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

Residual or Recurrent Precancerous Lesions After Treatment of Cervical Lesions in Human Immunodeficiency Virus-infected Women: A Systematic Review and Meta-analysis of Treatment Failure

BACKGROUND

Screening and treating premalignant cervical lesions (cervical intraepithelial neoplasia 2+ [CIN2+]) is an effective way to prevent cervical cancer, and recommendations exist for the monitoring of treatment success. Yet, there is no specific recommendation for human immunodeficiency virus (HIV)-infected women, who are at a known, increased risk of cervical cancer.

METHODS

A systematic review was performed by searching MEDLINE, EMBASE, and Web of Science for studies published from January 1980 through May 2018. Eligible studies described the prevalence of histologically- and/or cytologically-defined lesions in HIV-infected women at least 6 months post-treatment. The primary endpoint was treatment failure, defined as the presence of residual and/or recurrent high-grade CIN2+/high-grade squamous intraepithelial lesions post-treatment. The pooled prevalence in HIV-infected women and the odds ratios (ORs) for HIV-infected compared to HIV-uninfected women were estimated using random-effects models.

RESULTS

Among 40 eligible studies, the pooled prevalence of treatment failure in HIV-infected women was 21.4% (95% confidence interval [CI] 15.8-27.0). There was no significant difference in the treatment failure prevalence for cryotherapy (13.9%, 95% CI 6.1-21.6) versus loop electrosurgical excision procedure (13.8%, 95% CI 8.9-18.7; P = .9), but the treatment failure prevalence was significantly higher in women with positive (47.2%, 95% CI 22.0-74.0) than with negative (19.4%, 95% CI 11.8-30.2) excision margin (OR 3.4, 95% CI 1.5-7.7). Treatment failure was significantly increased in HIV-infected versus HIV-uninfected women, both overall (OR 2.7, 95% CI 2.0-3.5) and in all sub-group analyses.

CONCLUSIONS

There is strong evidence for an increased risk of treatment failure in HIV-infected women, in comparison to their HIV-negative counterparts. The only significant predictor of treatment failure in HIV-infected women was a positive margin status, but further data is needed on long-term outcomes after ablative treatment in HIV-infected women.

Suppressive antiretroviral therapy associates with effective treatment of high-grade cervical intraepithelial neoplasia

OBJECTIVES

To assess if women living with HIV (WLWH) have poorer outcome after treatment of cervical intraepithelial neoplasia grade 2, grade 3, adenocarcinoma in situ or cervical cancer (CIN2+) than HIV-negative women (HNW) and to identify predictors of CIN2+ treatment failure and recurrence in WLWH.

DESIGN

Population-based cohort study with follow-up between 1983 and 2015.

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+ (n = 179) sometime between 1983 and 2014. For each WLWH, two HNW resident in the same counties and matched for country of birth, diagnosed with CIN2+, were chosen as controls. Treatment failure was defined as the presence of CIN2+ at initial follow-up. Recurrence was defined as the presence of CIN1+ subsequent to an initial normal follow-up.

RESULTS

WLWH were three times more likely to have treatment failure (odds ratio (OR) 3.7 [95% confidence interval (CI) 2.0-6.8]) and five times more likely to recur (hazard ratio 5.0 [95% CI 2.1-11.6]) than HNW. Suppressive antiretroviral therapy (ART) at time of treatment of CIN2+ was associated with reduced OR of treatment failure (OR 0.3 [95% CI 0.1-0.8]). Immunosuppression (CD4 cell count <200 cells/μl) associated strongly with treatment failure (OR compared with CD4 cell count ≥500: 8.5 [95% CI 2.3-30.7]).

CONCLUSION

Suppressive ART is associated with effective treatment of CIN2+. Early HIV diagnosis and ART are essential for successful CIN2+ treatment.

Factors influencing decisions about surgical treatment of cervical precancerous lesions

Cervical precancerous lesions represented by cervical intraepithelial neoplasia (CIN) and cervical glandular intraepithelial neoplasia may progress to invasive cancer. The principle treatment of CIN is eradication of the transformation zone. However, all eradication methods are associated with some adverse events, particularly with perinatal consequences. It is therefore necessary to identify which women have CIN that has a low risk of transformation into invasive cancer. The presence of modifying factors can help to stratify CIN lesions according to their malignant potential. The evaluation of HPV genotype in particular holds great promise for defining patients at greater risk. Tailoring treatment to the individual patient is going to become a major consideration in the management of cervical precancerous lesions.

Implementation of cervical cancer prevention services for HIV-infected women in Zambia: measuring program effectiveness

BACKGROUND

Cervical cancer kills more women in low-income nations than any other malignancy. A variety of research and demonstration efforts have proven the efficacy and effectiveness of low-cost cervical cancer prevention methods but none in routine program implementation settings of the developing world, particularly in HIV-infected women.

METHODS

In our public sector cervical cancer prevention program in Zambia, nurses conduct screening using visual inspection with acetic acid aided by digital cervicography. Women with visible lesions are offered same-visit cryotherapy or referred for histologic evaluation and clinical management. We analyzed clinical outcomes and modeled program effectiveness among HIV-infected women by estimating the total number of cervical cancer deaths prevented through screening and treatment.

RESULTS

Between 2006 and 2008, 6572 HIV-infected women were screened, 53.6% (3523) had visible lesions, 58.5% (2062) were eligible for cryotherapy and 41.5% (1461) were referred for histologic evaluation. A total of 75% (1095 out of 1462) of patients who were referred for evaluation complied. Pathology results from 65% (715 out of 1095) of women revealed benign abnormalities in 21% (151), cervical intraepithelial neoplasia (CIN) I in 30% (214), CIN 2/3 in 33% (235) and invasive cervical cancer in 16.1% (115, of which 69% were early stage). Using a conditional probability model, we estimated that our program prevented 142 cervical cancer deaths (high/low range: 238-96) among the 6572 HIV-infected women screened, or one cervical cancer death prevented per 46 (corresponding range: 28-68) HIV-infected women screened.

CONCLUSION

Our prevention efforts using setting-appropriate human resources and technology have reduced morbidity and mortality from cervical cancer among HIV-infected women in Zambia. Financial support for implementing cervical cancer prevention programs integrated within HIV/AIDS care programs is warranted. Our prevention model can serve as the implementation platform for future low-cost HPV-based screening methods, and our results may provide the basis for comparison of programmatic effectiveness of future prevention efforts.

The impact of highly active antiretroviral therapy on prevalence and incidence of cervical human papillomavirus infections in HIV-positive adolescents

Background

The implementation of highly active antiretroviral therapy (HAART) among HIV-positive patients results in immune reconstitution, slower progression of HIV disease, and a decrease in the occurrence of opportunistic infections. However, the impact of HAART on cervical human papillomavirus (HPV) infection, clearance, and persistence in high-risk adolescents remains controversial.

Methods

HIV-positive and high-risk HIV-negative female adolescents were enrolled in the Reaching for Excellence in Adolescent Care and Health (REACH) longitudinal cohort study. At each semi-annual clinical visit, cervical lavage samples were tested for 30 HPV types. Type-specific and carcinogenic risk-specific HPV prevalence and incidence were compared in 373 eligible participants: 146 HIV-negative female adolescents with a median follow-up of 721.5 [IQR: 483-1301] days and 227 HIV-positive female adolescents. Of the 227 HIV-positive participants, a fixed set (n = 100) were examined both before and after HAART initiation; 70 were examined only before HAART initiation; and 57 were examined only after HAART initiation, with overall median follow-up of 271 [IQR: 86.5-473] and 427.25 [IQR: 200-871] days respectively for before and after HAART initiation.

Results

Of the 373 eligible participants, 262 (70%) were infected with at least one type of HPV at baseline, and 78 of the remaining 111 (70%) became infected with at least one type of HPV by the end of the study. Overall, the incidence and prevalence of HPV types 58, 53/66, 68/70, and 31/33/35 were much higher than the established carcinogenic and HPV vaccine types 16 and 18, especially in HIV-positive females both before and after HAART initiation. Baseline prevalence for individual high-risk HPV types ranged, depending on type, from 0.7-10%, 1-17%, and 1-18% in the HIV-negative group, the HIV-positive before HAART initiation group, and the HIV-positive after HAART initiation group, respectively. Likewise, the incidence ranged, depending on HPV type, from 0.64-9.83 cases/100 PY, 3.00-12.80 cases/100 PY, and 1.49-17.05 cases/100 PY in the three groups, respectively. The patterns of each HPV type infection, clearance, and persistence did not differ considerably before or after the introduction of HAART and were clearly independent of CD4⁺ change within the short post-HAART follow-up period.

Conclusions

HAART did not immediately affect the incidence of type-specific HPV infections within a short-period follow-up; however, future studies are warranted in larger populations to evaluate HAART's impact over longer periods.

Outcomes after an excisional procedure for cervical intraepithelial neoplasia in HIV-infected women

OBJECTIVE

To determine predictors of treatment failure and recurrence after surgical excisional procedures for CIN in HIV-infected women.

METHODS

A retrospective cohort study was conducted in which 136 eligible HIV-infected women treated for CIN between 1999 and 2005 were included. Data were abstracted from charts and computer databases. Treatment failures were defined as the presence of CIN 1+ at initial follow-up. Recurrences were defined as the presence of CIN 1+ subsequent to initial normal follow-up.

RESULTS

Treatment failure at initial follow-up was common, occurring in 51% of CIN 1 and 55% of CIN 2+. Most lesions detected at treatment failure were high grade (>70%), regardless of the grade of initial lesion. Significant risk factors for treatment failure were loop electrosurgical excision procedure (LEEP) compared to cold knife conization (RR=1.76; 95% CI: 1.15-2.64), and low CD4+ count (p=0.04). Among those with an initial normal clinical evaluation, 55% eventually recurred. As with treatment failure, most lesions detected at recurrence were high grade. Risk factors for recurrence included use of LEEP (hazard ratio [HR]=3.38; 95% CI: 1.55-7.39), higher HIV RNA level, and the presence of positive margins at treatment (HR=6.12; 95% CI: 1.90-19.73).

CONCLUSIONS

Most CIN treatment of HIV-infected women studied either failed or resulted in recurrence. Of particular concern, many of these subsequent lesions were high grade. Conization, however, was associated with significantly less failure/recurrence than LEEP. Clinicians treating CIN in HIV-infected women should avoid raising expectations of cure and instead focus on the achievable goal of cancer prevention until there are better therapies for this patient population.

The impact of antiretroviral therapy on HPV and cervical intraepithelial neoplasia: current evidence and directions for future research

Increasing numbers of human immunodeficiency virus (HIV)-infected women are now accessing life-prolonging highly active antiretroviral therapy (HAART) in developing countries. There is a need for better understanding of interactions of human papillomavirus (HPV) and HIV, especially in the context of increasing life expectancy due to HAART. The data regarding the impact of HAART on reducing the incidence and progression and facilitating the regression of HPV infection and cervical abnormalities is largely inconsistent. Published studies differ in their study designs (prospective or retrospective cohorts or record linkage studies), screening and diagnostic protocols, duration and type of HAART use, recruitment and referral strategies, and definitions of screening test and disease positivity. Due to the ethical and resource limitations in conducting randomized trials of the impact of HAART on incidence of HPV, CIN, and cervical cancer among HIV-infected women, it is important to consider innovative study designs, including quasi-experimental trials and operations research in sentinel populations to answer the critical research questions in this area.

HAART use in women with HIV and influence on cervical intraepithelial neoplasia: a clinical opinion

OBJECTIVES

Study the role of highly active antiretroviral therapy (HAART) in cervical disease in women with human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections.

MATERIALS AND METHODS

A systematic review of current literature and the results summarized in the following headings: HIV and cytological evidence of disease, HIV and HPV, and HAART and HIV in women with HPV-associated cervical disease.

RESULTS

Limited data is available to study the influence of HAART on HPV-related cervical disease in women with HIV. There is evidence that the use of HAART may lead to immune restoration and thereby prevent severe recurrent HPV disease, thus influencing associated cervical disease.

CONCLUSIONS

Little data is available on HAART and its role in HPV-associated cervical disease in women with HIV. Immune restoration may decrease the severity and recurrence of HPV infection and potentially impact cervical disease. Population-based studies are needed to further evaluate the role of HAART in HPV associated cervical disease.

Prevention of cervical cancer in women with HIV

PURPOSE OF REVIEW

Cervical cancer, caused by the human papillomavirus (HPV), is the only cancer that is almost preventable through regular screening. In high-resource, as in low-resource and middle-resource countries, women hit by the AIDS epidemic have a high prevalence of infection with HPV and related disease, including cervical cancer. The question whether cervical screening, which helped to reduce dramatically cervical cancer rates through the detection of precancerous lesions in the general population, is as efficient in the setting of HIV is still debated.

RECENT FINDINGS

The risk for cervical cancer remained high and stable during the last decade in HIV-infected women, and incidence did not decrease with improving CD4 cell counts in women receiving antiviral therapy. Optimal methods to improve both the sensitivity and the specificity of cervical cancer screening are currently evaluated. The use of HPV DNA tests in primary screening endorsed in the general population may be less specific in immunocompromised women and might thus not be as efficient on screening. HPV vaccines, recently available, have no therapeutic effect and might thus not be very useful in preventing cervical cancer in a population highly infected with multiple and persistent HPV.

SUMMARY

Cervical cancer prevention remains an important goal in HIV-infected women and specific guidelines are warranted for this increasing population.

Outcome of loop electrosurgical excision for HIV-positive women in a low-resource outpatient setting

OBJECTIVE

To assess outcome in HIV-positive women undergoing the loop electrosurgical excision procedure (LEEP).

METHOD

A prospective study was conducted with 789 outpatients undergoing LEEP at Chiang Mai University Hospital between October 2004 and June 2008.

RESULTS

The 70 HIV-positive women (8.9%) were younger (P<0.001) and had a lower parity (P<0.001) than the remaining women. The proportion of women undergoing LEEP for persistent low-grade lesions was higher (8.6% vs 1.9%) and the prevalence of margin involvement was higher (60.0% vs 49.4%) among the HIV-positive women. After adjusting for age, parity, menopausal status, size of excised lesion, and histopathologic result, HIV infection was not significantly associated with LEEP complications (adjusted odds ratio, 0.41; 95% confidence interval, 0.15-1.15).

CONCLUSION

The higher risk of resection margin involvement in HIV-infected women was not associated with LEEP complications.

HIV-Infected Patients With Anal Carcinoma Who Subsequently Developed Oral Squamous Cell Carcinoma: Report of 2 Cases

We describe 2 patients who had human immunodeficiency virus (HIV) infection and who first developed human papillomavirus (HPV)-related anal squamous cell carcinoma and later, oral squamous cell carcinoma. At the time each patient developed oral cancer, they were responding well to antiretroviral therapy with undetectable viral loads. Careful screening for oral cancers may be indicated in HIV-infected patients with HPV-associated anal cancer.

Recurrence of cervical intraepithelial neoplasia grades 2 or 3 in HIV-infected women treated by large loop excision of the transformation zone (LLETZ)

CONTEXT AND OBJECTIVE

Women infected by HIV are more likely to have cervical cancer and its precursors. Treatment of the precursor lesions can prevent this neoplasia. The aim of this study was to assess the likelihood of recurrent cervical intraepithelial neoplasia grades 2 or 3 (CIN 2-3) in HIV-infected women, compared with HIV-negative women, all treated by large loop excision of the transformation zone (LLETZ).

DESIGN AND SETTING

A cohort study in Instituto Fernandes Figueira, Fundação Oswaldo Cruz (IFF-Fiocruz), Rio de Janeiro.

METHOD

55 HIV-positive and 212 HIV-negative women were followed up after LLETZ for CIN 2-3 (range: 6-133 months).

RESULTS

The incidence of recurrent CIN 2-3 was 30.06/10,000 woman-months in the HIV-positive group and 4.88/10,000 woman-months in the HIV-negative group (relative risk, RR = 6.16; 95% confidence interval, CI: 2.07-18.34). The likelihood of recurrence reached 26% at the 62nd month of follow-up among the HIV-positive women, and remained stable at almost 0.6% at the 93rd month of follow-up among the HIV-negative women. We were unable to demonstrate other prognostic factors relating to CIN recurrence, but the use of highly active antiretroviral therapy (HAART) may decrease the risk of this occurrence among HIV patients.

CONCLUSION

After LLETZ there is a higher risk of recurrence of CIN 2-3 among HIV-positive women than among HIV-negative women. This higher risk was not influenced by margin status or grade of cervical disease treated. The use of HAART may decrease the risk of this occurrence in HIV patients.

Outcomes after treatment of cervical intraepithelial neoplasia among women with HIV

OBJECTIVE

To describe outcomes after treatment of cervical intraepithelial neoplasia (CIN) in women with HIV.

MATERIALS AND METHODS

Women in two prospective cohort studies, the Women's Interagency HIV Study (WIHS) and the HIV Epidemiology Research Study (HERS), were followed every 6 months after treatment of CIN using human papillomavirus (HPV) testing and cytology with colposcopy as indicated. Identification of CIN or a squamous intraepithelial lesion (SIL) within 6 months was defined as treatment failure and later disease as recurrence.

RESULTS

Follow-up was available for 170 HIV-seropositive and 15 HIV-seronegative women. Treatment failed in 84 (45%) women (79 HIV seropositive and 5 HIV seronegative). Failure was more likely in women with lower CD4 counts (CD4 < 200 cells/microL: odds ratio [OR] = 2.96; 95% CI = 1.4-6.2) and detectable HPV DNA (OR 8.20; 95% CI = 1.8-37.4; p = .01). After successful treatment, recurrence-free probabilities at 1,2, 3, and 5 years were .79, .64, .49, and .34, respectively. HIV-seronegative women were less likely to recur than HIV-seropositive women (p = .03). In multivariable analysis of HIV-positive women, recurrence was more likely among women treated for CIN 2,3 (hazard ratio [HR] = 2.4; 95% CI = 1.4-4.8), those with CD4 count of less than 200 cells/microL (HR = 2.9; 95% CI = 1.3-6.5) and those with HPV after treatment (HR 2.9; 95% CI = 1.4-6.1); oncogenic HPV was more strongly associated with recurrence than nononcogenic HPV (p(trend) = .009). Most failures and recurrences were low grade, but one adenocarcinoma was diagnosed 4.2 years after therapy for CIN 1.

CONCLUSION

Treatment failure and recurrence are common in women with HIV but are usually low grade.

Outcomes of loop electrosurgical excision procedure for cervical neoplasia in human immunodeficiency virus-infected women

The objective of this study was to evaluate the treatment outcomes and complications in human immunodeficiency virus (HIV)-infected women undergoing loop electrosurgical excision procedure (LEEP) for cervical neoplasia. The medical record of 60 evaluable HIV-infected women who had abnormal Papanicolaou (Pap) smear and underwent LEEP following colposcopy at Chiang Mai University Hospital between May 1998 and June 2004 was reviewed. Thirty-one (51.7%) had associated genital infection at screening. Twenty-five (41.7%) had opportunistic infection, but only 18 (30.0%) were treated with antiretroviral therapy. The most common abnormal Pap smear was high-grade squamous intraepithelial lesion (46.7%), followed by low-grade squamous intraepithelial lesion (40.0%). Forty (66.7%) women had clear surgical margins after LEEP. Only one (1.7%) woman had severe intraoperative hemorrhage. Early and late postoperative hemorrhage were noted in three (5%) women of each period. Localized infection of the cervix was detected in seven (11.7%) women. Two (3.3%) women developed cervical stenosis at 6 months after LEEP. There was no significant difference in overall complications between HIV-infected women and the control group (P= 0.24). Among 60 HIV-infected women, no statistical difference in the rate of margins involvement (P= 1.00) and complications (P= 0.85) could be demonstrated between HIV-infected women who received antiretroviral therapy and those who did not. Disease-free rate at 6 and 12 months were 97.1% and 88%, respectively. These data demonstrated that LEEP appears to be safe and effective in HIV-infected women.

AIDS malignancies

Among individuals with HIV-infection, coinfection with oncogenic viruses including EBV, HHV-8, and HPV cause significant cancer-related morbidity and mortality. It is clear that these viruses interact with HIV in unique ways that predispose HIV-infected individuals to malignant diseases. In general, treatment directed specifically against these viruses does not appear to change the natural history of the malignant disease, and once the malignancy develops, if their health permits, HIV-infected patients should be treated using similar treatment protocols to HIV-negative patients. However, for the less frequent HIV-related malignancies, such as PEL, or MCD, optimal treatments are still emerging. For certain AIDS-defining malignancies, it is clear that the widespread access to HAART has significantly decreased the incidence, and improved outcomes. However, for other cancers, such as the HPV-related tumors, the role of HAART is much less clear. Further research into prevention and treatment of these oncogenic virally mediated AIDS-related malignancies is necessary.

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.

Limited Impact of Immunosuppression and Haart on the Incidence of Cervical Squamous Intraepithelial Lesions in HIV-Positive Women

Background

Although highly active antiretroviral therapy (HAART) has lowered the incidence of various opportunistic diseases, its impact on cervical squamous intraepithelial lesions (SILs) is unclear. Our objective was to compare the incidence of SILs in HIV-infected women receiving HAART versus those not receiving HAART and to determine the role of risk factors including immunosuppression in the pathogenesis of SIL.

Methods

A total of 298 HIV-infected women with normal Papanicolaou (Pap) smear and normal colposcopic findings at enrollment were followed-up until incident SIL or last follow-up visit. Cox regression modelling was used to assess risks factors for incident SIL.

Results

Eighty-eight women developed SILs, including 75 low-grade lesions, during a median follow-up of 28 months (16–52; incidence of 8.7 cases per 100 person-years). No invasive cervical cancers were identified. Incidence decreased from 10.7 to 6.5 per 100 person-years in non-receiving versus receiving HAART women (relative risk [RR]: 0.7; 95% confidence interval [CI]: 0.4–1.2, P=0.15, from the adjusted Cox model). Incident SIL was not associated to low CD4+ T-cell count ( P=0.54). In multivariate analysis, the only significant risk factor for incident lesion was the age between 30–39 compared with over 40 (RR: 3.5; 95% CI: 1.4–8.9; P=0.02).

Conclusion

No impact in the development of SIL was evidenced for CD4+ T-cell counts, but we cannot exclude a modest impact of HAART. All HIV-positive women should be offered to participate in cervical cancer screening programmes whether or not they receive effective antiretroviral therapy.

High rate of recurrence of cervical intraepithelial neoplasia after surgery in HIV-positive women

OBJECTIVE

Our study investigated the rate of recurrence of cervical intraepithelial neoplasia (CIN) in HIV-positive women after surgery in the era of highly active antiretroviral therapy (HAART).

METHODS

One hundred twenty-one HIV-positive women were followed-up with cytology, colposcopy, and histology after surgery for CIN. We conducted univariate and multivariate analyses to determine the relation between recurrence of CIN and risk factors using Cox proportional hazard models with left truncation.

RESULTS

The rate of recurrence of any CIN was 22.3 per 100 patient-years and the rate of high-grade CIN was 8.6 per 100 patient-years during 166 and 279 patient-years of follow-up, respectively. In multivariate analysis, a positive margin was associated with a risk of recurrence of any CIN (relative risk [RR] = 3.5, 95% confidence interval [CI]: 1.2-9.8) and a risk of recurrence of high-grade CIN (RR = 9.0, 95% CI: 2.2-36.5). CD4 counts <200 cells/mm were associated with a risk of recurrence of any CIN (RR = 9.4, 95% CI: 2.7-32.7) but not with a risk of recurrence of high-grade CIN. HAART exhibited a protective effect on the recurrence of any CIN (RR = 0.3, 95% CI: 0.1-0.7) and of high-grade CIN (RR = 0.2, 95% CI: 0.1-0.7).

CONCLUSION

CD4 cell counts <200/mm(3) and a positive margin were predictors of recurrence, whereas HAART had a strong protective effect. Although surgery is highly effective in immunocompetent patients, it seems to be effective only in preventing progression to cancer in HIV-infected women.

Anal intraepithelial neoplasia in the highly active antiretroviral therapy era among HIV-positive men who have sex with men

OBJECTIVES

The incidence of anal cancer among men who have sex with men (MSM) has continued to increase since the introduction of highly active antiretroviral therapy (HAART). The prevalence of the putative anal cancer precursor, anal intraepithelial neoplasia (AIN) was high among HIV-positive MSM prior to the availability of HAART but little is known about AIN since HAART was introduced. We characterized the prevalence of AIN among HIV-positive MSM and examined the association between AIN and various factors including use of HAART.

DESIGN AND METHODS

A baseline point-prevalence analyses in a prospective cohort study of AIN was performed at a university-based research clinic. A total of 357 HIV-positive MSM with no history of anal cancer completed a questionnaire detailing behaviors and medical history, anal cytology and human papillomavirus (HPV) testing, and high-resolution anoscopy with biopsy for detection of AIN.

RESULTS

Eighty-one percent of participants with available CD4+ cell counts at baseline had AIN of any grade; 52% had AIN 2 or 3; and 95% had anal HPV infection. In multivariate analysis, detection of > or = 6 HPV types [odds ratio (OR), 36; 95% confidence interval (CI), 7.4-171) and use of HAART (OR, 10; 95% CI, 2.6-38) were associated with AIN after adjustment for length of time participants were HIV-positive, CD4+ cell count and HIV viral load.

CONCLUSIONS

The prevalence of AIN has remained high among HIV-positive MSM after the introduction of HAART. Our data indicate that HAART is not associated with a reduced prevalence of AIN and support measures to prevent anal cancer among HIV-positive MSM whether or not they are using HAART.

Human papillomavirus-related cervical and anal disease in HIV-infected individuals in the era of highly active antiretroviral therapy

HIV-infected men who have sex with men remain at high risk of developing anal cancer despite the widespread use of highly active antiretroviral therapy (HAART). In HIV-infected women, however, there is some evidence that HAART may be associated with regression of human papillomavirus (HPV)-related cervical disease. So far, epidemiologic data provided by cancer registries have shown no reduction in the incidence of cervical and anal cancer in patients with HIV infection since the initiation of HAART in 1996. Recent data suggest that HPV infection occurs in the anal canal of immunocompromised patients, as an opportunistic infection, in the absence of receptive anal intercourse. Taken together, these lines of evidence support the need for developing anal and cervical cancer screening programs for patients with HIV, whether untreated or on HAART.

Management of cervical premalignant lesions

Management of cervical preneoplasia starts with an abnormal smear result. The use of the Bethesda system is recommended. The management of patients with low-grade abnormal smear results varies around the world. Patients with atypical squamous cells on cytology are recommended to be subclassified into atypical squamous cells of undetermined significance (ASCUS) and atypical squamous cells where high-grade squamous intra-epithelial lesions (HSIL) cannot be excluded (ASCH) groups. While patients with ASCUS can be followed with cytology or colposcopy, the risk of having cervical intra-epithelial neoplasia (CIN) is higher in patients with ASCH. Such patients, as well as those with low-grade squamous intra-epithelial lesions on cytology, should be referred for colposcopy to ensure that diagnosis and treatment in CIN is detected. Patients with HSIL should be referred promptly for colposcopic assessment. This should, usually at the same clinic visit, be followed by large loop excision of the transformation zone (LLETZ). Although this is effective treatment, around 15% of patients will have persistent/recurrent disease on cytological follow-up. Patients with positive human papillomavirus DNA tests at follow-up seem to have a considerably higher risk of recurrent preneoplasia than those who have negative tests. Patients over 50 years of age have much higher recurrence risks than younger patients. These factors impact on second-line treatment and follow-up schedules. An important benefit of conservative treatment for CIN with LLETZ is retention of fertility. LLETZ is associated with an increased risk of preterm prelabour rupture of membranes and preterm birth, but not with other adverse pregnancy outcome measures. Conservative excisional management of adenocarcinoma in situ by LLETZ or cold knife cone biopsy is not reported to be as effective as that of CIN, with high risk of residual and recurrent disease at follow-up. Conversely, LLETZ may be acceptable treatment for micro-invasive squamous carcinoma if the excision margins are free of disease and there is no evidence of lymphovascular involvement. The ability to detect and treat premalignant lesions on the cervix reversed the natural history of cervical cancer. Methods of conservative treatment that evolved over decades have been proven safe and effective, allowing retention of fertility. Good clinical guidelines have been developed for most clinical scenarios while some uncertainties persist for other scenarios.

Management and outcome of cervical intraepithelial neoplasia lesions: a study of matched cases according to HIV status

OBJECTIVES

To assess whether adequate strategies are used for the management of cervical intraepithelial neoplasia (CIN) in HIV-positive patients.

METHODS

SETTING

Retrospective study in a HIV reference university hospital. Sixty-eight HIV-infected patients who had undergone a cervical biopsy between January 1995 and March 2002 were matched for CIN and age with HIV-negative patients.

OUTCOME

Assess mean of treatment strategy. Assess mean of treatment failure by immediate follow-up PAP smear and recurrence rate by long-term follow-up smears.

RESULTS

Both groups of patients received similar treatments for their cervical anomalies. HIV-positive women were two times more likely to have involved margins after conisation than HIV-negative women (P < 0.01). Globally, two thirds of HIV-negative patients had a first follow-up PAP smear that was normal, while this was the case in only one third of HIV-positive women. These proportions were also significantly different after conisation (P < 0.01). The same differences were also observed after sustained follow-up. HIV-infected women who showed a recurrence of dysplasia were more likely to have failed antiviral therapy (9/44) than those without any recurrence (7/12) (P < 0.01).

CONCLUSIONS

Higher rates of recurrence were observed among HIV-infected women, indicating that CIN management is more difficult and may require adapted guidelines in HIV-positive patients. In HIV-infected patients, an association was found between the absence of recurrence and a viral response to antiviral therapy.

Antitumour effects of antiretroviral therapy

Infection by human immunodeficiency virus (HIV) is associated with an increased risk of certain tumours, particularly Kaposi's sarcoma, non-Hodgkin's lymphomas and cervical cancer. However, the incidence of these tumours in HIV-infected patients has decreased significantly since the widespread use of highly active antiretroviral therapy (HAART). This effect cannot be solely explained by the ability of these drugs to suppress HIV replication and thereby reconstitute the immune system. Recent studies have shown that inhibitors of the HIV aspartyl protease, which are widely used in HAART, have direct anti-angiogenic and antitumour effects that are unrelated to their antiviral activity. So these drugs might be used to treat cancer in patients who are not infected with HIV.

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.

Abnormal Vaginal Cytology in HIV-Infected and At-Risk Women After Hysterectomy

OBJECTIVE

To determine the frequency of and risk factors for abnormal vaginal Papanicolaou smears in HIV-infected women after hysterectomy.

METHODS

Data were from the HIV Epidemiology Research (HER) study, a prospective multisite study of HIV-infected and uninfected women. Semiannual vaginal Papanicolaou smears and colposcopy data were obtained from 102 HIV-infected and 46 at-risk women who had hysterectomy either before or during the study. Analytic models used include Cox proportional hazards (women with hysterectomy during the study) and multiple logistic regressions, which corrected for repeated measures (all women).

RESULTS

Among the HIV-infected women, evidence of cervical intraepithelial neoplasia before or at hysterectomy was associated with abnormal cytology during follow-up; 63% had squamous intraepithelial lesions (SIL) on vaginal Papanicolaou smears following hysterectomy. CD4 counts of <200 cells/microL at hysterectomy and HIV viral load of >10,000 copies/mL at hysterectomy were predictive of SIL vaginal cytology. Prevalent SIL vaginal cytology was associated with low CD4 count and human papillomavirus risk type. Of the 102 HIV-infected women, 16 (16%) had vaginal intraepithelial neoplasia on biopsy.

CONCLUSIONS

The high rate of SIL on vaginal Papanicolaou smears and the presence of high-grade vaginal intraepithelial neoplasia among HIV-infected women after hysterectomy demonstrate the need for continued follow-up for lower genital tract lesions.

Antiretroviral therapy and the clinical evolution of human papillomavirus-associated genital lesions in HIV-positive women

The effect of antiretroviral therapy on the natural history of human papillomavirus (HPV)-associated genital lesions was evaluated in 201 human immunodeficiency virus (HIV)-infected women who were followed-up for 1-6 years. Gynecologic examinations were performed every 6-12 months. HPV sequences in cervico-vaginal cells, analyzed by polymerase chain reaction and typed by restriction fragment-length polymorphism analysis, were repeatedly detected in 126 women; 29 had transient HPV infection. Genital lesions were found in 137 patients; prevalence was comparable in women who were receiving different antiretroviral regimens. Regression of low-grade lesions was more prevalent among patients receiving highly active antiretroviral therapy than among those receiving other regimens; high-grade lesions regressed in the majority of cases, regardless of antiretroviral therapy. HPV infection persisted in nearly 80% of the cases. In conclusion, our data show that antiretroviral therapy does not prevent the development of HPV-associated lesions and does not eliminate HPV infection; therefore, early and strict gynecologic follow-up of HIV-infected women is warranted.

The Impact of HIV Antiviral Therapy on Human Papillomavirus (Hpv) Infections and Hpv-Related Diseases

Human papillomavirus (HPV) infections play an important role in the pathogenesis of anogenital cancer and its precursors. HIV-infected individuals exhibit a high prevalence of HPV DNA. Several studies have further shown that HIV-infected individuals have an increased prevalence of squamous intraepithelial lesions (SIL) of the cervix, vulva and anus. The incidence of invasive cervical cancer is also elevated in HIV-positive women as well as that of anal cancer in HIV-positive women and men. Given the relationship between HIV-induced immunosuppression and HPV-associated disease, treatment with highly active antiretroviral therapy (HAART) has the potential, through immune reconstitution of the host, to alter the natural history of HPV infection and SIL. However, data on the impact of HAART on HPV disease are sparse and mixed results have been reported.

Cervical human papillomavirus infection and cervical intraepithelial neoplasia in women positive for human immunodeficiency virus in the era of highly active antiretroviral therapy

PURPOSE OF REVIEW

Human papillomavirus (HPV) has been strongly implicated in the pathogenesis of cervical intraepithelial neoplasia (CIN) and cervical cancer. Women who are positive for the human immunodeficiency virus (HIV) have been shown to be at increased risk for cervicovaginal HPV infection and CIN, and cervical cancer is an acquired immunodeficiency syndrome-defining illness. The purpose of this review is to summarize recent studies of cervical HPV infection and CIN in HIV-positive women and to describe the effect of highly active antiretroviral therapy (HAART) on the course of CIN.

RELEVANT FINDINGS

HIV-positive women have a higher prevalence of cervical HPV infection than HIV-negative women, and HPV infection is more persistent in the HIV-positive population. The incidence of high-grade CIN is increased in HIV-positive women. HAART has not been shown to affect HPV detection, and data on its effect on the natural history of CIN are mixed. Some studies show no effect of HAART on the natural history of CIN, and others show a statistically significant but modest beneficial effect.

SUMMARY

Cervical HPV infection and CIN are clearly increased in HIV-positive women when compared with risk-matched HIV-negative women. HAART appears to have limited ability to clear HPV infection and induce regression of CIN in HIV-positive women. Combined with the high prevalence of cervical HPV infection and CIN, current data suggest that CIN should be aggressively sought and treated in HIV-positive women, including those who have responded well to HAART with good HIV viral load suppression and increasing CD4+ levels.

Gender differences and sex-specific manifestations associated with human immunodeficiency virus infection in women

The rapidly growing rates of human immunodeficiency virus (HIV) infection among women has prompted many challenging issues related to the management and consequences of HIV and its complications in this population. This paper reviews the current evidence with regard to various aspects of HIV infection in women. Special emphasis is placed on gender-differences as well as sex-specific manifestation of this disease, including epidemiology, viral load determination and disease progression, related morbidity, and anti-retroviral therapy. It is concluded that current advances in the understanding of HIV infection among women may lead to further refinement and optimization efforts in the management of HIV-infected women.

Human Immunodeficiency Virus Infection: A Focus on Women

Nearly half of all HIV infections worldwide occur in women, and 20% of AIDS cases in the United States are women. Differences in HIV virologic and immunologic markers occur between men and women and have been studied to determine the effect on disease progression, mortality, and treatment. Certain adverse clinical events associated with highly active retroviral therapy (HAART), such as drug rashes and lipodystrophy, may affect women more than men. Depressive symptoms and low mental health quality of life occur commonly in HIV-infected women and can influence whether a woman will use HAART. Substance abuse among HIV-infected women is common, which can play a factor in coinfection rate with other infectious diseases and adherence to therapy. Also, HIV-infected women are at risk for increased severity and prevalence of human papillomavirus, which can be associated with cervical cancer. As demographics of HIV infection change, medical, psychological, and social problems must be addressed.

Cervical neoplasia and the HIV-infected patient

HPV infection and cervical dysplasia occur more frequently in HIV-infected women. All HIV-infected women should be screened at least annually for cervical cancer with cervical cytology. All patients with any abnormality in the Pap smear should be referred for colposcopic evaluation. Patients with documented high-grade dysplasia should be treated. All patients must be observed closely after treatment for recurrence. Treatment with agents such as imiquimod or 5-FU may help to decrease recurrence rates. Patients who are diagnosed with cervical cancer should be treated with surgery or concurrent chemotherapy and radiation as determined by extent of disease and health status. It appears that HAART may have a positive impact on cervical dysplasia and cancer. Thus, all HIV-infected patients should be managed optimally on HAART. Hopefully, as patients live longer and healthier on HAART, they will be more compliant with cervical cancer screening, and cervical cancer will become an increasingly rare disease.

Factors affecting abnormal Pap smear follow-up among HIV-infected women

Women with HIV infection are at least 10 times more likely to have an abnormal Pap smear than women who are HIV negative. Unfortunately, many women with HIV do not return for care after an abnormal Pap smear. Through the use of focus groups and individual interviews, HIV-positive women's experiences with abnormal Pap smears and the factors that affected whether they returned for care were explored. Two thirds of the 18 participants were minority women, and the average age was 40. Using techniques of constant comparative analysis, five factors were identified that affected whether women came back for care. These factors included fear, the asymptomatic nature of the problem, life circumstances, the participant's perspectives on health, and the health care provider. The findings from this study have implications for clinical practice and future research regarding adherence and abnormal Pap smear follow-up among women with HIV.

Highly active antiretroviral therapy enhances regression of cervical intraepithelial neoplasia in HIV-seropositive women

OBJECTIVE

This study was undertaken to investigate the impact of highly active antiretroviral therapy (HAART) on the regression of cervical intraepithelial neoplasia (CIN) in HIV-infected women.

DESIGN

Prospective study of 168 HIV-infected women with evidence of CIN until regression to a lower grade or to normality (end-point) or until surgical treatment or last visit. Ninety-six patients received HAART.

METHODS

Women were examined every 6 months by Papanicolaou smears, colposcopy, and biopsy if required. The probability of CIN regression was calculated using survival analysis. HAART was entered as a time-dependent covariate according to the date of first prescription.

RESULTS

Regression of CIN was observed in 67 (39.9%) women. The probability of regression at 12 months was significantly higher for high-grade CIN [23.8%; 95% confidence interval (CI), 14.2-33.5] than for low-grade lesions (14.8%; 95% CI, 7.0-22.6) (P = 0.04). The risk of regression of CIN was twice as high in women receiving HAART as compared with women not receiving HAART (relative hazard of regression, 1.93; 95% CI, 1.14-3.29). There was a trend for a larger increase in CD4 cell counts among those women taking HAART and who showed regression as compared with those who did not regress.

CONCLUSION

The positive impact of HAART on CIN regression may be associated with some restoration of specific immune reactivity. This is not sufficient enough, however, to modify the gynecological follow-up of HIV-infected women.

Recrudescence of cervical dysplasia among women who are infected with the human immunodeficiency virus: a case-control analysis

OBJECTIVE

The purpose of this study was to compare the recurrence rates of cervical dysplasia after ablation therapy and hysterectomy for women who are positive for the human immunodeficiency virus and for women who are negative for the human immunodeficiency virus.

STUDY DESIGN

Forty-three women who were positive for the human immunodeficiency virus were compared with 103 patients who were negative for the human immunodeficiency virus after cryotherapy, laser ablation, loop electrosurgical excision procedure, conization, and hysterectomy for cervical dysplasia. All patients were followed up for at least 24 months. Patients with preexisting cervical cancer or with positive margins after treatment were excluded.

RESULTS

Recurrence was higher in the HIV positive group for all modalities (73% vs 27%; P =.019). Higher recurrence rates were seen with CD4 counts <200 cells/mm3 (55% vs 26%).

CONCLUSION

Hysterectomy fared better than standard therapy (50% vs 86%), but recurrences were significant.

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.