SAN DIEGOAIDS experts have long worried that human
immunodeficiency virus (HIV) infection might increase a womans
risk of cervical cancer, particularly in the presence of concurrent
human papillomavirus (HPV) infection.
Results of the Womens Interagency HIV study, reported at the 31st
annual meeting of the Society of Gynecologic Oncologists
(SGO), show that although most HIV-positive women have some abnormal
cervical cytology, progression to cancer is not necessarily accelerated.
Progression is more likely in patients who also have HPV infection
and/or poor immune status, such as CD4 cell counts less than 200
cells/mm³, said L. Stewart Massad, MD, of the Department of
Gynecologic Oncology, Cook County Hospital, Chicago.
Risk is related to HPV and degree of immunosuppression,
Dr. Massad told ONI in an interview. HIV-positive women with
good immune status and no HPV do as well as HIV-negative women, but
HIV-positive women with poor immune status and no HPV do worse.
Similarly, women with HPV do worse than women without HPV across all
groups of HIV status.
The study included data from 2,390 women at six US sites (1,860
HIV-positive women and 530 HIV-negative comparison women). The
investigators obtained cervical Pap smears, CD4 counts, and HIV RNA
measurements every 6 months over 3.5 years.
The cumulative risk of having an abnormal Pap smear during the study
period was significantly higher among the HIV-positive women than the
HIV-negative women (66.4% vs 33.4%, P < .01), but only
eight women, all of them HIV positive, developed cancer (see Table).
The adjusted relative risk of developing a low-grade squamous
intraepithelial lesion (LSIL) or higher among women who were both HIV
and HPV positive and whose CD4 counts were under 200 cells/mm³
was 12 (range, 6.5 to 22.2), compared to women with neither HIV nor HPV.
Multivariate analysis showed that HPV infection, HIV infection, low
CD4 count, and high HIV RNA level increased the risk of progression
(P <.01). Odds of progression were 4.1 times higher among
HIV/HPV-positive women with CD4 counts less than 200 cells/mm³
than among HIV/HPV-negative women.
The researchers concluded that abnormal cytology occurs in most
HIV-positive women followed for 3.5 years but that high-grade changes
The most important clinical message from our study is that risk
for abnormal Pap smear has to be determined on an individual basis.
Women who are HIV positive with good immune status have an outlook as
good as that of HIV-negative women with the same HPV status,
Dr. Massad said. Clinicians should continue to stick with the
CDC guidelines for cervical cancer screening and let HIV-positive
women know that cervical disease is not a relentless, hopeless
process leading to cancer.