HIV This Week

Denny L, Boa R, Williamson AL, Allan B, Hardie D, Stan R, Myer L. Human Papillomavirus Infection and Cervical Disease in Human Immunodeficiency Virus-1-Infected Women. Obstet Gynecol. 2008 Jun;111(6):1380-1387.

Denny et al report on the natural history of high-risk human papillomavirus (HPV) infection and cervical disease in human immunodeficiency virus (HIV)-1-infected women living in Cape Town, South Africa. They studied prospectively 400 untreated, HIV-1-infected women who underwent high-risk HPV DNA testing, cytology, colposcopy, histology, and CD4 count testing every 6 months for 36 months. Human immunodeficiency virus viral loads and HPV type distribution were determined at entry and after 18 months. Sixty-eight percent of the women were high-risk HPV DNA positive at entry, 35% had a cytologic diagnosis of low-grade squamous intraepithelial lesion (LSIL), and 13% had high-grade squamous intraepithelial lesion (HSIL). There were no cancers. Abnormal cytology and high-risk HPV positivity were strongly correlated with low CD4 counts and high HIV viral loads. The most prevalent types of HPV were HPV-16, -52, -53, -35, and -18. Incident high-risk HPV infection occurred in 22%, and of those infected with high-risk HPV, 94% of infections persisted over an 18-month period, and 6% cleared their infections. Cytologic progression to SIL from normal/atypical squamous cells of undetermined significance cytology occurred in 17% of cases, but only 4% of cases of LSIL progressed to HSIL. Denny et al concluded that there is a high level of high-risk HPV infection in HIV-1 infected women, but progression to HSIL over 36 months occurred in the minority of cases. They recommend an initial coloscopy for an abnormal test, and if no high-grade lesion is identified, triennial screening would be appropriate. Human papillomavirus type 16 was the commonest, and HPV-18 was the fifth commonest, suggesting that vaccination against these two types would have a significant effect. LEVEL OF EVIDENCE: II.

Editors’ note: These findings of high-risk HPV infection in more than two-thirds of 400 women living with HIV and abnormal cervical cytology in 55% of them at baseline in this 3 year study are concerning. The study found that HPV-associated disease was strongly influenced by immune status, as reflected in CD4 counts and viral loads, suggesting that antiretroviral treatment can play an important role in preventing progression to cervical cancer.