December 2010 and December 2011 and analysed them using multivariable statistics. There was a significant association between recent CD4 count ≤350 cells/µl and cervical cytological abnormality (p < 0.001). A total of 6.3% of women with recent CD4 counts >350 cells/µl had abnormal cervical smear results, compared with 6.6% of the general population in the screening period 2010-11 and 7.2% of the general population in the screening period 2009-10. In our study population of women with recent CD4 counts >350 cells/µl, the proportions of mild, moderate and severe dysplasia were also similar to national figures. This raises important questions about the cost effectiveness of blanket annual screening for HIV-positive women.

High-risk human papillomavirus infection in HIV-positive African women living in Europe

Introduction

Cervical infection with high-risk human papillomavirus (HRHPV) induces cervical cancer and is present in 14% of women in Europe. We assessed the prevalence and incidence of cervical HRHPV in a cohort of HIV-positive women living in Belgium.

Methods

Prospective observational program of screening and follow up of HRHPV cervical infection performed by Hybrid Capture in 825 HIV-positive women between 2002 and 2011. Women without normal cervix at baseline were excluded.

Results

The final analysis included 652 women: median age 38 years, African origin (81%), median HIV follow-up (66 months), median CD4 count (426 cells/μL) and 79% on antiretroviral therapy (cART). At baseline, HRHPV prevalence was 43% and decreased significantly as both age and CD4 cell count increased: highest prevalence (100%) in women <30 years and <200 CD4/μL and lowest (19%) in women >40 years and >500 CD4/μL (p<0.0001, multivariate analysis). The relative risk (RR) to carry HRHPV at baseline decreases proportionally by 11% for each 5 years-age increase and by 11% for each 100 CD4 cells/μL rise (RR=0.89, 95% CI: 0.85-0.93; p<0.0001, Poisson regression for both). During follow-up, incidence rate of HRHPV was 13.4 per 100 women-years.

Conclusions

We found a high HRHPV prevalence of 43% and an incidence rate of 13 per 100 women-years in this cohort of HIV-positive women living in Europe and on cART. Women under 40 years-age had the highest prevalence even with CD4 count >350 cells/μL. The magnitude of HRHPV epidemiology should prompt to evaluate the clinical efficacy of vaccines against HPV in HIV-infected women.

Genital warts and vulvar intraepithelial neoplasia: natural history and effects of treatment and human immunodeficiency virus infection

OBJECTIVE

To describe the natural history of genital warts and vulvar intraepithelial neoplasia (VIN) in women with human immunodeficiency virus (HIV).

METHODS

A cohort of 2,791 HIV-infected and 953 uninfected women followed for up to 13 years had genital examinations at 6-month intervals with biopsy for lesions suspicious for VIN.

RESULTS

The prevalence of warts was 4.4% (5.3% for HIV-seropositive women and 1.9% for HIV-seronegative women, P<.001). The cumulative incidence of warts was 33% (95% confidence interval [CI] 30-36%) in HIV-seropositive and 9% (95% CI 6-12%) in HIV-seronegative women (P<.001). In multivariable analysis, lower CD4 lymphocyte count, younger age, and current smoking were strongly associated with risk for incident warts. Among 501 HIV-seropositive and 43 HIV-seronegative women, warts regressed in 410 (82%) seropositive and 41 (95%) seronegative women (P=.02), most in the first year after diagnosis. In multivariable analysis, regression was negatively associated with HIV status and lower CD4 count as well as older age. Incident VIN of any grade occurred more frequently among HIV-seropositive than HIV-seronegative women: 0.42 (0.33-0.53) compared with 0.07 (0.02-0.18) per 100 person-years (P<.001). Positivity for VIN 2 was found in 58 women (55 with and three without HIV, P<.001). Two women with HIV developed stage IB squamous cell vulvar cancers.

CONCLUSION

Although genital warts and VIN are more common among HIV-seropositive than HIV-seronegative women, wart regression is common even in women with HIV, and cancers are infrequent.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00000797.

LEVEL OF EVIDENCE

II.

Progression and regression of premalignant cervical lesions in HIV-infected women from Soweto: a prospective cohort

OBJECTIVE

To ascertain progression and regression of cervical dysplasia in HIV-infected women in Soweto.

DESIGN

Prospective cohort.

METHODS

Women attending an HIV wellness clinic were offered cervical smears as part of care; smears were assessed using the Bethesda system. Those with high-grade lesions or worse were referred for colposcopy. Progression analyses included women with at least two smears at least 5.5 months apart. Hazard ratios were used to ascertain predictors of progression.

RESULTS

Two thousand, three hundred and twenty-five women had a baseline smear; their median age and CD4 cell count was 32 years and 312 cells/μl, respectively; 17% were taking highly active antiretroviral therapy (HAART); 62, 20 and 14% had normal, low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL), respectively. Of those with baseline normal or LSIL smears, 1074 had another smear; progression from normal to LSIL was 9.6/100 person-years (95% CI 8.3-11.1) and progression from normal or LSIL to HSIL was 4.6/100 person-years (95% CI 3.9-5.5). Of 225 women with LSIL at baseline and at least one subsequent smear at least 11.5 months later, 44.0% regressed to normal (21.2/100 person-years (95% CI 17.5-25.7)). Multivariate models suggested increasing risk for progression in women with CD4 cell count below 500 cells/μl and HAART may reduce the risk of progression [adjusted hazard ratio (aHR) 0.72 (0.52-0.99)].

CONCLUSION

HIV-infected women have high rates of prevalent and incident HSIL and LSIL with relatively low risk of regression to normal from LSIL. HAART appears to protect against progression. Our findings suggest cervical screening intervals should be less than 10 years - irrespective of age in women with CD4 cell counts below 500 cells/μl.

Cervical cancer screening among HIV-infected women in a health department setting

HIV-infected women are at increased risk of developing invasive cervical cancer and present for care at a later stage of disease. Because of this susceptibility, the US Preventive Services Task Force and Centers for Disease Control and Prevention recommend that HIV-infected women receive two Pap smears during their first year after diagnosis, then annually thereafter. The aim of this study was to determine adherence to these screening guidelines and associations between demographic factors and receipt of Pap smears at a local health department in Florida. Demographic and Pap smear data were extracted from randomly selected medical records of 200 HIV-infected women receiving care between January 2000 and May 2006. Descriptive statistics and chi(2) associations were determined. Overall, 83% of women received at least one Pap smear in their first year after enrollment; 24.5% received the recommended two Pap smears. The women were predominantly minorities (57.4% African Americans; 22.8% Hispanics) and economically disadvantaged (mean income $8,180). First year Pap smear rate was significantly associated with type of insurance (p = 0.0185) and Pap smear facility (p < 0.0001), with a trend toward association with HIV risk behavior (p = 0.0593). First-year Pap smear rate was not associated with age, income, ethnicity, or incarceration history. Although this health department provided similar cervical cancer screening levels to those reported elsewhere, rates fall short of evidence-based guidelines. Future research must address low second Pap smear rates in the context of patient and provider barriers to improve early detection and prevention of cervical cancer in HIV-infected women.

Histologic correlates of glandular abnormalities in cervical cytology among women with human immunodeficiency virus

OBJECTIVE

To estimate the frequency and histologic correlates of glandular abnormalities in cervical cytology among women with the human immunodeficiency virus (HIV) and to compare findings with those of women without HIV.

METHODS

In a cohort study of HIV-infected and uninfected women followed between 1994 and 2007, Pap tests were obtained every 6 months. Glandular abnormalities, including atypical glandular cells (AGC), adenocarcinoma in situ (AIS), and adenocarcinoma, were identified and correlated with biopsy histology. Multivariate models to summarize data across visits used generalized estimating equations. The association of Pap and histology results was assessed using chi tests.

RESULTS

Of 48,362 Pap tests from 3,766 women, glandular abnormalities were found in 341 (0.7%) tests from 244 (6%) women, including 93 (1.0%) of 9,564 Pap tests among HIV-seropositive women with CD4 lymphocyte counts less than 250/mm, 103 (0.8%) of 13,023 tests among those with counts 250-500/mm, 68 (0.6%) of 12,470 tests among women with counts greater than 500/mm, and 70 (0.6%) of 11,769 tests among HIV-seronegative women (P for trend=.006). Colposcopy was documented for only 148 (61%) of 244 index Pap tests in women with glandular abnormalities. After index abnormal tests, endocervical curettings were obtained from 106 (43%) women, cervical biopsies from 76 (38%), and endometrial biopsies from 19 (8%). Squamous lesions predominated among histologic findings and histology results did not differ by HIV serostatus (P=.16).

CONCLUSION

Although immunosuppression increased the risk of glandular Pap test abnormalities in women with HIV, these remained uncommon. Compliance with management guidelines can improved.

LEVEL OF EVIDENCE

II.

Incidence of cervical disease associated to HPV in human immunodeficiency infected women under highly active antiretroviral therapy

BACKGROUND

Women infected with human immunodeficiency virus (HIV) may be at higher risk of developing cervical cancer than non infected women. In a pilot study, we assessed the relationships among cervical cytology abnormalities associated to Human Papillomavirus (HPV), HIV infection and Highly Active Antiretroviral Therapy (HAART) on the development of Squamous Intraepithelial lesions (SILs). Out of the 70 HIV infected women from Douala -Cameroon (Central Africa) that we included in the study, half (35) were under HAART. After obtaining information related to their lifestyle and sexual behaviour, cervicovaginal samples for Pap smears and venous blood for CD4 count were collected and further divided into two groups based upon the presence or absence of cervical cytology abnormalities i.e. those with normal cervical cytology and those with low and high Squamous Intraepithelial lesions (LSIL, HSIL).

RESULTS

Assessment was done according to current antiretroviral regimens available nationwide and CD4 count. It was revealed that 44.3% of HIV-infected women had normal cytology. The overall prevalence of LSIL and HSIL associated to HPV in the studied groups was 24.3% (17/70) and 31.4% (22/70) respectively. Among the 22 HSIL-positive women, 63.6% (14/22) were not on antiretroviral therapy, while 36.4% (8/22) were under HAART. HIV infected women under HAART with positive HSIL, showed a median CD4+ T cell count of 253.7 +/- 31.7 higher than those without therapy (164.7 +/- 26.1). The incidence of HSIL related to HPV infection within the study group independently of HAART initiation was high.

CONCLUSION

These results suggest the need for extension and expansion of the current study in order to evaluate the incidence of HPV infection and cervical cancer among HIV-infected and non HIV- infected women in Cameroon.

Smoking enhances risk for new external genital warts in men

Repeat episodes of HPV-related external genital warts reflect recurring or new infections. No study before has been sufficiently powered to delineate how tobacco use, prior history of EGWs and HIV infection affect the risk for new EGWs. Behavioral, laboratory and examination data for 2,835 Multicenter AIDS Cohort Study participants examined at 21,519 semi-annual visits were evaluated. Fourteen percent (391/2835) of men reported or were diagnosed with EGWs at 3% (675/21,519) of study visits. Multivariate analyses showed smoking, prior episodes of EGWs, HIV infection and CD4+ T-lymphocyte count among the infected, each differentially influenced the risk for new EGWs.

Long-term incidence of cervical cancer in women with human immunodeficiency virus

BACKGROUND

The objective of this study was to estimate the incidence of invasive cervical cancer (ICC) in women with human immunodeficiency virus (HIV) and compare it with the incidence in HIV-uninfected women.

METHODS

In a cohort study of HIV-infected and uninfected women who had Papanicolaou tests obtained every 6 months, pathology reports were retrieved for women who had biopsy results or a self-report of ICC. Histology was reviewed when reports confirmed ICC. Incidence rates were calculated and compared with those in HIV-negative women.

RESULTS

After a median follow-up of 10.3 years, 3 ICCs were confirmed in HIV-seropositive women, and none were confirmed in HIV-seronegative women. The ICC incidence rate was not found to be associated significantly with HIV status (HIV-negative women [0 of 100,000 person-years] vs HIV-positive women [21.4 of 100,000 person-years]; P = .59). A calculated incidence rate ratio standardized to expected results from the Surveillance Epidemiology and End Results database that was restricted to HIV-infected Women's Interagency HIV Study participants was 1.32 (95% confidence interval, 0.27-3.85; P = 0.80).

CONCLUSIONS

Among women with HIV in a prospective study that incorporated cervical cancer prevention measures, the incidence of ICC was not significantly higher than that in a comparison group of HIV-negative women.

Human papillomavirus detection and typification in cutaneous and mucosal lesions of HIV-seropositive patients

Summary:

High-risk human papillomavirus (HPV) in a lesion is related to an increased chance of neoplasic transformation, especially when with immunosuppression, as in HIV infection. We investigated HPV frequency in cutaneous and mucosal lesions of HIV-seropositive male patients. The frequency of malignancy, its association with the HPV type detected and some clinical variables were also assessed. A total of 38 lesions from 27 patients were studied in a period of 18 months. The biopsied fragment was submitted to HPV detection and typification, through polymerase chain reaction with generic (MY09/11) and specific (types 6, 11, 16 and 18) primers. HPV frequency was 63.2%, with detection of HPV types 6, 11 or 16 in 18 lesions and with multi-infection in three. There was low detection of high-risk HPV (type 16, 18.4%) and no HPV type 18. Of the lesions, 36.8% were already premalignant or malignant, and the frequency of moderate or severe dysplasia was higher in the study patients than that described in the HIV-seronegative population. High-risk HPV (type 16) was detected in four benign lesions and low-risk HPV (type 6) in three premalignant genital lesions. There was no significant association between the clinical variables and an increase in the prevalence of premalignant or malignant lesions.

Squamous cervical lesions in women with human immunodeficiency virus: long-term follow-up

OBJECTIVE

To estimate the frequency of and trends in abnormal Pap test results in women with human immunodeficiency virus (HIV) and HIV-uninfected women.

METHODS

In a cohort study of HIV-infected and uninfected women, Pap tests were obtained every 6 months. Results of atypical squamous cells of undetermined significance (ASC-US) or worse were considered abnormal.

RESULTS

Over a median of 8.4 years, 23,843 Pap tests were obtained from 1,931 HIV-positive women with 6,828 Pap tests from 533 HIV-negative women (13 women seroconverted during the study). Among women with HIV, Pap test results were ASC-US in 4,462 (19%), low-grade squamous intraepithelial lesion (LSIL) in 3,199 (13%), high-grade squamous intraepithelial lesion (HSIL) in 267 (1%), and cancer in 11 (0.05%). The incidence of abnormal Pap test results was 179 in 1,000 person-years for HIV-positive and 75 in 1,000 person-years for HIV-negative women (incidence rate ratio 2.4, 95% confidence interval 2.0-2.8). The incidence of HSIL or cancer was 4.4 in 1,000 person-years for HIV-positive and 1.3 in 1,000 person-years for HIV-negative women (incidence rate ratio 3.4, 95% confidence interval 1.2-9.5).

CONCLUSION

Among women with HIV in a cervical cancer prevention program, Pap test abnormalities are common, but high-grade abnormalities are infrequent.

LEVEL OF EVIDENCE

II.

The prevalence of human papillomavirus (HPV) infection in paired urine and cervical smear samples of HIV-infected women

BACKGROUND

HIV-infected women are at increased risk for cervical dysplasia. Cervical dysplasia is caused by persistent infections with certain types of human papillomavirus (HPV). Conventional testing for genital HPV infections requires cervical cytology. A non-invasive screening method by detection of HPV DNA in urine samples is preferable but is not a routine practice.

OBJECTIVES

To investigate the prevalence and concordance of HPV in paired urine and cervical smear samples and cytological results of Pap smears in HIV-infected women.

STUDY DESIGN

Paired urine and cervical smear samples were collected from 27 HIV-infected women.

RESULTS

The HPV prevalence in urine and cervical smear samples was 81.5% and 51.9%, respectively (p = 0.01). The concordance for HPV positivity and negativity between urine and cervical smear samples is 71%. Seven women (25.9%) had an abnormal cervical smear of Pap II or higher. In all urine samples from these cases HPV DNA was detected.

CONCLUSION

In the present study we show that the HPV prevalence in urine and cervical smear samples of HIV-infected women is high and HPV test results are highly concordant. Therefore, urine samples can be used as medium for HPV testing. HPV testing in urine samples is a simple, reliable, non-invasive screening method.

Cervical Cancer Screening of Women Living with HIV Infection: A Must in the Era of Antiretroviral Therapy

Women living with human immunodeficiency virus (HIV) infection have a much higher risk of human papillomavirus infection and cervical cancer than do HIV-uninfected women. Before the introduction of antiretroviral therapy, the lack of cervical cancer screening among HIV-infected women probably had little influence on their life expectancies because of the high competing mortality associated with other causes, but the situation is changing rapidly everywhere. In sub-Saharan Africa, for instance, approximately 400,000 HIV-infected women were receiving antiretroviral therapy in 2005. Funds given to antiretroviral therapy programs in low-resource countries not only support the purchase of drugs, but they also support the development of clinical infrastructures and laboratories. Because women who receive antiretroviral therapy are observed regularly, they can also receive the continuity of care needed for cervical screening. Therefore, the real opportunity to prevent cervical cancer in HIV-infected women in low-resource countries should not be missed, especially as new, inexpensive screening methods (e.g., rapid human papillomavirus tests) are under evaluation.

Markers of human papillomavirus infection and their correlation with cervical dysplasia in human immunodeficiency virus-positive women

Human papillomavirus (HPV) genotypes and HPV DNA load were analysed in cervical smears from 76 human immunodeficiency virus (HIV)-positive and 54 HIV-negative women. The prevalence of genotypes was similar for all women, with the exception of HPV62, which was over-represented in HIV-positive samples. HIV-positive women showed a higher prevalence of multiple genotypes that correlated neither with CD4(+) T-cell counts nor with cervical dysplasia. No significant differences were observed in terms of total or single-type HPV DNA load. The HPV DNA load in both HIV-positive and HIV-negative women was significantly higher in squamous intra-epithelial lesions than in negative Pap smears.

Human papillomavirus infection and disease in the HIV+ individual

HPV infection of both the genital tract and oral cavity of HIV+ men and women is increased. HPV-related pathology is also increased in the HIV+ individuals, usually with further increases seen for those HIV+ individuals with lower CD4 cell counts. Fortunately, the rates of cervical cancer and anal cancer are relatively low and not related to CD4 cell count. Treatment of the HIV+ individual with HPV-related disease is challenging and requires close long-term follow-up to prevent recurrent disease. The mechanism of how HPV and HIV interact is still not known but is more likely to be linked to immune suppression rather than a direct interaction between viruses. The newly developed HPV vaccines will likely have a significant impact on HPV-related disease in immunocompetent individuals. It remains to be seen what impact these vaccine will have on the immune depressed.

Human papillomavirus: the burden of infection

Vaccines for preventing human papillomavirus (HPV) infection are far along in clinical development and testing, and hold great promise for reducing HPV infections and HPV-associated disease. HPV is the most common sexually transmitted infection in the United States, affecting an estimated 75% of the U.S. population. HPV infection is highly prevalent in sexually active adolescents and young adults. Sexual activity is the most important risk factor for infection, with 64% to 82% of sexually active adolescent girls testing positive for HPV. Clinical manifestations of HPV infection include genital warts, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer, all of which cause significant morbidity and, in the case of cervical cancer, mortality. The majority of HPV-associated disease is caused by 4 HPV types: HPV 6 and 11 are responsible for low-grade genital lesions and more than 90% of genital warts, and HPV 16 and 18 both account for approximately 70% of all high-grade CIN or dysplasia and invasive cervical cancer. Although current screening methods have proven effective in reducing cervical cancer incidence and associated mortality, more than 10,000 women are diagnosed annually and 4000 U.S. women die from the disease each year.

Novel methods to treat and prevent human papillomavirus infection

The human papillomavirus (HPV), a ubiquitous sexually transmitted virus, is the causative agent for cervical dysplasia and carcinoma worldwide. Current treatment methods primarily utilize ablative and excisional procedures to remove dysplastic, HPV-infected cervical tissue. However, these procedures require intensive cytopathological surveillance and carry inherent risks of bleeding, infection and possible future pregnancy complications. Development of an effective vaccine against HPV would dramatically reduce the need for costly cytological and histological surveillance. HPV represents an ideal candidate for vaccine development, and current research efforts in the realm of prophylactic and therapeutic vaccine design show great promise. A host of various vaccine techniques are currently being developed and tested and, if effective, will have a significant impact on the incidence of cervical dysplasia and carcinoma.

Human papillomavirus infection and cervical intraepithelial neoplasia in a cohort of low-risk women

OBJECTIVE

This study was a prospective examination of the incidence of human papillomavirus (HPV) infection in a low-risk female population and an assessment of the risk of development of LSIL with HPV infection.

STUDY DESIGN

In a longitudinal study, women aged 19-60 years--non-smokers, and married or living with a constant partner, who presented for cervical cancer screening at an outpatient clinic--were invited to participate in a prospective study of cervical HPV infection, and were examined every 3 months.

RESULTS

Of the 464 women at risk, 20 presented with HPV infections during the follow-up. Low-grade squamous intraepithelial lesions (LSIL) event developed in 18 women. Among these women, 13 were HPV-positive (10 high-risk and 3 low-risk types). The average duration of new LSIL was 20.1 months (95% CI: 13.9-26.3) and 55.3 months (95% CI: 45.7-64.9) in the HPV-positive and negative groups, respectively, the difference was statistically significant (p<0.001). With the use of Cox proportional hazard regression, we estimated the relative risk as 90.0 for a first instance of LSIL among women testing positive for HPV as compared with women testing negative for HPV.

CONCLUSION

This study has provided evidence that HPV infection is associated with an increased risk of LSIL.

Association between HLA-DQB1 and cervical dysplasia in Vietnamese women

Host genetic background seems to play a key role in cervical carcinogenesis as only a small subset of women infected with high-risk human papillomaviruses (HPVs) develop cervical cancer. The rate of cervical cancer in Vietnamese women is notably high. To explore the association of human leukocyte antigen (HLA)-DQB1 alleles, HPV infection, and cervical dysplasia in this population, cervical smears were obtained from 101 women attending the obstetrics and gynecology clinic of Da Nang General Hospital in Vietnam. Besides the Papanicolaou test, HPV and HLA-DQB1 genotyping were performed using cervical smear DNA. Additionally, a subset of 30 blood samples was used as the gold standard for HLA genotyping. HLA-DQB1 alleles showed no association with HPV infection status. However, a positive association with cervical dysplasia was found for HLA-DQB1*0302 (P= 0.0229, relative risk (RR) = 4.737) and HLA-DQB1*0601 (P= 0.0370, RR = 4.038), whereas HLA-DQB1*0301 (P= 0.0152, RR = 0.221) was found negatively associated. The low diversity of HLA-DQB1 alleles, wide spectrum of HPV genotypes, and high prevalence of HPV 16 and HPV 18 observed in the study population suggest a permissive/susceptible genetic background that deserves further research. Total concordance of HLA-DQB1 genotyping results between blood and cervical cells confirms the potential value of cervical smears as an effective tool for the development of cervical cancer biomarkers.

Proceedings From the First Asia-Oceania Research Organisation on Genital Infections and Neoplasia (AOGIN) Meeting

The First Asia-Oceania Research Organisation on Genital Infections and Neoplasia (AOGIN) Meeting was held in Kota Kinabalu, Malaysia, in July 2005. The conference covered regional issues relating to infection with the human papillomavirus—epidemiology, virology, and immunology, testing, screening, and prevention strategies—as well as cervical cancer screening and its management.

Contribución de la captura de híbridos de segunda generación del virus del papiloma humano en el cribado de afección cervical en mujeres con infección por el virus de la inmunodeficiencia humana

BACKGROUND AND OBJECTIVE

The causal relationship between human papillomavirus (HPV) and cervical cancer is well established. The initial diagnosis of HPV-related cervical infection is currently performed by HPV-associated changes in cervical cytology. We aimed to study the accuracy and concordance between HPV ADN detection by second-generation hybrid capture (HC-2) and cervical cytological changes for the diagnosis of HPV cervical infection in human immunodeficiency virus (HIV+) outpatients.

PATIENTS AND METHOD

From March 1999 to August 2002, 139 HIV+ patients were included. HPV infection was determined by cytology and HC-2. The accuracy and level of concordance between both techniques was analyzed.

RESULTS

The applicability of the HC-2 test was 96%. Sixty-eight (49%) patients were diagnosed with HPV infection by HC-2. High-oncogenetic-risk HPV genotypes were detected in 64 (46%) patients. The sensitivity, specificity and positive and negative predictive values of HC-2 in HPV detection were 78%, 69%, 61% and 83%, respectively. The concordance was K = 0.44 (95% confidence interval, 0.29-0.60); p < 0.001.

CONCLUSIONS

The HC-2 diagnostic technique for HPV-related cervical infection in HIV+ patients is a sensitive and specific test. The combined use of both tests might increase the diagnostic efficacy, and hence have positive repercussions on cervical pathology screening on an outpatient basis.

Natural History of Grade 1 Cervical Intraepithelial Neoplasia in Women With Human Immunodeficiency Virus

OBJECTIVE

We sought to estimate rates of progression and regression of grade 1 cervical intraepithelial neoplasia (CIN 1) among women with human immunodeficiency virus (HIV).

METHODS

In a multicenter prospective cohort study, HIV-seropositive and HIV-seronegative women were evaluated colposcopically after receiving an abnormal cytology test result between November 1994 and September 2002. Women with CIN 1 were included, except those who had undergone hysterectomy, cervical therapy, or had CIN 2-3 or cervical cancer. Those women who were included were followed cytologically twice yearly, with colposcopy repeated for atypia or worse.

RESULTS

We followed 223 women with CIN 1 (202 HIV seropositive and 21 HIV seronegative) for a mean of 3.3 person-years. Progression occurred in 8 HIV-seropositive women (incidence density, 1.2/100 person-years; 95% confidence interval [CI] 0.5-2.4/100 person-years) and in no HIV seronegative women. Regression occurred in 66 (33%) HIV-seropositive women (13/100 person-years, 95% CI 10-16/100 person-years) versus 14 (67%) seronegative women (32/100 person-years, relative risk 0.40, 95% CI 0.25-0.66; P < .001). In multivariate analysis, regression was associated with human papillomavirus (HPV) detection (hazard ratio [HR] for low risk 0.28, 95% CI 0.13-0.61, P = .001; and for high-risk 0.34, 95% CI 0.20-0.55, P < .001 versus no HPV detected) and Hispanic ethnicity (HR 0.48, 95% CI 0.230.98; P = .04); HIV serostatus was only marginally linked to regression (HR 0.52, 95% CI 0.27-1.03; P = .06), but seropositive women were less likely to regress when analysis was limited to 146 women with HPV detected at CIN 1 diagnosis (HR 0.18, 95% CI 0.05-0.62; P = .006).

CONCLUSION

Grade 1 cervical intraepithelial neoplasia infrequently progresses in women with HIV. Thus, observation appears safe absent other indications for treatment.

LEVEL OF EVIDENCE

II-1.

Langerhans' cell count and HLA class II profile in cervical intraepithelial neoplasia in the presence or absence of HIV infection

OBJECTIVES

The progression of immunosuppression in human immunodeficiency virus (HIV)+ women has been correlated with elevated incidence of squamous intraepithelial lesions (SIL), probably indicating the role of local immune milieu. In this study, we analysed S100, and HLA class II molecule expression in cervical biopsies according to HIV status, to the severity of SIL and to human papillomavirus (HPV) type.

METHODS

Biopsies from 34 HIV+ and 44 HIV- patients with normal cervix or low- or high-grade SIL were studied. Langerhans' cells (LC) (S100), HLA class II and HLA-DQ molecules were evaluated by immunohistochemistry. HPV detection was performed using polymerase chain reaction (PCR). For statistical analysis Mann-Whitney (P< or =0.05) and Spearman test were used.

RESULTS

Epithelial S100 and HLA class II density were significantly increased with the severity of lesion (P=0.032; P=0.005). Epithelial S100+ increased in HPV+ (P=0.038), and HLA class II density decreased in HPV 16+ (P=0.035) or 18+ (P<0.0001) samples. HIV infection was associated with increased stromal S100+ (P=0.0005) and decreased HLA class II densities (P=0.0001). Decreased stromal S100+ was observed in women with CD4<500 cells/microl (P=0.050). Among HIV+ patients with SIL, the lowest S100 and epithelial HLA class II densities were detected in women with CD4<200 cells/microl (P=0.045).

CONCLUSIONS

After the establishment of AIDS, increased numbers of immature LCs and a reduction in HLA class II occurred, possibly turning the cervical milieu more favourable to HPV persistence. HPV 16 and 18 infections may interfere with the antigen presenting activity, possibly as an evasion mechanism.

Low incidence of invasive cervical cancer among HIV-infected US women in a prevention program

OBJECTIVE

To measure the incidence of invasive cervical cancer (ICC) in US women infected with HIV.

DESIGN

Multicenter prospective cohort study, conducted between October 1994, and September 2001.

SETTING

HIV research centers operating as six urban consortia in the Women's Interagency HIV Study.

SUBJECTS

A total of 2131 women (462 HIV seronegative, 1661 HIV seropositive, and eight seroconverters). Women with a history of hysterectomy or of cervical cancer at baseline evaluation were excluded.

INTERVENTION

Cervical cytology obtained at 6-month intervals, with a colposcopy referral threshold of atypia, followed by individualized treatment.

MAIN OUTCOME MEASURE

ICC diagnoses obtained from study databases and regional cancer registries and confirmed by a gynecologic pathologist.

RESULTS

No incident ICC were observed in HIV seronegative women during 2375 woman-years of observation. During 8260 woman-years of observation, eight putative incident cases of cervical cancer were identified in HIV seropositive women, but only one was confirmed, yielding an incidence rate of 1.2/10 000 woman-years (95% confidence interval, 0.3-6.7/10 000 woman-years). The difference in incidence between HIV seropositive and seronegative women was not significant (P = 1.0).

CONCLUSION

ICC is uncommon in HIV-infected US women participating in a regular prevention program.

Human papillomavirus and cervical cancer

Of the many types of human papillomavirus (HPV), more than 30 infect the genital tract. The association between certain oncogenic (high-risk) strains of HPV and cervical cancer is well established. Although HPV is essential to the transformation of cervical epithelial cells, it is not sufficient, and a variety of cofactors and molecular events influence whether cervical cancer will develop. Early detection and treatment of precancerous lesions can prevent progression to cervical cancer. Identification of precancerous lesions has been primarily by cytologic screening of cervical cells. Cellular abnormalities, however, may be missed or may not be sufficiently distinct, and a portion of patients with borderline or mildly dyskaryotic cytomorphology will have higher-grade disease identified by subsequent colposcopy and biopsy. Sensitive and specific molecular techniques that detect HPV DNA and distinguish high-risk HPV types from low-risk HPV types have been introduced as an adjunct to cytology. Earlier detection of high-risk HPV types may improve triage, treatment, and follow-up in infected patients. Currently, the clearest role for HPV DNA testing is to improve diagnostic accuracy and limit unnecessary colposcopy in patients with borderline or mildly abnormal cytologic test results.

High prevalence of oncogenic human papillomavirus in the genital tract of women with human immunodeficiency virus

OBJECTIVE

The goal of this study was to determine the prevalence of human papillomavirus (HPV) and squamous intraepithelial lesions (SILs) in women infected with human immunodeficiency virus (HIV) in Mexico.

METHODS

Cases included women who were positive for human immunodeficiency virus (HIV) and accepted to participate. There were two control groups in this study: group A, heterosexual partners of HIV+ men; group B, commercial sex workers. Gynecologic examination was performed in all participants. Also, a cervical smear with colposcopy and a sample for detection of HPV DNA by polymerase chain reaction (PCR) were obtained in all subjects, as were CD4+ counts. Relative risks (RR) and 95% confidence interval were calculated.

RESULTS

Eighty-five HIV+ women agreed to participate in this study; the route of HIV infection was heterosexual in 78.8%; transfusion in 8.2%; paid donors in 3.5%; and 9.4% unknown. A total of 9 controls were included: 4 from group A and 5 from group B. HPV DNA was detected by PCR in 57 (69%) cases and in 26 (29%) controls from both groups (P < 0.0001). The RR of HPV infection was 5.5 (2.7-11.5). Also, a significant difference in the prevalence of high-risk HPV types was observed between cases and controls, RR = 12.8 (4.07-42.9). These associations were independent of CD4+ counts and antiretroviral therapy. No association was observed between HIV infection and the risk for high-grade SIL.

CONCLUSIONS

We observed a high prevalence of oncogenic HPV types in HIV-positive women. These women should be screened regularly for early diagnosis of premalignant lesions and prevention of cervical cancer.