monitoring of earlier-stage cervical abnormalities (CIN-2) may be preferable to
treatment for many women with HIV, a US study suggests. The findings, presented
at the Conference on Retroviruses and Opportunistic Infections (CROI 2017) in Seattle on
Tuesday, show that CIN-2 regressed in over three-quarters of women taking
antiretroviral therapy (ART), without the need for treatment. A higher CD4 count was
associated with a lower likelihood that the lesion would progress.
Cervical cancer is one of the most common causes of death
and illness in women globally. Women with HIV, especially those with lower CD4
cell counts, are at increased risk of developing cervical intra-epithelial
neoplasia or lesions (CIN) – changes in the cells of the cervix, sometimes
referred to as 'pre-cancerous' cell changes. The risk of developing CIN is
associated with infection with human papillomavirus (HPV),
which is present in more than 60% of women with HIV.
Lesions are graded according to severity. Many cases of
CIN-1 and some cases of CIN-2 will clear up without treatment, but the rate of
regression or progression is unclear in women living with HIV. In the general
population, CIN-2 is regressive in 30 to 40% of women, but women with HIV have
had lower rates of regression in previous studies. Regardless of HIV status,
women over the age of 25 are advised to have treatment for CIN-2.
Treatment can include surgically removing affected tissue. While this prevents progression to cervical
cancer, recent research has suggested such treatment can affect reproductive health, potentially leading to premature birth and
complications during pregnancy.
Around 8500 women with HIV give birth annually in the United States. Dr Kate Michel, presenting, noted that it is important to
provide guidance for those women with HIV who may delay CIN-2 treatment to
improve pregnancy outcomes.
and colleagues wanted to ascertain the risk of CIN-2 progression in women of reproductive age, including time to progression and
factors associated with progression, with CD4 cell count and HIV viral load
analysed as time-dependent covariates. The study included both women who had previously been treated for CIN-2 and those who had not.
Women under the age of 46 were included from the observational
Women’s Interagency HIV Study (WIHS). The study, begun in 1993, looks at the impact
and progression of HIV in women in clinical sites in and around ten
cities in the United States. It includes women living with HIV and women identified as being at high risk of HIV. A total of 116 women with biopsy-confirmed
CIN-2 were included in the study. Of these, 102 were HIV positive (41 had previously had CIN-2 treatment) and 14 were HIV negative (8 had previously been treated).
With a mean age
of 32 years, the majority of women were black or Hispanic, just over half
were smokers and 72% had one male partner. Women with HIV
were on average five years older than HIV-negative women.
regression, defined as biopsy-confirmed CIN-1 or no abnormalities detected by
biopsy or normal Pap (cervical screening) tests across all follow-up visits, was overall (63%) the
most common prognosis, independent of treatment, occurring in 62% and 71% of
HIV-positive and HIV-negative women respectively.
Combination ART was associated with a significant 78% decrease in
CIN-2 progression. Similarly each increase of 100 CD4 cells/mm3 was associated with
a significant 26% decrease in progression.
Seventeen per cent more
HIV-negative women had treatment for CIN-2 than HIV-positive women. Dr
Michel noted that this gap, while not statistically significant, warrants further
examination of reproductive health access for women with HIV.
Overall 18% of
women progressed to CIN-3 or dysplasia over a median of ten years (18%
HIV-positive and 21% HIV-negative women. Median time to progression in HIV-positive
women was three years (IQR: 2.4-3). No women progressed to cervical cancer.
concluded that for women with HIV considering pregnancy and with well-controlled
viral load on ART, a short-term conservative management of CIN-2 with close
monitoring provides an alternative to immediate surgery.