Drs. Abercrombie and Korn raise critical concerns regarding the need for vigilant monitoring and early intervention to prevent cervical intraepithelial neoplasia in human immunodeficiency virus (HIV)-infected women who have concomitant human papillomavirus (HPV) infection. The evidence is clear that women with HIV are at risk of both more virulent HPV infections and more rapid progression from infection to neoplasia. The authors underscore another critical finding: Women with HIV are at increased risk of developing noncervical condylomas, which are more difficult to detect by standard screening mechanisms and more difficult to treat with standard therapies.
Dearth of Management Recommendations
The dearth of recommendations for primary caregivers of women with concurrent HPV and HIV is discouraging and needs redress. Particularly in rural states, health care for HIV-infected women is often provided by a primary physician or nurse practitioner in consultation with an HIV specialist or immunologist at a distant medical center. Because HIV is beginning to be managed as chronic illness, aggressive treatment and screening are not consistently recommended for these women. Moreover, the classic problems for HIV-infected women of poverty, lack of social support, and inadequate access to care (or even information), remain the greatest barriers to the provision of aggressive strategies to prevent disease progression.
A major dissonance exists between what we know from research and what we can realistically expect to see in practice. There has been some inconsistency in the literature about recommendations for the frequency of Pap smears in HIV-infected women. Research conducted by Drs. Abercrombie and Korn suggests that even the most vigilant monitoring of Pap smears may be inadequate, and that colposcopy and careful examination of the lower genital tract are critical components of early detection efforts.
Creating a More Vigilant Management Approach
The question remains: How do we take this comprehensive review, which convincingly raises concerns regarding early and sustained management, and create a more vigilant clinical approach to managing women with HIV/HPV infections? Several suggestions come to mind: First, recommendations from the Centers for Disease Control (CDC) and the American College of Obstetrics and Gynecology need to be updated to reflect changes in our knowledge of the virulence of HPV in the immunocompromised woman. Furthermore, practitioners need to be made aware of the efficacy of vigilant, continued treatment in preventing progression to invasive cancer. Finally, a focus on better education of primary providers is warranted; one that both raises clinicians’ consciousness about the benefits of early, consistent treatment and integrates specific skills for assessment of HPV in the immunosuppressed patient.
One of the most critical aspects of research is dissemination; ie, getting the information out of the specialist literature and communicating it to the generalist practitioner. I encourage Abercrombie and Korn to widely disseminate the information contained in their review. It is critical that first-line practitioners become more aware of HIV-infected women’s increased vulnerability to virulent HPV infection and lower genital tract neoplasia.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
