Cervical
Abnormalities and Cancer Common among HIV Positive Women in Zambia, and Recurred
after Treatment in Brazil By
Liz Highleyman Past
research has shown that women with HIV are more likely than HIV negative women
to be infected with human
papillomavirus (HPV), and are more likely to develop pre-cancerous cell changes,
known as squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia
(CIN). They also have a faster rate of progression from low-grade to high-grade
SIL, are less likely to experience spontaneous regression, and are more likely
to experience recurrence after treatment. A
study presented at the XVI International AIDS Conference, held last week in Toronto,
found one of the highest-ever rates of cervical abnormalities and cancer among
HIV positive women. The
cross-sectional study included 150 non-pregnant, HIV-infected women receiving
care in Lusaka, Zambia. The women received pelvic examinations, and cervical cell
samples were tested for HPV and analyzed for cellular abnormalities using the
ThinPrep Pap Test. Results 
The median age of the study participants was 36 years. Only 2% smoked tobacco
(a known risk factor for cervical cancer), 17% had six or more lifetime sexual
partners (another known risk factor), and 25% reported consistent condom use.
The mean CD4 cell count was 161 cells/mm3.
77% were on antiretroviral therapy, but most had started HAART only within the
previous six months; the remaining 23% were treatment-naive.
More than 90% of the women had some degree of cervical cell abnormality:
-
Normal: 6.2%;
- Abnormal cells of undetermined significance: 17.2%;
- Low-grade
SIL: 23.4%;
- High-grade SIL: 33.8%'
- Cervical cancer: 19.3%.
The most common HPV types were 52, 61, 62, and 58; many women had multiple types.
More than 85% had one or more "high-risk" types associated with cervical
cancer, but many did not have the carcinogenic types 16 or 18.
In bivariate analyses, severe cervical abnormalities (high-grade SIL or cancer)
were significantly associated with:
- Older age;
- Lower CD4 cell count;
-
Presence of high-risk HPV types.
There appeared to be a linear relationship between decreasing CD4 cell counts
and increasing grades of cervical abnormalities.
In a multivariable logistic regression analysis, high-risk HPV was an independent
predictor of severe abnormalities (adjusted odds ratio 12.4; 95% CI 2.62-58.1;
P = 0.02).
Because most women had been on HAART only a short time, it was not possible to
determine whether antiretroviral therapy and CD4 cell recovery had an effect on
progression of cervical abnormalities.
Conclusion "The
high prevalence of abnormal squamous cytology in our study is one of the highest
reported in any population worldwide," the researchers concluded, suggesting
that this may be due to severe immunosuppression among the women studied, and
that poor nutrition may also play a role. Recurrence
after Treatment In
a related study, researchers looked at recurrence of cervical lesions after a
form of treatment called the loop electrosurgical excision procedure (LEEP), which
is used to excise abnormal cervical tissue. They
conducted a retrospective case-control study to analyze histopathological results
from 201 women (94 HIV positive and 107 HIV negative) who underwent LEEP in Belo
Horizonte, Brazil. Patients were followed for a mean of two years, with cytological
and colposcopic examinations every six months. Results
Cervical intraepithelial neoplasia (CIN) recurred in 40 women after LEEP.
In a logistic regression analysis, factors independently associated with recurrence
were:
- Glandular involvement (OR 9.11; 95% CI 3.02-27.48);
- HIV
infection (OR 4.6; 95% CI 1.88-11.21);
- Compromised margins of cervical lesions
(OR 2.59; 95% CI 1.07-6.7).
Rates of recurrence were 33% among HIV positive women, compared with 8% among
HIV negative women, a significant difference (P < 0.05).
Among the women with HIV, risk of recurrence was higher among those with lower
CD4 cell counts.
In a multivariate analysis, recurrence was most common among women with both glandular
involvement and compromised margins.
No cases of CIN progressed to invasive cervical cancer.
Conclusion
The researchers
concluded that the "[m]ain risk factors associated [with] cervical intraepithelial
neoplasia recurrence after loop electrosurgical excision procedure were HIV-1-infection,
glandular involvement, and compromised margins in cone biopsy." Need
for Screening and Treatment In
wealthy countries, invasive cervical cancer is not more common among HIV positive
women, largely due to routine Pap screening that detects early cervical lesions
at a treatable stage. In low-income countries before the advent of HAART, women
with cervical abnormalities typically died of other causes before they had a chance
to develop full-blown cervical cancer. In the Brazilian study, the absence of
progression to invasive cancer may have been attributable to regular follow-up
care. The authors
of the Zambian study concluded, "It is essential to develop, implement, and
evaluate cost-effective screening tests and appropriate treatment protocols for
HIV-infected women in resource limited settings who, on antiretroviral therapy,
may live long enough to develop HPV-induced invasive cervical cancer." 8/21/06 References G
Parham, V Sahasrabuddhe, S Vermund, and others. Prevalence and predictors of squamous
intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia.
XVI International AIDS Conference. Toronto, August 13-18, 2006. Abstract TUAB0303. G
Parham, V V Sahasrabuddhe, M H Mwanahamuntu, and others. Prevalence and predictors
of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka,
Zambia. Gynecologic Oncology. July 26, 2006 [Epub ahead of print]. M
I M Lima, V H Melo, C P Tafuri, and others. Risk factors to cervical intraepithelial
neoplasia recurrence after loop electrosurgical excision procedure in HIV-1- infected
and non-infected women. XVI International AIDS Conference. Toronto, August 13-18,
2006. Abstract TUAB0304.
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