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Persons P, Long M, Vegunta S. Latent HPV Infection: Does HPV Last Forever in Some Women? J Womens Health (Larchmt) 2023. [PMID: 36912823 DOI: 10.1089/jwh.2022.0436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Affiliation(s)
- Patress Persons
- Division of Community Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Margaret Long
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Suneela Vegunta
- Division of Women's Health-Internal Medicine, Mayo Clinic, Scottsdale, Arizona, USA
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HPV Type Distribution in Benign, High-Grade Squamous Intraepithelial Lesions and Squamous Cell Cancers of the Anus by HIV Status. Cancers (Basel) 2023; 15:cancers15030660. [PMID: 36765617 PMCID: PMC9913553 DOI: 10.3390/cancers15030660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/15/2023] [Accepted: 01/15/2023] [Indexed: 01/25/2023] Open
Abstract
The incidence of anal cancer is increasing, especially in high-risk groups, such as PLWH. HPV 16, a high-risk (HR) HPV genotype, is the most common genotype in anal high-grade squamous intraepithelial lesions (HSIL) and squamous cell carcinoma (SCC) in the general population. However, few studies have described the distribution of HR HPV genotypes other than HPV 16 in the anus of PLWH. HPV genotyping was performed by DNA amplification followed by dot-blot hybridization to identify the HR and low-risk (LR) genotypes in benign anal lesions (n = 34), HSIL (n = 30), and SCC (n = 51) of PLWH and HIV-negative individuals. HPV 16 was the most prominent HR HPV identified, but it was less common in HSIL and SCC from PLWH compared with HIV-negative individuals, and other non-HPV 16 HR HPV (non-16 HR HPV) types were more prevalent in samples from PLWH. A higher proportion of clinically normal tissues from PLWH were positive for one or more HPV genotypes. Multiple HPV infection was a hallmark feature for all tissues (benign, HSIL, SCC) of PLWH. These results indicate that the development of anal screening approaches based on HPV DNA testing need to include non-16 HR HPVs along with HPV 16, especially for PLWH. Along with anal cytology, these updated screening approaches may help to identify and prevent anal disease progression in PLWH.
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Liu J, Wu D, Zhu J, Dong S. Clinicopathological features of papillary thyroid carcinoma in HIV-infected patients. Front Oncol 2023; 13:1071923. [PMID: 37213296 PMCID: PMC10196459 DOI: 10.3389/fonc.2023.1071923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/24/2023] [Indexed: 05/23/2023] Open
Abstract
Background Papillary thyroid carcinoma (PTC) is the most common endocrine malignancy, with an increasing incidence over the last decades. Human immunodeficiency virus (HIV)-induced immune deficiency was one of risk factors for cancer tumorigenesis and development. The aim of this study was to describe the clinicopathological features of PTC in HIV-infected patients and discuss possible connections between PTC and HIV infection. Methods A total of 17670 patients from September 2009 to April 2022 who underwent PTC surgery for the first time were analyzed retrospectively. At last, 10 patients of PTC with HIV infection (HIV-positive group) and 40 patients without HIV infection (HIV-negative group) were included. The differences in general data and clinicopathological characteristics between the HIV-positive group and the HIV-negative group were analyzed. Results There were statistically significant differences in age and gender between the HIV-positive group and the HIV-negative group (P<0.05), and males and <55 years old accounted for a higher proportion in the HIV-positive group. The differences in tumor diameter and capsular invasion between the HIV-positive group and HIV-negative group were statistically significant (P<0.05). Meanwhile, in terms of extrathyroid extension (ETE), lymph node metastasis and distant metastasis, the HIV-positive group were significantly higher than the HIV-negative group (P<0.001). Conclusion HIV infection was a risk factor for larger tumors, more severe ETE, more lymph node metastasis, and more distant metastasis. HIV infection could promote PTC proliferation and make PTC more aggressive. Many factors such as tumor immune escape, secondary infection, etc. may are responsible for these effects. More attention and more thorough treatment should be paid to these patients.
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Affiliation(s)
- Jia Liu
- Department of Thyroid Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Deqian Wu
- Department of Thyroid Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Jinxin Zhu
- Department of Thyroid Surgery, General Surgery Center, First Hospital of Jilin University, Changchun, China
| | - Su Dong
- Department of Anesthesia, First Hospital of Jilin University, Changchun, China
- *Correspondence: Su Dong,
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Wagner A, Skof AS, Sehouli J, Richter R, Henrich W, von Weizsäcker K, Siedentopf JP, Chekerov R, Kaufmann AM, Rohr I. Genotype-specific high-risk human papillomavirus infections and risk factors for cervical dysplasia in women with human immunodeficiency virus in Germany: results from a single-center cross-sectional study. Int J Gynecol Cancer 2022; 32:716-723. [PMID: 35354606 DOI: 10.1136/ijgc-2021-003327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Women living with HIV have an increased risk of human papillomavirus (HPV) infection and cervical cancer. Little is known about genotype-specific HPV prevalence, the impact of antiretroviral therapy, immunological status, and additional risk factors in women living with HIV in Germany. The goal of this study was to characterize the risk profile for cervical dysplasia in these women. METHODS Patients with HIV infection presenting at Charité-Universitätsmedizin Berlin from October 2017 to September 2020 were included and underwent gynecological examination, colposcopy, cervical cytology and HPV genotype testing. HPV genotypes were stratified by carcinogenicity. Atypical squamous cells of undetermined significance or higher were considered abnormal cytology. Data were analyzed by SPSS software (version 26, 2019). A two-tailed p-value ≤0.05 was considered statistically significant. RESULTS A total of 84 women were evaluated. The majority (95.2%) received antiretroviral therapy. Median CD4 cell count was 564 cells/µl (range 20-1969). 95.2% were previously screened for cervical cancer. High-risk HPV prevalence was 44%. High-high-risk HPV subtypes (16, 18, 31, 33, 45, 52, 58) were significantly associated with abnormal cytology (p<0.001). HPV16 was the most common genotype (23%), was significantly associated with abnormal cytology (p=0.002) and was the main risk factor for abnormal cytology (OR 8.55, 95% CI 2.15 to 34.13, p=0.002), followed by age <35 years (OR 4.96, 95% CI 1.23 to 19.61, p=0.033) and cigarette smoking (OR 3.944, 95% CI 0.98 to 15.88, p=0.053). CONCLUSIONS Antiretroviral therapy and adherence to cervical cancer screening was high. High-high-risk HPV, especially HPV16, coincided with high incidence of cytological abnormalities. Women living with HIV in Germany have adequate immune status and are often pre-screened for cervical cancer, and therefore have a different risk profile for cervical dysplasia than in low-income or medium-income countries. Adapted screening programs should be defined.
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Affiliation(s)
- Alexandra Wagner
- Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Anna Sophie Skof
- Department of Gynecology with Center for Oncological Surgery, Laboratory for Gynecological Tumor Immunology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Jalid Sehouli
- Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Rolf Richter
- Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Wolfgang Henrich
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Katharina von Weizsäcker
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Jan-Peter Siedentopf
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Radoslav Chekerov
- Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Andreas M Kaufmann
- Department of Gynecology with Center for Oncological Surgery, Laboratory for Gynecological Tumor Immunology, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Irena Rohr
- Department of Gynecology with Center for Oncological Surgery, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
- Department of Obstetrics, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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Carlander C, Lagheden C, Eklund C, Nordqvist Kleppe S, Dzabic M, Wagner P, Sparén P, Dillner J. Nonvaccine human papillomavirus genotype common in women with HIV failing cervical precancer treatment. AIDS 2021; 35:2367-2374. [PMID: 34723851 DOI: 10.1097/qad.0000000000003026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to assess failure after treatment of high-grade cervical intraepithelial neoplasia (CIN2+) by HIV status and human papillomavirus (HPV) type. DESIGN A population-based register study. METHODS The Swedish National HIV Registry, the Swedish Population Registry and the Swedish National Cervical Screening Registry were linked to identify all women in Stockholm and Gothenburg counties (Sweden) living with HIV and diagnosed with CIN2+ sometime between 1983 and 2014 (n = 179). HIV-negative controls with CIN2+, were matched (2 : 1) for country of birth. CIN2+ biopsies were retrieved from biobanks and genotyped. Absolute risk and adjusted odds ratios (adjOR) of treatment failure by HIV status given HPV type (HPV16/18 vs. non-HPV16/18) were calculated. RESULTS HPV16 (32%) and HPV35 (24%) dominated in women living with HIV (WLWH) with failure, HPV35 mainly in women born in sub-Saharan Africa (67%). The absolute risk of failure in women with HPV16/18 was 26% [95% confidence interval (95% CI) 14-44] in WLWH and 12% in HIV-negative (95% CI 7-19). The absolute risk of failure in women with non-HPV16/18 was 20% (95% CI 12-31) in WLWH and 5% in HIV-negative (95% CI 2-11). WLWH with non-HPV16/18 were six times more likely to fail than HIV-negative (adjOR 6.1, 95% CI 2.0-18.6). CONCLUSION HPV35, not included in current HPV vaccines, was the second most common type in WLWH with failure. WLWH with non-HPV16/18 were six times more likely to fail than HIV-negative. This could have implications for surveillance and vaccination post CIN2+ treatment, particularly in WLWH from sub-Saharan Africa.
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Affiliation(s)
- Christina Carlander
- Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm
- Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Uppsala
| | - Camilla Lagheden
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Carina Eklund
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sara Nordqvist Kleppe
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mensur Dzabic
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Philippe Wagner
- Centre for Clinical Research Västmanland, Västmanland County Hospital, Uppsala University, Uppsala
| | - Pär Sparén
- Department of Medical Epidemiology and Biostatistics
| | - Joakim Dillner
- Division of Clinical Pathology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Castle PE, Einstein MH, Sahasrabuddhe VV. Cervical cancer prevention and control in women living with human immunodeficiency virus. CA Cancer J Clin 2021; 71:505-526. [PMID: 34499351 PMCID: PMC10054840 DOI: 10.3322/caac.21696] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/07/2021] [Accepted: 08/10/2021] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Philip E Castle
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland
| | - Mark H Einstein
- Department of Obstetrics, Gynecology, and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Vikrant V Sahasrabuddhe
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland
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da Silva BEB, de Lemos LMD, de Aragão Batista MV, Lima CA, Martins-Filho PR, Santos VS. Prevalence of human papillomavirus infection in Brazilian women living with HIV: a systematic review and meta-analysis. Expert Rev Anti Infect Ther 2021; 20:611-620. [PMID: 34612128 DOI: 10.1080/14787210.2022.1990039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We systematically investigated the prevalence of HPV, high-risk HPV and its genotypes in women living with human immunodeficiency virus (WLHIV) in Brazil. METHODS A systematic search was performed up to 15 December 2020. We included studies that used molecular methods for HPV detection in cervical samples and reported the prevalence of HPV in Brazilian WLHIV. The pooled prevalence of HPV, high-risk HPV (HR HPV) and HPV types and their 95% confidence interval (CI) were estimated. Subgroup analyses and meta-regression were conducted. RESULTS Thity-seven studies accounting for 8,436 WLHIV were included. The pooled HPV prevalence was 62% (95%CI 55-68%; I2 = 96.98%; P < 0.001). Prevalence of high-risk HPV was 40% (95%CI, 54-68%; I2 = 94.23%; P < 0.001). We found a wide variety of high-risk HPV genotypes. The high-risk HPV types most reported were HPV 16 (16%) and HPV 58 (6%). We found an increasing ratio of positivity from normal cervix to cancer. There were different factors associated with high-risk HPV, with low CD4+ count the most frequent. CONCLUSION The increase in the ratio of high-risk HPV positivity from normal cervix to carcinogenic lesions highlights the need to implement well-established testing for high-risk HPV in this population.
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Affiliation(s)
| | | | | | - Carlos Anselmo Lima
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil
| | - Paulo Ricardo Martins-Filho
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, Brazil
| | - Victor Santana Santos
- Graduate Program in Health Sciences, Federal University of Sergipe, Aracaju, Brazil.,Centre for Epidemiology and Public Health, Federal University of Alagoas, Arapiraca, Brazil.,Graduate Program in Health Sciences, Federal University of Alagoas, Maceió, Brazil
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Kuguyo O, Dube Mandishora RS, Thomford NE, Makunike-Mutasa R, Nhachi CFB, Matimba A, Dandara C. High-risk HPV genotypes in Zimbabwean women with cervical cancer: Comparative analyses between HIV-negative and HIV-positive women. PLoS One 2021; 16:e0257324. [PMID: 34582476 PMCID: PMC8478215 DOI: 10.1371/journal.pone.0257324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/30/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus HPV (HR-HPV) modifies cervical cancer risk in people living with HIV, yet African populations are under-represented. We aimed to compare the frequency, multiplicity and consanguinity of HR-HPVs in HIV-negative and HIV-positive Zimbabwean women. METHODS This was a cross-sectional study consisting of women with histologically confirmed cervical cancer attending Parirenyatwa Group of Hospitals in Harare, Zimbabwe. Information on HIV status was also collected for comparative analysis. Genomic DNA was extracted from 258 formalin fixed paraffin embedded tumour tissue samples, and analysed for 14 HR-HPV genotypes. Data was analysed using Graphpad Prism and STATA. RESULTS Forty-five percent of the cohort was HIV-positive, with a median age of 51 (IQR = 42-62) years. HR-HPV positivity was detected in 96% of biospecimens analysed. HPV16 (48%), was the most prevalent genotype, followed by HPV35 (26%), HPV18 (25%), HPV58 (11%) and HPV33 (10%), irrespective of HIV status. One third of the cohort harboured a single HPV infection, and HPV16 (41%), HPV18 (21%) and HPV35 (21%) were the most prevalent. HIV status did not influence the prevalence and rate of multiple HPV infections (p>0.05). We reported significant (p<0.05) consanguinity of HPV16/18 (OR = 0.3; 95% CI = 0.1-0.9), HPV16/33 (OR = 0.3; 95% CI = 0.1-1.0), HPV16/35 (OR = 3.3; 95% CI = 2.0-6.0), HPV35/51 (OR = 6.0; 95%CI = 1.8-15.0); HPV39/51 (OR = 6.4; 95% CI = 1.8-15), HPV31/52 (OR = 6.2; 95% CI = 1.8-15), HPV39/56 (OR = 11 95% CI = 8-12), HPV59/68 (OR = 8.2; 95% CI = 5.3-12.4), HPV66/68 (OR = 7; 95% CI = 2.4-13.5), independent of age and HIV status. CONCLUSION We found that HIV does not influence the frequency, multiplicity and consanguinity of HR-HPV in cervical cancer. For the first time, we report high prevalence of HPV35 among women with confirmed cervical cancer in Zimbabwe, providing additional evidence of HPV diversity in sub-Saharan Africa. The data obtained here probes the need for larger prospective studies to further elucidate HPV diversity and possibility of selective pressure on genotypes.
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Affiliation(s)
- Oppah Kuguyo
- Department of Clinical Pharmacology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- Division of Human Genetics, Department of Pathology, Pharmacogenomics and Drug Metabolism Group, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory, Cape Town, South Africa
| | - Racheal S. Dube Mandishora
- Faculty of Health Sciences, Department of Medical Microbiology Unit, University of Zimbabwe College of Health Sciences, Harare Zimbabwe University of Zimbabwe, Medical Microbiology Unit, Harare, Zimbabwe
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer, Lyon, France
| | - Nicholas Ekow Thomford
- Division of Human Genetics, Department of Pathology, Pharmacogenomics and Drug Metabolism Group, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory, Cape Town, South Africa
- Department of Medical Biochemistry, School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, PMB, Ghana
| | - Rudo Makunike-Mutasa
- Department of Pathology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Charles F. B. Nhachi
- Department of Clinical Pharmacology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Alice Matimba
- Advanced Courses and Scientific Conferences, Wellcome Genome Campus, Hinxton, United Kingdom
| | - Collet Dandara
- Division of Human Genetics, Department of Pathology, Pharmacogenomics and Drug Metabolism Group, Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Observatory, Cape Town, South Africa
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Godfrey C, Prainito A, Lapidos-Salaiz I, Barnhart M, Watts DH. Reducing cervical cancer deaths in women living with HIV: PEPFAR and the Go Further partnership. Prev Med 2021; 144:106295. [PMID: 33678226 DOI: 10.1016/j.ypmed.2020.106295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/16/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
Women with HIV bear a significant burden of Human Papillomavirus (HPV) related cervical disease, and a have a higher risk of dying from cervical cancer should it occur. WLH have increased acquisition of HPV and decreased clearance, leading to persistent HPV infection: a risk for cervical cancer. The greatest burden of HIV in women occurs in sub-Saharan Africa where diagnostic and treatment services for cervical disease are limited. This paper will describe the epidemiology of HPV related cervical disease in women living with HIV (WLH) and the efforts to treat precursor lesions in HIV treatment programs supported by the President's Emergency Plan for AIDS Relief (PEPFAR.
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Affiliation(s)
- Catherine Godfrey
- Office of the Global AIDS Coordinator, Department of State, 1800 G St. Suite 10300, Washington DC 20003, United States of America.
| | - Amber Prainito
- Office of the Global AIDS Coordinator, Department of State, 1800 G St. Suite 10300, Washington DC 20003, United States of America
| | - Ilana Lapidos-Salaiz
- United States Agency for International Development, 1300 Pennsylvania Ave NW, Washington DC 20004, United States of America
| | - Matthew Barnhart
- United States Agency for International Development, 1300 Pennsylvania Ave NW, Washington DC 20004, United States of America
| | - D Heather Watts
- Office of the Global AIDS Coordinator, Department of State, 1800 G St. Suite 10300, Washington DC 20003, United States of America
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