Papanicolaou smear abnormalities in ambulatory care sites for women infected with the human immunodeficiency virus

Colpocytological abnormalities in HIV infected and uninfected pregnant women: prevalence, persistence and progression

In this retrospective case-control study, we analyse data of 48 HIV-positive pregnant patients, versus a control group of 99 HIV-negative pregnant women, followed as outpatients by our department from 2009 to 2014. The aims of the study were to investigate the prevalence, persistence and progression of cervical squamous intraepithelial lesions (SIL) in each group and to correlate colpo-cytological lesions to the socio-demographic and clinical-laboratory findings in the HIV + pregnant women. In our study we observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions. Pap smear and colposcopy should be part of routine care for HIV-infected pregnant women because these lesions behave aggressively in these patients. Success of prevention depends on massive access of patients to screening. HAART reduces viral load and maintains CD4 count and can affect progression of SIL. Multidisciplinary services on the same site appear to be one promising strategy to improve compliance in patients. Impact Statement What is already known on this subject: Our study provided novel information on a highly vulnerable population of young HIV + pregnant women. What the results of this study add: We observed that immunosuppression, HPV infection and vaginal coinfections were predictive of cervical lesions remarkable with colposcopy. We could consider these important risk factors to evaluate to establish an appropriate strategy of management for these patients. What the implications are of these findings for clinical practice and/or further research: Association of the risk between SIL presence and HIV and HPV infection also deserves additional investigation. We believe that Pap smears and colposcopies should be part of the routine care for HIV-infected women because these lesions behave particularly aggressively in these patients.

Cervical cytological changes in HIV-infected patients attending care and treatment clinic at Muhimbili National Hospital, Dar es Salaam, Tanzania

BACKGROUND

Tanzania is among Sub-Saharan countries mostly affected by the HIV and AIDS pandemic, females being more vulnerable than males. HIV infected women appear to have a higher rate of persistent infection by high risk types of human papillomavirus (HPV) strongly associated with high-grade squamous intraepithelial lesions (HSIL) and invasive cervical carcinoma. Furthermore, although HIV infection and cervical cancer are major public health problems, the frequency and HIV/HPV association of cervical cancer and HSIL is not well documented in Tanzania, thus limiting the development of preventive and therapeutic strategies.

METHODS

A prospective unmatched, case-control study of HIV-seropositive, ≥ 18 years of age and consenting non-pregnant patients attending the care and treatment center (CTC) at Muhimbili National Hoospital (MNH) as cases was done between 2005 and 2006. HIV seronegative, non-pregnant and consenting women recruited from the Cervical Cancer Screening unit (CCSU) at ORCI were used as controls while those who did not consent to study participation and/or individuals under < 18 years were excluded. Pap smears were collected for routine cytodiagnosis and P53 immunohistochemistry (IHC). Cervical lesions were classified according to the Modified Bethesda System.

RESULTS

A total of 170 participants from the two centers were recruited including 50 HIV-seronegative controls were from the CCSU. Ages ranged from 20-66 years (mean 40.5 years) for cases and 20-69 years (mean 41.6 years) for controls. The age group 36-45 years was the most affected by HIV (39.2%, n = 47). Cervicitis, squamous intraepithelial lesions (SIL) and carcinoma constituted 28.3% (n = 34), 38.3% (n = 46) and 5.8% (n = 7) respectively among cases, and 28% (n = 14), 34% (n = 17) and 2% (n = 1) for controls, although this was not statistically significant (P-value = 0.61). IHC showed that p53 was not detectable in HPV + Pap smears and cell blocks indicating possible degradation.

CONCLUSIONS

The frequency of SIL and carcinoma appeared to be higher among HIV-infected women on HAART compared to seronegative controls and as expected increased with age. HIV seropositive patients appeared to present earlier with SIL compared to those HIV seronegative suggesting a role of HIV in altering the natural history of HPV infection and cervical lesions. The absence of p53 immunoreactivity in HPV + lesions is indicative of the ability of HPV E6 proteins to interact with the tumor suppressor gene and pave way for viral-induced oncogenesis in the studied Tanzanian women.

Lack of association between cervical dysplasia and IBD: a large case-control study

BACKGROUND

It has been variously reported that women with inflammatory bowel disease (IBD) have an increased risk of cervical dysplasia. We aimed to assess in a large, accurately phenotyped, case-controlled population whether women with IBD had increased rates of abnormal cervical smears and if this was affected by immunosuppressant therapy or disease phenotype.

METHODS

Women with IBD diagnosed prior to the age of 60 were studied at a single tertiary referral center in Scotland. Full cervical smear histories were available on 411 women (204 Crohn's disease, 207 ulcerative colitis, median age at diagnosis 28.4 years, median current age 44.1 years). All the cases were matched 1:4 to healthy controls (n = 1644) from the same geographical location.

RESULTS

There was no difference in rates of abnormal smears between patients with IBD (80.5% negative, 10.5% low-grade, and 9.0% high-grade dysplasia) and controls (85.4%, 7.7%, and 6.9%, P = 0.37). The use of immunosuppressant therapy had no impact on rates of cervical dysplasia or neoplasia. Furthermore, there was no effect of disease location, behavior, or oral contraceptive use. However, there were significantly more abnormal cervical smears in IBD patients who were current smokers compared with exsmokers and those who had never smoked (27.4% versus 11.4%, P = 0.001, odds ratio = 2.95, 95% confidence interval = 1.55-5.50).

CONCLUSIONS

Women with IBD are not at increased risk of abnormal cervical smears unless they smoke. These data suggest that young women with IBD should be managed as per the background population; attending for regular smear testing, and undergoing vaccination against cervical cancer when available.

Prevalence and risk factors for human papillomavirus and cervical intraepithelial neoplasia among HIV-positive women at a tertiary level hospital in India

OBJECTIVES

The hypothesis to be tested was that the prevalence of human papillomavirus (HPV) and cervical intraepithelial neoplasia would be significantly higher in HIV seropositive women as compared with seronegative controls. Secondary aims were to determine the risk factors for HPV and cervical intraepithelial neoplasia and the HPV types in HIV-positive women.

MATERIALS AND METHODS

A cross-sectional study of women 18 to 49 years old was done. Seventy-five women who were HIV seropositive and 58 seronegative women, of whom 27 had HIV-positive partners, participated in the study. A Pap smear and a cervical swab for HPV were done. Women with Pap smear abnormality underwent colposcopy and large loop excision procedures if indicated.

RESULTS

Ten (13.3%) HIV-positive women had high-grade squamous intraepithelial lesion as compared with 2 (3.4%) seronegative women (odds ratio [OR] 4.3; 95% CI = 0.9-41.7; p =.048). Among the HIV-positive women, 28 (37.3%) had high-risk HPV, whereas only 9 (15.5%) had high-risk HPV among seronegative women (OR 3.2; 95% CI = 1.3-8.3; p =.009). Among women who were positive for high-risk HPV, the HIV-positive women were significantly more likely to have more than 1 HPV type (OR 7.4; 95% CI = 1.4-43.7; p =.005). Women who had coitus at less than 18 years of age were more likely to have high-risk HPV infection (OR 2.9; 95% CI = 1.2-6.2; p =.013) even after controlling for HIV status.

CONCLUSIONS

HIV-positive women have a higher risk for multiple HPV infections as compared with seronegative women. Behavioral factors dominate HIV in determining HPV infections and resultant cervical neoplasia.

Gynecologic issues in the HIV-infected woman

In this article, gynecologic conditions of increased importance in the HIV-infected woman are discussed. Women living with HIV may have an increase in menstrual disorders, lower genital tract neoplasias, gynecologic surgery, and sexually transmitted infections. The literature relevant to choosing a method of contraception for HIV-positive women is also discussed. With the advent of HAART, seropositive women are now facing issues around longevity, such as menopause and disorders of bone mineral density, as well as those associated with fertility.

Validation of a low-cost, liquid-based screening method for cervical intraepithelial neoplasia

OBJECTIVE

The objective of the study was to validate a low-cost, liquid-based method for cervical cancer screening.

STUDY DESIGN

We conducted a retrospective, split-sample comparison of 300 liquid-based cervical cytology samples from a group of 150 human immunodeficiency virus-seropositive women and 150 women from low-risk general gynecology clinics whose specimens were screened via standard liquid-based methodology as part of routine care. Residual samples from each specimen were used to prepare a slide using a novel, inexpensive manual membrane method of liquid-based cytology. These slides were screened by a cytotechnologist and abnormal cases were reviewed by a pathologist. Final diagnoses from the manual membrane method of liquid-based cytology slides were compared with the original diagnoses and available cervical biopsy data.

RESULTS

There was good overall agreement between the manual membrane method of liquid-based cytology and original cytology diagnoses (76.3% agreement; kappa = 0.52, 95% confidence interval 0.44 to 0.59). Using available biopsy data to determine the accuracy of each method to identify high-grade squamous intraepithelial lesions, the manual membrane method of liquid-based cytology method was found to have a higher sensitivity (71.4% versus 57.1%) and lower specificity (82.1% versus 89.7%). The slightly higher referral rate to colposcopy using the manual membrane method of liquid-based cytology method was limited to women from the low-risk general gynecology clinics (16.7% versus 12.0%, P = .05).

CONCLUSION

The low-cost manual membrane method of liquid-based cytology cervical cytology method is comparable with a standard commercial method. Consequently, it may be of value in alternative screening strategies in resource-limited settings.

Gynecologic issues in the HIV-infected woman

Science has made great strides in understanding the management of the many gynecologic conditions that affect HIV-positive women with an increased frequency. As HIV-infected women's life expectancy continues to lengthen, new treatments are necessary for recurring conditions, such as lower genital tract neoplasias. The medical field has much to learn about the interaction between sex steroids, HIV-infection, and the immune system. As knowledge grows, clinicians will be better equipped to counsel women about contraceptive issues, pregnancy, and menopause.

The predictive value of cytologic testing in women with the human immunodeficiency virus who have low-grade squamous cervical lesions: a substudy of a randomized, phase III chemoprevention trial

OBJECTIVE

The purpose of this study was to determine whether the progression of low-grade squamous intraepithelial lesions of the cervix in women with the human immunodeficiency virus can be predicted reliably by standard cytologic testing.

STUDY DESIGN

As part of a previously reported trial, 288 biopsy specimens were collected from 117 women with the human immunodeficiency virus. These specimens underwent central and local interpretation, which were compared and correlated with cytologic results. Ninety-two subjects had matched cytologic/histologic pairs at study termination, which were compared to determine whether cytologic testing was predictive of progression.

RESULTS

Of the central histologic interpretations, 26 of 288 interpretations (9%) differed from local results, 97 of 246 cytologic/histologic pairs (39%) were discordant, and 21 subjects had progression to high-grade squamous intraepithelial lesions by histologic evidence. Cytologic testing showed high-grade squamous intraepithelial lesions in 4 of 21 specimens (sensitivity, 19%). The remaining cytologic specimens were either low-grade squamous intraepithelial lesions or were normal.

CONCLUSION

This substudy of pathologic results from a randomized clinical trial suggests that, although the risk of progression of low-grade squamous intraepithelial lesions is low, follow-up cytologic testing is unreliable. Colposcopic evaluation with directed biopsies should be continued.

Improved outcome of cervical neoplasia in HIV-infected women in the era of highly active antiretroviral therapy

Cervical neoplasia has been associated with human immunodeficiency virus (HIV) infection. Both preinvasive disease and invasive cervical cancer have been reported to have a much poorer outcome in HIV-infected women than in the general population. The use of highly active antiretroviral therapy (HAART) has resulted in significant improvements in the treatment of HIV infection, including a decrease in the incidence and severity of several acquired immune deficiency syndrome (AIDS)-related malignancies. Two cases of cervical dysplasia in HIV-infected women are presented, one from the pre-HAART era, who subsequently developed invasive cervical cancer and died, and one in whom HAART was used with good outcome. Data from several reports of the use of HAART in HIV-infected women indicates that the prognosis for cervical neoplasia is improved. Possible reasons for this improvement include better immune function seen in HAART-treated women, as well as increased surveillance for cervical neoplasia in HIV-infected women in recent years. However, the future impact of improved HIV care, including HAART, on cervical neoplasia is unclear.

The effect of highly active antiretroviral therapy on cervical cytologic changes associated with oncogenic HPV among HIV-infected women

OBJECTIVE

Cervical intraepithelial neoplasia (CIN), a common condition among HIV-infected women, has been linked to HIV load and immune status. Highly active antiretroviral therapy (HAART) improves immunologic and virologic status. This study was undertaken to determine the relationship between HAART use and CIN.

DESIGN

Cohort study. The Women's Interagency HIV Study (WIHS) in five cities in the USA (Bronx/Manhattan, New York; Brooklyn, New York; Chicago, Illinois; Los Angeles, California; San Francisco Bay area, California; Washington, District of Columbia).

METHODS

HIV-infected women were followed every 6 months with Papanicolaou smears and cervicovaginal lavage for human papillomavirus (HPV) DNA testing. To characterize exposures that changed over time and to capture the dynamic nature of cytologic changes, Papanicolaou smear findings from each participant's consecutive visits were defined as a pair. We determined the proportion of all pairs that exhibited either regression or progression, according to HAART exposure, HPV results and Papanicolaou smear status. As participants could contribute multiple pairs, inferences were based on robust methods to adjust for correlated observations.

RESULTS

Women with persistent HPV infection were more likely to have progression of their lesions. After adjustment for CD4 cell count and Papanicolaou smear status, women on HAART were 40% (95% confidence interval, 4-81%) more likely to demonstrate regression and less likely (odds ratio, 0.68; 95% confidence interval, 0.52-0.88) to demonstrate progression

CONCLUSIONS

HAART altered the course of HPV disease in HIV-infected women, reducing progression and increasing regression. As HPV disease is a common sex-specific manifestation of HIV disease this effect of HAART would be a major additional benefit from this modality of therapy.

Evolution of cervical abnormalities among women with HIV-1: evidence from surveillance cytology in the women's interagency HIV study

OBJECTIVE

To determine incidence, progression, and regression rates for abnormal cervical cytology and their correlates among women with HIV.

METHODS

In a multicenter prospective cohort study conducted October 1, 1994, through September 30, 1999 at university, public, and private medical centers and clinics, 1639 HIV-seropositive and 452 seronegative women were evaluated every 6 months for up to 5 years using history, cervical cytology, T-cell subsets, and quantitative plasma HIV RNA. Human papillomavirus (HPV) typing at baseline was determined by polymerase chain reaction. Cytology was read using the Bethesda system, with any smear showing at least atypia considered abnormal. Poisson regression identified factors associated with incident cytologic abnormalities whereas logistic regression identified those associated with progression and regression after an abnormality.

RESULTS

At least one abnormal smear was found during all of follow-up among 73.0% of HIV-seropositive patients and 42.3% of seronegatives (p <.001). Only 5.9% of seropositives ever developed high-grade lesions, and the proportion with high-grade findings did not rise over time. Incidence of atypical squamous cells of uncertain significance (ASCUS) or more severe lesions among HIV-seropositive patients and seronegative patients was 26.4 and 11.0/100 woman-years (rate ratio [RR], 2.4; 95% confidence interval [CI], 1.9-3.0), whereas that of at least low-grade squamous intraepithelial lesions (SIL) was 8.9 and 2.2/100 (RR, 4.0; CI, 2.6-6.1). HIV status, detection of the presence of human papillomavirus (HPV), CD4 lymphocyte count, and HIV RNA level predicted incidence of abnormal cytology (p <.05); HPV detection and HIV RNA level predicted progression (p <.01); and HPV detection, CD4 lymphocyte count, and HIV RNA level predicted regression (p <.001). Rates of incidence, progression, and regression of abnormal cytology did not differ between HIV seronegative women and seropositive women with CD4 lymphocyte counts >200/mm(3) and HIV RNA levels <4000/ml of similar HPV status.

CONCLUSIONS

Although HIV infected women were at high risk for abnormal cytology, high-grade changes were uncommon. HIV status, HPV detection, CD4 lymphocyte count, and HIV RNA level predicted the incidence of cervical cytologic abnormalities. Progression was significantly increased only among the most immunosuppressed women, while regression was significantly reduced in all HIV seropositive women except those with the best controlled HIV disease.

Effect of excisional therapy and highly active antiretroviral therapy on cervical intraepithelial neoplasia in women infected with human immunodeficiency virus

OBJECTIVE

Our purpose was to determine the rates of recurrence, persistence, and progression of cervical intraepithelial neoplasia in women who were seropositive for human immunodeficiency virus after excisional therapy with and without highly active antiretroviral therapy.

STUDY DESIGN

The records of 118 women with cervical intraepithelial neoplasia, 56 of whom were infected with human immunodeficiency virus and 62 of whom were not infected, were examined to compare outcomes. Demographic, behavioral, and clinical indices were analyzed.

RESULTS

Of 54 women infected with human immunodeficiency virus, 31 (57.4%) had persistent or recurrent cervical intraepithelial neoplasia, in comparison with 10 (16.7%) of 60 noninfected women (P <.01). Progression occurred in 4 (16.7%) of 54 in the infected group and in 3 (5.0%) of 60 in the noninfected group (P <.05). In 21 (60.0%) of 35 infected women, in comparison with 8 (32%) of 25 noninfected women, disease persisted 6 months after diagnosis if treatment was not given (P <.05). Of 19 infected women, 10 (52.6%) had recurrent disease after treatment, compared with 2 (5.7%) of 35 noninfected women (P <.01). Risk factors for recurrence in women who were seropositive for human immunodeficiency virus included margin involvement of specimens obtained by loop electrosurgical excision (87.5% vs 20.0%l; P <.05). Exposure to highly active antiretroviral therapy, including therapy with protease inhibitors, was associated with a lower recurrence or persistence rate (17.6% vs. 70.3%; P <.05) and a lower progression rate (0% vs. 24%; P <.05).

CONCLUSION

Women infected with human immunodeficiency virus had high rates of recurrent and persistent cervical intraepithelial neoplasia despite standard therapy. Low CD4(+) levels and margin involvement of specimens obtained by loop electrosurgical excision are risk factors for recurrence. The use of highly active antiretroviral therapy is associated with a lower risk of recurrence, persistence, and progression of cervical intraepithelial neoplasia.

Clinical care issues for women living with HIV and AIDS in the United States

As the number of women infected with HIV in the United States continues to increase, the medical community is faced with the challenge of providing adequate and appropriate care to them. This paper reviews key questions concerning the state of knowledge on the epidemiology, biology, and clinical care of women living with HIV and AIDS in the United States. Because heterosexual transmission accounts for a growing number of cases among women, biological factors and cofactors that may enhance women's susceptibility to HIV infection are also reviewed. HIV-related gynecological issues are presented separately to evaluate whether gynecological complications are distinct in HIV-uninfected and HIV-infected women. Questions of whether there are sex-specific differences in the efficacy and adverse effects of new antiviral agents are discussed. In addition, significant gaps are highlighted that still exist in our understanding of both the effects of HIV and HIV-related drugs upon pregnancy. Finally, the psychiatric stresses and complications that affect women living with HIV and AIDS are also discussed. In each section of this review, gaps in our knowledge of these issues are identified. To properly address these disparities in knowledge, not only do efforts to gather sex-specific biomedical data need to be more exacting, but there is a distinct need to conduct more sex-specific research concerning HIV.

The false negative rate of cervical smears in high risk HIV seropositive and seronegative women

We undertook a prospective study of cytology and concurrent colposcopically directed biopsies of both Human Immunodeficiencey Virus seronegative (HIV-) and seropositive (HIV +) women at high risk for cervical intraepithelial neoplasia (CIN) to determine the accuracy of Pap smears in this population. Women were recruited from a sexually transmitted disease clinic and a women's prison in eastern Massachusetts. All were interviewed, blood was tested for HIV with CD4 counts done in 101 of the 102 HIV + women, and all received a pelvic exam that included a conventional Pap smear, a Thinprep test, and colposcopy with directed biopsies and endocervical curettage. A total of 184 women volunteered. 82 were HIV- and 102 were HIV+. The prevalence of CIN in HIV+ women was 37%, more than twice the 17% prevalence of CIN in HIV-women (P = 0.002). When Atypical Squamous Cells of Undetermined Significance (ASCUS) findings were included with "negative" cytology, the conventional Pap smear false negative rates for HIV- and HIV+ women were 21% and 37%, respectively. When ASCUS was included with "positive" cytology, the false negative rates dropped to 14.3% for HIV- women and 10.5% for HIV+ women. We conclude that ASCUS diagnoses comprised the majority of false negatives in HIV+ women.

Adherence to colposcopy among women with HIV infection

In the general population, nonadherence to the recommendation to have colposcopy in women with abnormal cytologic smears is estimated at 30% to 80%, but studies have failed to identify consistent risk factors for nonadherence. The purpose of this analysis is to assess adherence to colposcopy in a subset of participants in the Women's Interagency HIV Study (WIHS), an ongoing multisite longitudinal study of HIV infection in women in the United States and determine factors associated with nonadherence. Identification of such predictors would be useful in designing strategies to improve adherence in this group.

METHODS

Adherence to colposcopy was examined in a cohort of 462 women with, or at risk for, HIV infection with abnormal cervical cytology on entry into WIHS. Adherence was defined as having colposcopy done within 6 months of an abnormal cytology result.

RESULTS

Overall adherence to colposcopy was 65% (302 of 462). A multivariate logistic regression model revealed that the odds of adherence were significantly lower for the women who were HIV-infected (p = .011), current crack/cocaine users (p = .040), ever too ill to get medical care (p = .033), not recruited by WIHS study staff (p = .004), and less concerned about the care of their children (p = .037). Among HIV-seropositive women, low CD4 counts, high viral loads, and presence of AIDS-defining illness were not predictive of nonadherence.

DISCUSSION

Adherence to colposcopy among WIHS participants was at the upper limit of the reported range in the United States. Chemical dependency and domestic violence may negatively impact on colposcopy adherence whereas supportive study personnel, having health insurance, and concerns about raising one's children appear to be motivators for adherence to colposcopy in this study. HIV infection was a risk factor for nonadherence, but markers of advanced disease were not predictive of nonadherence.

Prevalence and predictors of squamous cell abnormalities in Papanicolaou smears from women infected with HIV-1. Women's Interagency HIV Study Group

BACKGROUND

Cervical neoplasia occurs with increased frequency among women infected with HIV-1.

OBJECTIVE

To characterize prevalence of and risk factors for abnormal cervical cytology among women with HIV and to compare them to uninfected women.

METHODS

Baseline cervical cytology was obtained from 1713 women seropositive for HIV and 482 at-risk control women who were enrolled in the Women's Interagency HIV Study, a multicenter prospective cohort study conducted in six U.S. cities. Associations with sociodemographic, medical, and sexual variables were assessed by Fisher's exact test, Mantel extension test, and logistic regression analysis.

RESULTS

Cervical cytology was abnormal in 38.3% of HIV-infected women (atypical squamous cells of uncertain significance [ASCUS] 20.9%, low-grade squamous cells of uncertain significance [LSIL] 14.9%, high-grade squamous cells of uncertain significance [HSIL] 2.3%, cancer 0.2%) and 16.2% of HIV-uninfected women (ASCUS 12.7%, LSIL 2.3%, HSIL 1.2%, cancer 0.0%). Risk factors for any abnormal cytology in multivariate analysis included HIV infection, CD4 cell count, HIV RNA level, detection of human papillomavirus (HPV), a prior history of abnormal cytology, employment, and number of male sex partners within 6 months of enrollment. Prior abortion was associated with a decreased risk of cytologic abnormality.

CONCLUSIONS

Cervical cytologic abnormalities were frequent among women infected with HIV, although high-grade changes were found in only 2.5%. Factors linked to sexual and reproductive history, HPV infection, and HIV disease all influenced risk.

Management of cervical neoplasia in human immunodeficiency virus-infected women

The existence of cervical neoplasia in women with human immunodeficiency virus (HIV) represents one of the most serious challenges in the oncologic care of immunosuppressed patients. While the development of most cancers in the immunosuppressed patient can be attributed solely to immune deficiency, the relationship between squamous cell neoplasia of the cervix and HIV is quite unique because of common sexual behavioral risk factors. Screening strategies in HIV-positive women must take into account the high prevalence of cervical dysplasia in this subgroup as well as the limitations of cytologic screening. Cervical dysplasia in HIV-positive women may be of higher grade than in HIV-negative patients, with more extensive involvement of the lower genital tract with HPV-associated lesions. The presence and severity of cervical neoplasia in HIV-positive women correlate with both quantitative and qualitative T-cell function. Standard therapies for preinvasive cervical disease have yielded suboptimal results with high recurrent rates. While poor treatment results of standard ablative and excisional therapies warrant unique therapeutic strategies, one must recognize that close surveillance and repetitive treatment have been successful in preventing progressive neoplasia and invasive cervical carcinoma. The disease characteristics of invasive cervical carcinoma may take a more aggressive clinical course in HIV-infected women. HIV-positive women with cervical cancer have higher recurrence and death rates with shorter intervals to recurrence and death than do HIV-negative control subjects. CD4 status does influence subsequent outcome. In general, the same principles that guide the oncologic management of cervical cancer in immunocompetent patients should be applied. However, extremely close monitoring for both therapeutic efficacy and unusual toxicity must be instituted.

Early regression of cervical lesions in HIV-seropositive women receiving highly active antiretroviral therapy

OBJECTIVE

Advanced HIV disease is associated with a high prevalence of cervical squamous intra-epithelial lesions (SIL) and of infection with oncogenic human papillomavirus (HPV) genotypes. Triple-combination antiretroviral therapy results in decreased plasma HIV viral load, increased CD4 cell counts and partial restoration of immune functions in patients with severe HIV disease. This study investigated the outcome of SIL in HIV-seropositive women undergoing triple combination antiretroviral treatment.

METHODS

Forty-nine women who started triple-combination antiretroviral therapy, including a protease inhibitor, were examined prior to and after a median 5-month treatment. We collected cytological, colposcopic and histologic data and assessed the presence of HPV DNA in cervical smears by PCR and Southern blot hybridization (SBH).

RESULTS

The prevalence of SIL decreased from 69 to 53% during follow-up (P < 0.0001). Among 13 women who initially presented with high-grade SIL, conversion to lower grade was observed in two women and a full regression to normality was observed in one. Cytology also returned to normality in nine out of 21 women who initially presented with low-grade SIL. The high prevalence of HPV infection as detected by SBH and PCR was similar at the first and second examinations and the same high-risk viral genotypes were identified at both examinations in all infected patients but one. There was a higher increase in absolute CD4 cells in the subgroup of patients whose lesions regressed (99 versus 50 x 10(6)/l, P=0.03).

CONCLUSION

Our observations demonstrate that active antiretroviral therapy may result in a reduced prevalence of cervical squamous intra-epithelial lesions despite the absence of clearance of HPV infection.

Is HIV infection a risk factor for advanced cervical cancer?

OBJECTIVES

To compare HIV-infected and HIV-negative women with invasive cervical cancer with respect to predictors of advanced disease.

METHODS

A retrospective analysis of 28 HIV-positive and 132 HIV-negative women with invasive cervical carcinoma was conducted and the two groups were compared with regard to stage of disease, demographic and behavioral variables, and risk factors for advanced disease.

RESULTS

Overall, HIV-infected women were more likely to have advanced disease, because 78% of HIV-positive women had Stage II to IV compared with 55% of HIV-negative women (odds ratio [OR] = 3.1; p = .03). Substance abuse was strongly associated with HIV infection, as were high-risk sexual variables. Although HIV infection was associated with a threefold increase in advance stage cervical cancer in a univariate analysis, only symptom duration and lack of a recent Papanicolaou smear were significant predictors of advanced disease in a multiple logistic regression analysis.

CONCLUSIONS

The major predictors of advanced cervical cancer are similar in HIV-positive and HIV-negative women, although the reasons for these predictors may be very different. It is likely that a large proportion of HIV-positive patients with cervical cancer acquire HIV infection after initiation of the neoplastic process.

Prevalence, risk factors, and accuracy of cytologic screening for cervical intraepithelial neoplasia in women with the human immunodeficiency virus

OBJECTIVES

The objective was to evaluate the sensitivity and specificity of cervical cytology in women infected with the human immunodeficiency virus (HIV), risk factors for abnormal cytology in HIV-infected and uninfected women, and risk factors for histologic diagnosis of cervical intraepithelial neoplasia (CIN) in HIV-infected women.

METHODS

Methods included a cross-sectional analysis of cervical cytology, colposcopic impression, and histology in 248 HIV-infected women and multivariate analyses of risk factors for abnormal cytology in 253 HIV-infected and 220 uninfected women and risk factors for CIN in 186 HIV-infected women.

RESULTS

The sensitivity and specificity of cytology for all CIN grades were 0.60 and 0.80 and, for high-grade CIN, 0.83 and 0.74. The prevalence of abnormal cytology was 32.9% in HIV-infected and 7.6% in HIV-negative women. Independent risk factors for abnormal cytology were immunodeficiency [odds ratio (OR) 8-17, P < 0.001] and human papillomavirus (HPV) infection (OR = 5, P < 0.001). The prevalence of CIN on histology was 32% in HIV-infected women, and the only independent risk factor for CIN was oncogenic HPV type (OR = 5, P = 0.005).

CONCLUSION

Given the high prevalence of abnormal cytology and CIN in HIV-infected women, cytologic screening has significant limitations. Both immunodeficiency and type of HPV infection are important risk factors.

Natural history of HIV infection in women

Women represent the fastest growing group of adults with AIDS, and poor African-American and Latina women are disproportionately affected. There are differences in the clinical presentation of HIV symptoms in women. Although disease progression seems to be similar for women and men, women with HIV infection seem to have a higher mortality rate than men. Gender, racial, and class differences in access to care may account for this. Phases of the natural history of HIV infection in women are reviewed and include prevention opportunities, acute infection, viral and immunologic parameters of pathogenesis, therapeutic plans, and terminal care.

HIV-1 induces cytotoxic T lymphocytes in the cervix of infected women

Although T lymphocytes are present in the genital mucosa, their function in sexually transmitted diseases is unproven. To determine if cervical T cells mediate HIV-specific cytolysis, mononuclear cells in cytobrush specimens from HIV-1-infected women were stimulated in vitro with antigen. Resultant cell lines lysed autologous targets expressing HIV-1 proteins in 12/19 (63%) subjects, and these responses were detected intermittently on repeated visits. All 8 subjects with blood CD4+ counts > or =500 cells/microl had HIV-1-specific cervical CTL, whereas only 4/11 with counts <500 cells/microl had detectable responses (P = 0.008). Class II MHC-restricted CD4+ CTL clones lysed targets expressing Env gp41 or infected with HIV-1. Class I MHC-restricted CD8+ clones recognized HIV-1 Gag- or Pol-expressing targets, and the epitopes were mapped to within 9-20 amino acids. Comparisons of intra-individual cervical and blood CTL specificities indicate that epitopes recognized by CTL in the cervix were commonly recognized in the blood. These studies provide the first definitive evidence for an MHC-restricted effector function in human cervical lymphocytes.

Anogenital papillomavirus infection and neoplasia in immunodeficient women

This article reviews the impact of infection with human immunodeficiency virus (HIV) on HPV infections and HPV-associated lesions of the female anogenital tract. Studies investigating HPV infections in HIV-seropositive women are presented as well as the possibility that HIV can influence HPV expression directly through molecular interactions between viral genes and indirectly through immunosuppression. Studies linking HIV infection to invasive cervical cancer and cervical intraepithelial neoplasia are reviewed; recommended protocols for cervical cancer screening in HIV-seropositive women for cervical disease also are presented.

Intra-epithelial and invasive cervical neoplasia during HIV infection

Patients affected by human immunodeficiency virus (HIV) infection present an elevated risk of developing cancer. In the last 10 years, the relationship between human papilloma virus (HPV) infection and female cervical intra-epithelial neoplasia (CIN) has been established. Several studies have described an increased prevalence of both cervical HPV infection and CIN among HIV-positive women compared to HIV-negative ones. A high recurrence rate of CIN after standard treatment has been noted in HIV-infected women and the severity of these lesions seems to be inversely correlated to immune function. Taking into account these data, the Centers for Disease Control (CDC) since 1993 have included invasive cervical carcinoma among the AIDS-defining conditions. Once cervical cancer develops in HIV-positive women, the disease may be aggressive and less responsive to treatment. A primary means by which HIV infection may influence the pathogenesis of HPV-associated cervical pathology is by molecular interaction between HIV and HPV genes. Although these have not been well defined, an upregulation of HPV E6 and E7 genes expression by HIV proteins (such as tat) has been postulated by some authors. Cervical cytology appears to be adequate as a screening tool for the cervical intra-epithelial neoplasia in HIV-positive women, but the high recurrence rate and multifocality of this disease reinforces the need for careful evaluation and follow-up of the entire anogenital tract in these women. Probably in the next few years, cervical tumours will represent one of the most frequent complications of HIV infection, a part of progression through AIDS. This points to a need for greater interdisciplinary co-operation for a best disease definition and for the development of effective prevention measures.

Cervical intraepithelial neoplasia in pregnant intravenous drug users infected with human immunodeficiency virus type 1

OBJECTIVE

The purpose of this study was to evaluate the frequency and natural history of cervical intraepithelial neoplasia (CIN) during pregnancy in past or current intravenous drug users infected with human immunodeficiency virus type 1 (HIV-1).

STUDY DESIGN

We prospectively evaluated 48 pregnant HIV-1 seropositive patients and 38 HIV seronegative controls. All the subjects were current or past intravenous drug users. Follow-up visits were carried out each trimester of pregnancy and 8-12 weeks post-partum with Papanicolau smears, colposcopic examinations and, when necessary, colposcopically directed cervical biopsies.

RESULTS

Thirteen of 48 HIV-seropositive women (27.1%) and three of 38 HIV-seronegative controls (7.9%) (P = 0.027 by Fisher exact test) had biopsy-proven CIN at the beginning of pregnancy. High-grade CIN was detected in 10 cases (20.8%) and in two (5.3%) controls (P = 0.058 by Fisher exact test). None of the cervical squamous intraepithelial lesions progressed throughout pregnancy, in both cases and controls. Post-partum cold-knife cervical conization was performed on seven patients with CIN III and examination of the cone biopsy specimens demonstrated persistence of CIN III.

CONCLUSIONS

HIV-infected intravenous drug users are at high risk of CIN during pregnancy, thus requiring adequate screening programs. Our preliminary data suggest that the progression rate of CIN during gestation is low in this high-risk group.

A population-based, controlled study of the relation between HIV infection and cervical neoplasia

OBJECTIVE

To study a geographically defined population of women exposed to a drug-related risk for human immunodeficiency virus (HIV), together with carefully matched neighbourhood controls, in order to examine (1) the proportion of different groups having cervical cytopathology screening; (2) the association between HIV infection and cervical intraepithelial neoplasia; (3) the independent effect of CD4+ lymphocyte count and duration of HIV infection; and (4) the correspondence between cervical cytopathology and colposcopically directed biopsy.

DESIGN

A population-based study.

SUBJECTS

All women domiciled in Lothians with the following characteristics: between 1983 and 1987 they had a history of injection drug use or a seropositive partner with a history of injection drug use; they had a pregnancy after that exposure where their serostatus was known. In addition, neighbourhood controls were identified by computer matching for the following criteria--post-code sector, housing deprivation score, age, parity, pregnancy outcome, ethnic group, year of pregnancy, smoking.

MAIN OUTCOME MEASURES

Search was carried out for the cervical smear nearest in time to the index pregnancy end date, providing serostatus was known at that time. All identified smears were assessed by a cytopathologist without knowledge of clinical information, study group or serostatus.

RESULTS

Of 376 women, appropriate cervical smears were identified for 336. The proportions screened in the different groups were similar. There were more abnormal smears in the seropositive group than in the drug-related seronegative (P < 0.01) or the neighbourhood control groups (P < 0.001). HIV-infected women with abnormal smears had lower CD4+ lymphocyte counts (P < 0.0005). There was a reasonable correspondence between cytopathological classification and histological grading, and this was of similar strength in cases and controls (weighted kappa 0.72, 0.74).

CONCLUSIONS

There is a definite relation between HIV infection and cervical intraepithelial neoplasia. This is related to immune depletion but whether this is the sole mechanism for the association is unclear.

Characteristics of cervical intraepithelial neoplasia in women infected with the human immunodeficiency virus

OBJECTIVE

Our purpose was to compare characteristics of cervical intraepithelial neoplasia in relation to human immunodeficiency virus infection among women referred to a public hospital colposcopy clinic with Papanicolaou smears showing cervical intraepithelial neoplasia.

STUDY DESIGN

An evaluation of cervical intraepithelial neoplasia severity, lesion size, and vulvovaginal lesions with respect to human immunodeficiency virus status was performed.

RESULTS

(1) Human immunodeficiency virus prevalence in 482 women with cytologic characteristics of cervical intraepithelial neoplasia was 13%. (2) In human immunodeficiency virus-infected patients, Papanicolaou smears were less adequate for evaluation and correlated less well with histologic findings than in uninfected patients (p < 0.05). (3) Human immunodeficiency virus-infected patients (n = 47) had more advanced cervical intraepithelial neoplasia, larger cervical lesions, and more associated vulvovaginal lesions than human immunodeficiency virus-negative patients (n = 161). In human immunodeficiency virus-positive women, the severity of cervical intraepithelial neoplasia was not associated with age, whereas in human immunodeficiency virus-negative women, increasing severity was significantly associated with increasing age.

CONCLUSION

High rates of human immunodeficiency virus infection in inner-city colposcopy services and high-grade, extensive cervical lesions in infected women warrant special attention.

Multiple primary gynecologic neoplasms in a young HIV-positive patient

Immune suppression from human immunodeficiency virus (HIV) infection is frequently associated with the development of certain neoplasms, including Kaposi's sarcoma and non-Hodgkin's lymphoma. A young patient with a 5-year history of HIV infection was found simultaneously to have invasive carcinoma of the breast, microinvasive carcinoma of the cervix, and intraepithelial neoplasia of the vulva. In view of the early nature of these neoplasms, conservative therapy was utilized; lumpectomy and adjuvant radiation therapy, conservative hysterectomy, and local therapy for the breast carcinoma, cervical carcinoma and vulvar intraepithelial neoplasia, respectively. Epithelial malignancies appear to be more common in the HIV-positive population than previously appreciated. To our knowledge this is the first report of multiple primary gynecologic neoplasms in association with HIV infection.