SAN DIEGOHuman immunodeficiency virus (HIV)-infected women from
the southeastern United States are more likely to have contracted HIV
through heterosexual contact, to be black, and to harbor multiple
subtypes of human papillomavirus (HPV) than are HIV-positive women
from other parts of the country, Ronald D. Alvarez, MD, said at the 31st
Annual Meeting of the Society of Gynecologic Oncologists (SGO).
Dr. Alvarez and his colleagues reported longitudinal data on the
epidemiology of HPV in HIV-infected women treated at a University of
Alabama at Birmingham HIV clinic that serves as a referral center for
the southeastern United States.
States with some of the highest AIDS rates are clustered in the
Northeast and in the South, but most HPV/HIV epidemiology studies
have been conducted in patients from large urban centers in the
Northeast, West, and Midwest, Dr. Alvarez told ONI in an
interview. He is professor of gynecologic oncology, University of
Alabama at Birmingham.
The study included 177 HIV-infected women from a predominantly rural
epicenter of HIV infection. Women were prospectively enrolled in the
study. They completed a detailed questionnaire and underwent complete
pelvic examination, Pap smear, and colposcopic examination.
Researchers tested the patients cervical vaginal lavage samples
by polymerase chain reaction (PCR) for the presence of HPV DNA,
screened patients for other sexually transmitted diseases, and
measured absolute CD4 cell counts and plasma HIV-1 RNA levels.
Examinations have been repeated every 6 months since the study began
in 1996, and 72% of patients have been followed for at least 1 year.
The median age of the study cohort was 37, and 69% were black; 84%
had at least a high school education, and 13% had college degrees.
Most of these women (85%) had contracted HIV through heterosexual
contact, Dr. Alvarez said.
At baseline, the median CD4 count was 436 cells/mm³; median
HIV-1 RNA level was 1,944 copies/mL (range, less than 25 to nearly
800,000); and median duration of HIV seropositivity was 49 months.
Most patients (84%) received some type of HIV-specific therapy at
some time during the study.
Fifty percent of patients had an abnormal Pap smear at study entry,
and throughout the 3-year study period, 56% had an abnormal Pap smear
at some point, Dr. Alvarez said. Most women (77 of 89) whose Pap
smears were normal at entry continued to have normal Pap smears.
Three quarters of the women had HPV DNA detected at some point in the
study, including 61% of the women who continued to have normal Pap
smears. HPV infection generally persisted in patients throughout the
Dr. Alvarez said that HPV analysis revealed several interesting
findings. These included the presence of a variety of HPV
types, most commonly types 6, 45, 52, 61, and 70. Interestingly,
HPV types 16 and 18 were noted in only 4% of the study
population, he said.
The researchers detected 28 previously unidentified HPV types in
study participants, and 42% of patients were infected with multiple
In this study, the most common HPV types, with the exception of
HPV 6, appear to be closely related to other HPV subtypes commonly
associated with high risk of developing high-grade cervical
dysplasia, Dr. Alvarez said.
The study suggested that use of more intensive antiretroviral therapy
regimens might be associated with clearance of HPV infection.
The burden of HIV infection is being increasingly borne by
women, Dr. Alvarez told ONI. The proportion of women
accounting for new AIDS cases rose from 7% in 1985 to 23% by 1998.
The increased risk of developing cervical neoplasia is of particular
concern in this growing population, and in 1993 the CDC recognized
cervical neoplasia as an AIDS-defining illness in HIV-positive women.
Dr. Alvarez described the population of HIV-infected patients drawn
from the University of Alabama at Birmingham clinic as
demographically unique. The prevalence of abnormal cervical
cytology and HPV infection is high in this population, infection with
multiple and novel HPV types is common, and HPV infection generally
He emphasized that studies of the epidemiology of HPV and cervical
neoplasia in HIV-infected women should include diverse patient
populations to present an accurate picture of the interactions
between these two infections.