Risk of Cervical Precancer and Cancer Among HIV-Infected Women With Normal Cervical Cytology and No Evidence of Oncogenic HPV Infection

ArticleinJAMA The Journal of the American Medical Association 308(4):362-9 · July 2012with11 Reads
Impact Factor: 35.29 · DOI: 10.1001/jama.2012.5664 · Source: PubMed
Abstract

US cervical cancer screening guidelines for human immunodeficiency virus (HIV)-uninfected women 30 years or older have recently been revised, increasing the suggested interval between Papanicolaou (Pap) tests from 3 years to 5 years among those with normal cervical cytology (Pap test) results who test negative for oncogenic human papillomavirus (HPV). Whether a 3-year or 5-year screening interval could be used in HIV-infected women who are cytologically normal and oncogenic HPV-negative is unknown. To determine the risk of cervical precancer or cancer defined cytologically (high-grade squamous intraepithelial lesions or greater [HSIL+]) or histologically (cervical intraepithelial neoplasia 2 or greater [CIN-2+]), as 2 separate end points, in HIV-infected women and HIV-uninfected women who at baseline had a normal Pap test result and were negative for oncogenic HPV. Participants included 420 HIV-infected women and 279 HIV-uninfected women with normal cervical cytology at their enrollment in a multi-institutional US cohort of the Women's Interagency HIV Study, between October 1, 2001, and September 30, 2002, with follow-up through April 30, 2011. Semiannual visits at 6 clinical sites included Pap testing and, if indicated, cervical biopsy. Cervicovaginal lavage specimens from enrollment were tested for HPV DNA using polymerase chain reaction. The primary analysis was truncated at 5 years of follow-up. Five-year cumulative incidence of cervical precancer and cancer. No oncogenic HPV was detected in 369 (88% [95% CI, 84%-91%]) HIV-infected women and 255 (91% [95% CI, 88%-94%]) HIV-uninfected women with normal cervical cytology at enrollment. Among these oncogenic HPV-negative women, 2 cases of HSIL+ were observed; an HIV-uninfected woman and an HIV-infected woman with a CD4 cell count of 500 cells/μL or greater. Histologic data were obtained from 4 of the 6 clinical sites. There were 6 cases of CIN-2+ in 145 HIV-uninfected women (cumulative incidence, 5% [95% CI, 1%-8%]) and 9 cases in 219 HIV-infected women (cumulative incidence, 5% [95% CI, 2%-8%]). This included 1 case of CIN-2+ in 44 oncogenic HPV-negative HIV-infected women with CD4 cell count less than 350 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), 1 case in 47 women with CD4 cell count of 350 to 499 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), and 7 cases in 128 women with CD4 cell count of 500 cells/μL or greater (cumulative incidence, 6% [95% CI, 2%-10%]). One HIV-infected and 1 HIV-uninfected woman had CIN-3, but none had cancer. The 5-year cumulative incidence of HSIL+ and CIN-2+ was similar in HIV-infected women and HIV-uninfected women who were cytologically normal and oncogenic HPV-negative at enrollment.

    • "However, if rates of dysplasia are high as reported from other cohorts [1,3,7-11], this yields for new approaches to cervical screening in WLWH. We support the idea of cytology as part of an annual review [15,33] and integration of HIV care and cervical screening in a single clinic setting [14,35,38]. Another measure-inspired by Australian health authorities [15] – could be an opt in automated reminder system with written invitations to women with overdue cervical cytologies. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Women living with HIV (WLWH) are at increased risk of invasive cervical cancer (ICC). International HIV guidelines suggest cervical screening twice the first year after HIV diagnosis and thereafter annually. Adherence to the HIV cervical screening program in Denmark is unknown. Methods We studied women from a population-based, nationwide HIV cohort in Denmark and a cohort of age-matched females from the general population. Screening behaviour was assessed from 1999–2010. Adjusted odds ratios (OR’s) for screening attendance in the two cohorts and potential predictors of attendance to guidelines were estimated. Pathology specimens were identified from The Danish Pathology Data Bank. Results We followed 1143 WLWH and 17,145 controls with no prior history of ICC for 9,509 and 157,362 person-years. The first year after HIV diagnosis 2.6% of WLWH obtained the recommended two cervical cytologies. During the different calendar intervals throughout the study period between 29-46% of WLWH followed the HIV cervical screening guidelines. Adjusted OR’s of attendance to the general population screening program for WLWH aged 30, 40 and 50 years, compared to controls, were 0.69 (95% CI: 0.56-0.87), 0.67 (0.55-0.80) and 0.84 (0.61-1.15). Predictors of attendance to the HIV cervical screening program were a CD4 count > 350 cells/μL and HIV RNA < 500 copies/mL. Calendar period after 2002 and HIV RNA < 500 copies/mL predicted attendance to the general population cervical screening program. Conclusions The majority of WLWH do not follow the HIV guidelines for cervical screening. We support the idea of cytology as part of an annual review and integration of HIV care and cervical screening in a single clinic setting.
    Full-text · Article · May 2014 · BMC Infectious Diseases
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  • [Show abstract] [Hide abstract] ABSTRACT: Objective. In the late 1980s Romania was confronted with one of the most painful public health problems of the time, but the drama was not publicly disclosed earlier than 1989s: children who had been infected with human immunodeficiency virus (HIV) in hospitals during medical procedures. About 21 years after this event, this generation has reached reproductive age and a new tragedy is about to occur on the foundations of the old one. The purpose of our work was to assess the prevalence of dysplastic lesions of the cervix in HIV positive patients in order to propose a coherent and evidence based strategy of early detection, treatment and follow-up in this particular group of patients. Methods. We enrolled a total of 37 HIV positive patients who were investigated by performing Pap cytological examination. Results. All the patients in the study were iatrogenic infected with HIV during childhood. The results were then compared with those of 237 healthy patients of the same age group (control group) undergoing smear examinations at the same time and same cytology laboratory. There was no statistical significant difference between HIV positive patients and normal control group regarding abnormal Pap test in the same age group. Conclusions. Our data showed no differences regarding abnormal Pap smears between the two analyzed groups, although many other studies suggested that women living with HIV infection have a much higher risk of precancerous dysplastic lesions of the cervix than do HIV-uninfected women. These findings could open new open questions for many other further debate studies.
    No preview · Article · Jan 2012 · Gineco.ro
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  • No preview · Article · Jul 2012 · JAMA The Journal of the American Medical Association
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