February 24, 2005
Infection with human papillomavirus (HPV) is a significant cause of cervical dysplasia, anal dysplasia and cancer globally. The largest burden is seen in resource-limited settings, mostly due to the limited availability of screening and treatment options. Among HIV-infected individuals coinfected with HPV, the risk of both cervical and anal neoplasia is even higher than in HIV-uninfected individuals. Compared to the dramatic decline in other HIV-related complications due to effective antiretroviral therapy, the risks associated with HPV infection have remained elevated.
In addition, while screening for cervical disease in HIV-infected women has been a mainstay of recommended evaluations since early in the epidemic, there is growing recognition that women are also at risk for anal HPV infection with its associated dysplasia and neoplasia. Therefore, continued work is important to determine the optimal approaches for screening anal and cervical abnormalities among men and women living with HIV.
Thomas Young, from the University of California-San Francisco, and colleagues looked at the prevalence of cervical and anal dysplasia in 161 women undergoing care at San Francisco General Hospital's large HIV clinic between 2000 and 2004 (Abstract 900). Forty-eight percent of the women were on antiretroviral therapy at some point; the mean CD4+ cell count was 401 cells/mm3. While Young et al found 29% and 42% of women had abnormal cervical and anal Pap smears, respectively, low rates of high-grade squamous intraepithelial lesions were seen (4% in both anal and cervical Pap smears).
Using 214 cervical and anal Pap smear pairs (completed within 6 months of each other), the study found that 36% of women with normal cervical Pap smears had abnormal anal Pap smears. These data suggest that dysplasia remains a clinical issue for women in the highly active antiretroviral therapy (HAART) era, and that providers need to expand anal screening for women regardless of cervical screening results.
The study does leave some key questions unanswered, including the role of HPV screening, changes over time for women on effective HAART, the best technique and timing for anal dysplasia screening, and the optimal management of detected lesions.
In a related poster presentation (Abstract 901), French researcher Isabelle Heard and colleagues looked at the 2-year incidence of cervical intraepithelial neoplasia (CIN) among HIV-infected women. They found that 1 in 5 women with normal baseline Pap smears developed CIN within 2 years. However, 84% of incident CIN was low grade, with no invasive cancer detected during 867 person-years of follow-up. A higher risk was found in younger women (30 to 39 years versus older than 40 years), but in women who were on HAART, a 2-fold lower risk was noted.
These data remind us that cervical and anal dysplasia remain a clinical concern for women living with HIV, although the risk may be decreasing in the setting of HAART. While encouraging results for an effective HPV vaccine were presented in the plenary session on Feb. 25 by Kathrin U. Jansen (Abstract 126), the impact on HPV infection rates and the development of HPV-related neoplasia for people living with HIV remains to be defined.