Cervical Intraepithelial Neoplasia - Women With HIV
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 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.
Women infected with HIV are at increased risk of developing cervical intraepithelial neoplasia (CIN), a cervical cancer precursor. The risk of developing CIN is associated with infection with human papillomavirus (HPV), which is detected in more than 60% of HIV-infected women, and HIV-induced immunodeficiency. In immunocompetent HIV-seronegative women, recently published recommendations for the management of CIN call for expectant management of low-grade lesions and for surgical excision or ablation of high-grade CIN. Several studies have indicated a high rate of success of current treatment strategies for CIN in immunocompetent women. In contrast, failure of surgical treatment has been reported in HIV-positive women as well as an increased risk of recurrence of CIN. Recurrence rates were reported to be greater in women with low CD4 T-cell counts, reaching 87% at 3 years in severely immunocompromised women. Significant progress in HIV therapy has been achieved since these early studies were published, with the introduction and widespread use of highly active antiretroviral therapy (HAART), which has resulted in a dramatic decrease in AIDS-associated mortality and morbidity. The increase in life expectancy associated with HAART may provide opportunities for lesions to recur or to progress to invasive cervical carcinoma (ICC). Conversely, immune restoration associated with antiretroviral therapy could result in enhanced host immune responses and control of cervical neoplasia, potentially leading to excisional therapy being more effective for eradication of CIN.
In the present study, we examined the rate of persistence and/or recurrence of CIN in a group of HIV-infected women after standard surgical therapy, focusing on the impact of the modalities of surgical treatment and HAART on recurrence rates.