Compared to the general population, HIV-positive women have a high risk of cervical cancer and thus are advised to undergo more frequent screening tests. This creates a burden for HIV-positive patients and the health care system, leading to frequent biopsies, which often do not reveal clinically relevant disease.
A new study by researchers at Albert Einstein College of Medicine of Yeshiva University suggests that HIV-positive women may be able to use new methods that can help to safely reduce the frequency of screening in some women, similar to practices accepted in the general population. The findings will be published in the July 25 issue of the Journal of the American Medical Association (JAMA), a theme issue on HIV/AIDS.
Howard Strickler, M.D., M.P.H., professor of epidemiology and population health at Einstein and senior author of the study, presented the findings July 22 at a JAMA media briefing at the International AIDS Conference.
As of 2009, 1.2 million people age 13 and older were living with HIV in the United States, according to the Centers for Disease Control and Prevention. Women accounted for about one-quarter of those infected.
In March 2012, the United States Preventive Services Task Force revised its cervical cancer screening guidelines for HIV-negative women aged 30 or older to once every five years from once every three years provided they have a normal Pap smear test and a negative test for human papillomavirus (HPV), the virus mainly responsible for cervical cancer. The Pap test detects precancerous or cancerous changes in the cervical lining and the HPV test detects cancer-associated types of the virus.
But those guidelines did not update screening recommendations for HIV-positive women. Current recommendations for HIV-positive women are to have two Pap tests, at six-month intervals, in the first year following diagnosis of HIV and, if normal, on an annual basis from then on. HPV testing is not currently recommended for HIV-positive women.
The current study looked at whether cervical cancer screening could be reduced in HIV-positive women who have a normal Pap test and a negative test for HPV. The Einstein researchers reasoned that for women with a normal Pap test and no evidence of cervical HPV infection, the risk of cervical precancer or cancer is likely to be very low for several years regardless of HIV status.
"It is widely thought that before cervical precancer or cervical cancer can develop, there must be persistent infection by a cancer-associated HPV, as well as the accumulation of additional genetic changes over time," said Dr. Strickler.
The study analyzed data on 420 HIV-positive and 279 HIV-negative women who were enrolled in the Women's Interagency HIV Study (WIHS), the largest prospective study of HIV-positive women in the US. (Montefiore Medical Center, the University Hospital for Einstein, is one of the six clinical sites for WIHS.) At enrollment, each woman had a normal Pap test and tested negative for the cancer-related HPV types. The women's rates of cervical precancer and cancer were measured after three- and five-years of follow-up.
At both the three- and five-year screening intervals, the incidence of cervical precancer was found to be similar in both HIV-positive and HIV-negative women. No cases of cervical cancer were detected in either group.
"Overall, few cases of cervical precancer would have gone undiagnosed if the HIV-positive women did not have any additional Pap tests during the five years following enrollment -- no more than in the HIV-negative group," said lead author Marla Keller, M.D., associate professor of medicine and of obstetrics & gynecology and women's health at Einstein and attending physician, medicine at Montefiore. "Thus, these data raise the possibility that HPV and Pap co-testing could be used to reduce the burden of frequent Pap tests and, by extension, unnecessary biopsies in HIV-positive women who are in long-term clinical follow-up."
Other contributors include Robert Burk, M.D.; Xianhong Xie, Ph.D.; Kathryn Anastos, M.D.; and Xiaonan Xue, Ph.D., all at Einstein; L. Stewart Massad, M.D. (Washington University School of Medicine, St. Louis, MO); Howard Minkoff, M.D. (Maimonides Medical Center, Brooklyn, NY); Gypsyamber D'Souza, Ph.D. (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); D. Heather Watts, M.D. (National Institute of Child Health and Human Development, Bethesda, MD); Alexandra Levine, M.D. (City of Hope National Medical Center, Duarte, CA); Philip Castle, Ph.D. (American Society for Clinical Pathology, Washington, DC); Christine Colie, M.D. (Georgetown University Medical Center, Washington, DC); and Joel Palefsky, M.D. (University of Southern California, San Francisco, CA).
The study was funded by several grants from the National Institutes of Health, including from the National Cancer Institute (CA085178), the National Institute of Allergy and Infectious Diseases (AI079763 and AI51519), the Eunice Kennedy Shriver National Institute of Child Health & Human Development (HD32632), and the National Center for Research Resources (RR024131 and RR025750).
Materials provided by Albert Einstein College of Medicine of Yeshiva University. Note: Content may be edited for style and length.
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