Cervical dysplasia in HIV infected women in Maiduguri, Nigeria

Prevalence and Risk Factors of Cervical Dysplasia among Human Immunodeficiency Virus Sero-Positive Females on Highly Active Antiretroviral Therapy in Enugu, Southeastern, Nigeria

OBJECTIVE

Evaluation of prevalence and risk factors of cervical dysplasia among Human Immunodeficiency Virus sero-positive (HIV+ve) females on Highly Active Antiretroviral Therapy (HAART) attending HIV clinic at University of Nigeria Teaching Hospital (UNTH) Enugu, Southeastern, Nigeria.

METHODS

Structured questionnaire was used to obtain socio-demographic and risk factors data. Cervical specimens were collected from 105 HIV +ve females on HAART and 104 HIV seronegative (HIV-ve) females. Pap smears were collected using cytobrush and Ayre's spatula in a secluded place. Smears were made on slides and placed in 95% ethyl alcohol for conventional Pap staining and the cytobrush washed into the preservative containers for later Immunocytochemistry staining. Blood samples were used for HIV screening. Immunocytochemistry activity using anti-P16INK4A was carried out on the Pap smears that were positive for cervical dysplasia.

RESULTS

Pap staining showed prevalence of cervical dysplasia among HIV+ve on HAART 19.05%, (ASCUS 14.29%, LSIL 3.81%, HSIL 0.95%) whereas HIV-ve was 6.73%, p = 0.008. Only the HSIL 0.95% was positive for P16INK4A. Odds ratios at 95% Confident Interval of the risk factors of cervical dysplasia were thus; HIV+ve, 3.26 (1.31-8.09), education less than secondary school 3.23 (1.25-8.37), polygamy 3.23 (1.25-8.37), smoking 1.36 (0.15-12.10), married 2.08 (0.43-2.31), grand multi gravidity 1.72 (0.72-4.11), grand multi parity 1.54 (0.66-3.61), positive history of sexually transmitted diseases 2.49 (1.06-5.80). Uptake of cervical cancer screening was low in both study groups, 7 (6.7%) among HIV+ve on HAART and 14 (13.5%) among HIV-ve females, P = 0.102.

CONCLUSION

HAART had cytoprotective effect against cervical dysplasia in HIV+ve females, by reducing progression of ASCUS to LSIL, HSIL and cervical cancer. Progression from normal to ASCUS increased which could be due to latency or/and prolonged persistent high risk HPV and HIV infections, of the most sexually active age group before diagnosed of HIV.

Association between patient-reported HIV status and provider recommendation for screening in an opportunistic cervical Cancer screening setting in Jos, Nigeria

BACKGROUND

Cervical cancer screening (CCS) is an important health service intervention for prevention of morbidity and mortality from invasive cervical cancer. The role of provider recommendation and referral is critical in utilization of this services particularly in settings where screening is largely opportunistic. We sought to understand how patient-reported human immunodeficiency virus (HIV) infection status is associated with provider referral in an opportunistic screening setting.

METHODS

We performed a cross-sectional analysis of data on a sample of women who had received a CCS at the "Operation Stop" cervical cancer (OSCC) screening service in Jos, Nigeria over a 10-year time period (2006-2016). We used the de-identified records of women who had their first CCS to analyze the association between patient-reported HIV and likelihood of provider-referral at first CCS. We performed descriptive statistics with relevant test of association using Student t-test (t-test) for continuous variables and Pearson chi square or Fisher exact test where applicable for categorical variables. We also used a bivariable and multivariable logistic regression models to estimate the independent association of patient-reported HIV on provider referral. All statistical tests were performed using STATA version 14.1, College Station, Texas, USA. Level of statistical significance was set at 0.05.

RESULTS

During the 10-year period, 14,088 women had their first CCS. The reported HIV prevalence in the population was 5.0%; 95% CI: 4.6, 5.4 (703/14,088). The median age of women who were screened was 37 years (IQR; 30-45). Women who were HIV infected received more referrals from providers compared to women who were HIV uninfected (68.7% versus 49.2%), p-value < 0.001. Similarly, we found an independent effect of patient-reported HIV infection on the likelihood for provider-referral in the screened sample (aOR = 2.35; 95% CI: 1.95, 2.82).

CONCLUSION

Our analysis supports the design of health systems that facilitates providers' engagement and provision of necessary counseling for CCS in the course of routine clinical care. The practice of offering recommendation and referrals for CCS to women at high risk of cervical cancer, such as HIV infected women should be supported.

Noncommunicable diseases among HIV-infected persons in low-income and middle-income countries: a systematic review and meta-analysis

OBJECTIVE

To appropriately identify and treat noncommunicable diseases (NCDs) among persons living with HIV (PLHIV) in low-and-middle-income countries (LMICs), it is imperative to understand the burden of NCDs among PLHIV in LMICs and the current management of the diseases.

DESIGN

Systematic review and meta-analysis.

METHODS

We examined peer-reviewed literature published between 1 January 2010 and 31 December 2016 to assess currently available evidence regarding HIV and four selected NCDs (cardiovascular disease, cervical cancer, depression, and diabetes) in LMICs with a focus on sub-Saharan Africa. The databases, PubMed/MEDLINE, Cochrane Review, and Scopus, were searched to identify relevant literature. For conditions with adequate data available, pooled estimates for prevalence were generated using random fixed effects models.

RESULTS

Six thousand one hundred and forty-three abstracts were reviewed, 377 had potentially relevant prevalence data and 141 were included in the summary; 57 were selected for quantitative analysis. Pooled estimates for NCD prevalence were hypertension 21.2% (95% CI 16.3-27.1), hypercholesterolemia 22.2% (95% CI 14.7-32.1), elevated low-density lipoprotein 23.2% (95% CI 15.2-33.6), hypertriglyceridemia 27.2% (95% CI 20.7-34.8), low high-density lipoprotein 52.3% (95% CI 35.6-62.8), obesity 7.8% (95% CI 4.3-13.9), and depression 24.4% (95% CI 12.5-42.1). Invasive cervical cancer and diabetes prevalence were 1.3-1.7 and 1.3-18%, respectively. Few NCD-HIV integrated programs with screening and management approaches that are contextually appropriate for resource-limited settings exist.

CONCLUSION

Improved data collection and surveillance of NCDs among PLHIV in LMICs are necessary to inform integrated HIV/NCD care models. Although efforts to integrate care exist, further research is needed to optimize the efficacy of these programs.

Highly active antiretroviral therapy and cervical cytologic abnormalities among women with HIV infection in a limited-resource setting

OBJECTIVE

To examine the relationship between highly active antiretroviral therapy (HAART) and cervical cytologic abnormalities among women with HIV infection.

METHODS

A cross-sectional prospective study was undertaken of 110 women attending an HIV clinic in Nnewi, Nigeria, between January 2016 and January 2017. A cervical smear was obtained. A bivariate analysis was undertaken, and multiple logistic regression models were used to identify factors independently associated with cervical cytologic analysis.

RESULTS

Cervical cytologic abnormalities were identified in 31 (28.2%) participants. On bivariate analysis, use of HAART for 2-5 years was associated with a reduction in the risk of cervical cytologic abnormalities (P=0.033), and this risk was further reduced when HAART was taken for more than 5 years (P<0.001). Other factors that significantly reduced risk of cervical cytologic abnormalities included a CD4 count of 300 cells per mL or more (P<0.001), age 30 years or older (P<0.001), and time since HIV diagnosis of more than 5 years (P=0.021). On multivariate analysis, risk of cervical cytologic abnormalities among the women were significantly reduced by use of HAART for more than 5 years (P=0.032) and CD4 count of 300 cells per mL or more (P<0.001).

CONCLUSION

Long-term use of HAART and CD4 count of 300 cells per mL or more were associated with a reduced risk of cervical cytologic abnormalities.

The association between HIV infection, antiretroviral therapy and cervical squamous intraepithelial lesions in South Western Nigerian women

Introduction

Findings from studies that evaluated the effect of antiretroviral drug use on the development of cervical squamous intraepithelial lesion differed in their conclusions. This study investigated the association between HIV infection, antiretroviral drug use and cervical squamous intraepithelial lesion in a high HIV and cervical cancer burden setting- Nigeria.

Methods

A cross sectional study among 1140 women of known HIV status enrolled in a randomised study to determine the test characteristics of visual inspection in detecting cytology diagnosed squamous intraepithelial lesion. Multivariate analysis was used to determine the association between HIV infection, antiretroviral drug use and the twin outcome variables of cervical squamous intraepithelial lesion (SIL) and High grade squamous intraepithelial lesion (HSIL) while controlling for confounders.

Results

Prevalence of cervical squamous intraepithelial lesion was 8.5%, with a higher prevalence of 14.3% in HIV positive compared to 3.3% in HIV negative women (aOR: 5.4; 95% CI: 2.9–8.8). Not using antiretroviral drugs was found to be associated with an increased risk of SIL (aOR: 2.1; 95% CI: 1.4–3.5) and HSIL (aOR: 2.6; 95% CI: 1.1–6.4). Participants who had a CD4 cell count <200 cells/mm³, were also found to be at increased risk for SIL (aOR: 1.9; 95% CI: 1.1–5.9) and HSIL (aOR: 5.7; 95% CI: 1.1–7.2).

Conclusion

HIV infection and severe immunosuppression were found to be associated with increased risk of cervical squamous intraepithelial lesion but not viral load. For the first time, in the West African sub-region with specific HIV type and strains, we established the protective effect of antiretroviral drug use against the development of SIL. Integration of cervical cancer screening programme into HIV services and early initiation of antiretroviral drug in HIV positive women especially those with severe immune-suppression could therefore prove to be useful in preventing and controlling cervical cancer development in HIV positive women.

Abnormal cervical cytology among HIV-positive women in Nigeria

OBJECTIVE

To determine the prevalence of abnormal cervical smears and high-grade lesions among HIV-positive and HIV-negative women, and to assess the relationship between severity of disease and CD4 count.

METHODS

In a prospective cross-sectional comparative study, 250 HIV-positive and 250 HIV-negative women attending the University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria, were enrolled between January and March 2012. Cervical smear samples were collected from participants, examined, and reported via the Bethesda system. Data management and analysis was done with SPSS. Differences between the 2 study groups were determined by χ2 test and Student t test.

RESULTS

The prevalence of abnormal cervical smears was significantly higher among HIV-positive women (34.4%) than among HIV-negative women (20.2%) (P<0.01). The proportion of high-grade lesions was significantly higher among HIV-positive women (23.5%) than among HIV-negative women (8.2%) (P=0.025). HIV-positive women with a CD4 count below 500 cells/mm3 had significantly more abnormal cervical smears (28.3%) compared with those with a CD4 count of 500 cells/mm3 or more (6.1%) (P=0.04).

CONCLUSION

HIV-positive women were found to be at significantly greater risk of developing abnormal cervical cytology and high-grade lesions compared with HIV-negative women.

The burden, distribution and risk factors for cervical oncogenic human papilloma virus infection in HIV positive Nigerian women

BACKGROUND

The expected reduction in cervical cancer incidence as a result of increased access to antiretroviral therapy is yet to be seen. In this study we investigated the effect of HIV infection and treatment on high-risk (hr) human papilloma virus (HPV) prevalence and distribution.

METHODS

Cervical cells from 515 (220 HIV positive and 295 HIV negative) women, recruited during community cervical cancer screening programme in states of Ogun and Lagos and at the cervical cancer screen clinic, Nigerian Institute of Medical Research Lagos were evaluated for the presence of 13 hr HPV genotypes by polymerase chain reaction based assay.

RESULTS

The prevalence of high-risk HPV was 19.6% in the studied population. HPV 16 (3.9%), 35 (3.5%), 58 (3.3%) and 31 (3.3%) were the most common hr HPV infections detected. We observed that the prevalence of hr HPV was higher in HIV positives (24.5%) than 15.9% in HIV negative women (OR = 1.7; 95% CI: 1.1-2.7). A multivariate logistic regression analysis showed a lower hr HPV prevalence in HIV positive women on antiretroviral drugs (OR = 0.4; 95% CI: 0.3-0.5) and with CD4 count of 500 and above (OR = 0.7; 95% CI: 0.5-0.8). A higher prevalence of hr HPV was also noted in HIV positive women with CD4 count < 200 cells/mm³ (OR = 2.4; 95% CI: 1.7-5.9).

CONCLUSION

HPV 16, 35, 58 and 31 genotypes were the most common hr HPV infection in our study group, which could be regarded as high risk general population sample; with higher prevalence of HPV 16 and 35 in HIV positive women than in HIV negative women. The use of antiretroviral drugs was found to be associated with a lower prevalence of hr HPV infection, compared to those not on treatment. This study raises important issues that should be further investigated to enable the development of robust cervical cancer prevention and control strategies for women in our setting.

Willingness and acceptability of cervical cancer screening among HIV positive Nigerian women

Background

The proven benefit of integrating cervical cancer screening programme into HIV care has led to its adoption as a standard of care. However this is not operational in most HIV clinics in Nigeria. Of the various reasons given for non-implementation, none is backed by scientific evidence. This study was conducted to assess the willingness and acceptability of cervical cancer screening among HIV positive Nigerian women.

Methods

A cross sectional study of HIV positive women attending a large HIV treatment centre in Lagos, Nigeria. Respondents were identified using stratified sampling method. A pretested questionnaire was used to obtain information by trained research assistants. Obtained information were coded and managed using SPSS for windows version 19. Multivariate logistic regression model was used to determine independent predictor for acceptance of cervical cancer screening.

Results

Of the 1517 respondents that returned completed questionnaires, 853 (56.2%) were aware of cervical cancer. Though previous cervical cancer screening was low at 9.4%, 79.8% (1210) accepted to take the test. Cost of the test (35.2%) and religious denial (14.0%) were the most common reasons given for refusal to take the test. After controlling for confounding variables in a multivariate logistic regression model, having a tertiary education (OR = 1.4; 95% CI: 1.03-1.84), no living child (OR: 1.5; 95% CI: 1.1-2.0), recent HIV diagnosis (OR: 1.5; 95% CI: 1.1-2.0) and being aware of cervical cancer (OR: 1.5; 95% CI: 1.2-2.0) retained independent association with acceptance to screen for cervical cancer.

Conclusions

The study shows that HIV positive women in our environment are willing to screen for cervical cancer and that the integration of reproductive health service into existing HIV programmes will strengthen rather than disrupt the services.

Cervical dysplasia in Nigerian women infected with HIV

OBJECTIVE

To determine the prevalence of and risk factors for cervical dysplasia in HIV-positive women receiving care at the Jos University Teaching Hospital in Nigeria.

METHODS

A total of 369 HIV-positive women had cervical cytology performed; HIV-1 RNA viral load and CD4 counts were measured.

RESULTS

Of 369 participants, cervical dysplasia was present in 107 (29.0%) women. However, cervical cytology was abnormal in 252 (68.3%). Among those with abnormal cytology, 145 (57.5%) women had ASCUS, 56 (22.2%) had LSIL, and 51 (20.2%) had HSIL. Median CD4 lymphocyte count was lower in women with dysplasia compared with those without (142 vs 170 cells/mm(3); P=0.04), while median HIV RNA viral load was higher in women with dysplasia (101781 vs 77479 copies/mL; P=0.002). Low CD4 count (<200 cells/mm(3)) and evidence of HPV infection were significantly associated with cervical dysplasia.

CONCLUSION

A high prevalence of cervical dysplasia was found among HIV-positive Nigerian women, which was associated with increased immune suppression.

Squamous dysplasia of the rectum in a patient with ulcerative colitis treated with 6-mercaptopurine

Human papilloma virus (HPV) has been found to be a precursor and risk factor for both cervical and anal dysplasia. Cervical dysplasia, which is the precursor to carcinoma, is associated with immunosuppression from a variety of causes; reports of anal dysplasia associated with immune suppression exist as well. A recent study published in abstract form only demonstrated that women with inflammatory bowel disease (IBD) had high rates of cervical dysplasia and that those on immune suppressants had even higher rates of dysplasia. We report a case of a 50-year-old woman with refractory ulcerative colitis chronically treated with 6-mercaptopurine that developed severe squamous dysplasia of the rectum. The dysplastic mucosa was found to be positive for p16 (associated with high-risk HPV) after immunostaining. A total colectomy was performed. This case highlights the importance of immune suppression in the development of dysplasia of the anus/cervix secondary to HPV infection.