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Lower Genital Tract Neoplasia in Women With HIV Infection

Lower Genital Tract Neoplasia in Women With HIV Infection

ABSTRACT: Women who are infected with human immunodeficiency virus (HIV) are at greater risk for the development of lower genital tract neoplasia than are HIV-negative women. Among HIV-positive women, those who are more severely immunosuppressed appear to be at higher risk for cervical intraepithelial neoplasia (CIN), also known as squamous intraepithelial lesions (SILs). Women who are HIV-positive also are more likely than HIV-negative women to have multifocal lower genital tract neoplasia. Cervical cancer is one of the most important acquired immune deficiency syndrome (AIDS)–related malignancies in women. Cancer and intraepithelial neoplasia of the lower genital tract can be persistent, progressive, recurrent, and difficult to treat in HIV-positive women. The most effective method for treating SILs has not been determined. Regular performance of Pap smears in HIV-positive women is of critical importance, as is careful examination of the entire lower genital tract. Also, women with high-grade intraepithelial or cervical cancer should be tested for HIV. [ONCOLOGY 12(12):1735-1739, 1998]

Introduction

There has been a great deal of good news about
the acquired immune deficiency syndrome (AIDS) during the last few
years. Overall, the number of AIDS-related deaths has declined.[1]
Due to the successful use of protease inhibitors combined with
antiretroviral agents, the life expectancy for many people living
with human immunodeficiency virus (HIV) is expected to be greatly
extended and their quality of life improved. Use of the
antiretroviral zidovudine (Retrovir) has reduced the transmission of
HIV from mother to infant from 25% to 8%.[2] Finally, a study of (HIV
serostatus discordant) couples has revealed that condoms are an
effective method of preventing heterosexual transmission of HIV.[3]

The news about women has not been all good, however. The proportion
of women accounting for new AIDS cases rose from 7% in 1985 to 20% in
1996.[1] Deaths due to AIDS in 1996 decreased by 15% among men but increased
by 3% among women.[1] Although infants born to HIV-infected women who
used zidovudine during pregnancy are less likely to be infected with
HIV, the long-term consequences of zidovudine use for women and their
infants are still poorly understood. In addition, single
antiretroviral drug therapy is no longer the standard of HIV care;
nonetheless, combination HIV therapies have not been fully evaluated
in pregnant women. Lastly, although the male condom has been found to
effectively prevent the transmission of HIV, there still are no
effective preventive methods that are solely under the control of women.

The epidemiologic picture of HIV/AIDS in women also differs from the
picture in men. The number of AIDS cases is highest among white
homosexual men in the United States.[1] In contrast, women with AIDS
are more likely to be nonwhite (75%) and to acquire the disease from
intravenous drug use (34%) or heterosexual intercourse (40%). Cases
of woman-to-woman transmission have been documented[4,5] but the
total number of cases is unknown because this is not a transmission
category that must be reported to the Centers for Disease Control and
Prevention (CDC).

Women who become infected with HIV are likely to be socioeconomically
disadvantaged, as well as disenfranchised from the health-care
system. Unfortunately, women have either been invisible during the
AIDS epidemic[6] or they have been unfairly characterized as vectors
( eg, prostitutes) or vessels (eg, during pregnancy) of disease.

Another way in which the AIDS epidemic has affected women differently
than men relates to the unique clinical manifestations of HIV
disease. Of these, perhaps the most important manifestation in women
with HIV is lower genital tract neoplasia. In this article, we will
review the current body of knowledge about lower genital tract
neoplasia in HIV-infected women.

Human Papillomavirus Infection in HIV-Infected Women

Human papillomavirus (HPV) is a double-stranded, circular DNA virus
that can infect the stratified squamous epithelium of the lower
genital tract, where it can exist in a dormant state, undergo
replication (usually producing genital warts), or transform the host
DNA, leading to uncontrolled cell growth. More than 80 types of HPV
have been identified, about 15% of which infect the lower genital
tract. These are divided into high- and low- risk types according to
their degree of association with cervical cancer.

About 75% of invasive cervical cancers are associated with high-risk
HPV types (subtypes 16, 18, 31, or 45) and less than 10% with
low-risk types (subtypes 6 or 11). Low-grade cervical intraepithelial
neoplasia (CIN) is associated with low-risk HPV types in 30% to 40%
of cases and with high-risk types in < 20% of cases.[7]

Human papillomavirus infections are extremely common. Among young men
and women in the United States, 60% have had prior HPV infection, 10%
harbor subclinical infection detectable only by DNA testing, 4% have
infection detectable by cytology or colposcopic examination, and 1%
have grossly visible tumors. Only a very small proportion of
HPV-positive women will develop invasive cancers of the lower genital
tract. It is likely that HPV infection is necessary but not
sufficient to produce lower genital tract malignancy. Possible
cofactors leading to malignancy include tobacco smoking, other
genital tract infections, and immunosuppression.

The association of HIV and HPV is not surprising since both viruses
are sexually transmissible. Furthermore, since lower genital tract
neoplasia has been associated with iatrogenic immunosuppression (such
as after organ transplantation), the increased prevalence of
HPV-related neoplasia among women with HIV immunosuppression is to be expected.

There seems to be an increased prevalence of lower genital tract
neoplasia among HIV-infected women even when they are not
immunosuppressed. Wright et al reported an increased risk for CIN due
to HIV infection even after they controlled for the presence of HPV,
immunosuppression, age, drug use, and various factors related to
sexual activity.[8] Several studies have shown an increased detection
rate of HPV DNA from the genital tract of HIV-infected women.

The human immunodeficiency virus may directly interact with HPV. For
example, in vitro, HIV-1 transactivator “tat” protein
enhances HPV E2-dependent transcription of HPV-16.[9] However, in
vivo, HIV and HPV do not appear to coinfect the same cells; HIV is
found mostly in monocytic cells, while HPV is found in squamous
mucosal cells.[10] In the absence of immunosuppression, the
interaction between HIV and HPV remains unexplained.

Course of HPV Infection

Among persons infected with HPV, immunosuppression, as measured by
CD4+ cell counts, results in an increased proportion of CIN
(replicating and integrated HPV infection) and a decreased proportion
of latent HPV infections. The ratio of CIN to latent infection is 8:1
in the general population (“HIV-negative”), as compared
with ratios of 3:1 in HIV-positive individuals with CD4 cell counts
> 500/mm³ and 1:1 in those with CD4 counts < 200/mm³.[11]

Human immunodeficiency virus–infected women with high-grade CIN
seem to be infected with different types of HPV than are HIV-negative
women. Sun et al found that HPV types 16 and 18 predominated in
HIV-negative women, while HPV types “30s” and
“50s” were more common in the HIV-infected group.[11]

Moreover, HIV-infected women seem to shed HPV more frequently than
HIV-negative women.[12] Semiquantitative DNA testing has shown a
higher HPV viral load in some cervicovaginal lavage specimens
obtained from HIV-positive than from their HIV-negative counterparts.[13]

In summary, HIV and HPV seem to be interactive infections. Most of
the available evidence suggests significant differences in the course
of HPV in women infected with HIV. As more research is done in this
area, there are likely to be significant advances in our
understanding of the pathophysiology of HPV infections.

Lower Genital Tract Neoplasia

Cervical intraepithelial neoplasia, also known as cervical dysplasia
or squamous intraepithelial lesions (SILs), is common in women with
HIV. In a review of 21 studies, five of which were controlled
studies, Mandelblatt et al found that the odds of HIV-infected women
having CIN was 4.9 times (95% confidence interval [CI], 3.0 to 8.2)
greater than that of HIV-negative women.[14] The prevalence of CIN
among HIV-infected women ranges from 31% to 63%.[13,15-20]

By analyzing Pap smears obtained from women before and after HIV
seroconversion, Provencher et al demonstrated the development of
abnormal cellular changes after seroconversion. They found that 12%
of the smears were abnormal before seroconversion, as compared with
60% after seroconversion.[16]

In addition to having a higher prevalence of cervical dysplasia,
women who are HIV-positive have larger lesions, more advanced CIN,
and more vulvovaginal lesions than do HIV-negative women.[21]

Cervical Dysplasia and the Degree of Immunosuppression

There appears to be a relationship between the development of CIN and
the degree of immunosuppression. For instance, women with symptomatic
HIV infection are more likely to have CIN than are those with
asymptomatic HIV infection.[13,18,22] In addition, the degree of
immunosuppression (as measured by CD4+ cell counts) is correlated
with an increased frequency of CIN among women with HIV.[19,23,24]
This relationship between HIV immunosuppression and the development
of CIN is not a surprising, as an increased incidence of CIN and
cervical cancer has also been reported in other groups of
immunosuppressed women, such as renal transplant recipients.[25]

Adequacy of Pap Tests in Detecting Cervical Dysplasia

Some researchers and clinicians have questioned whether Pap smears
are an adequate method of detecting CIN in women with HIV. In an
uncontrolled study, Maiman et al found that only 1 of 13 CIN lesions
in HIV-infected women were detected by Pap smears.[18] Most of the
subsequent studies have found that Pap smears have adequate
sensitivity and specificity to detect CIN in women with HIV (Table
1
).[8,26,27]

Although Pap smears may be adequate for screening, minor
abnormalities on Pap smears may be more significant in HIV-positive
than in HIV-negative women. Wright et al found that 38% of the
HIV-positive women who had atypia on Pap smears had coexistent CIN
detected by colposcopy, as compared with 14% of the women who were
HIV-negative.[28] Based on these data, the current recommendations
are to screen HIV-positive women every 6 months with a Pap smear and
refer for colposcopy any woman who has atypia or CIN on her Pap smear.[29]

Multifocal Lower Genital Tract Neoplasia

Women with HIV are more likely to have multifocal lower genital tract
neoplasia than are women without HIV. In addition to the cervix,
neoplastic lesions are commonly found in other sites, such as the
vagina and vulva. In one study with a small sample size (N = 19), 90%
of the HIV-infected women had lesions on the vulva or perineum.[15]

Moreover, intraepithelial neoplasia in the vagina and on the vulva
may not always be accompanied by cervical lesions in HIV-infected
women. We found that 15% of 52 HIV-infected women who were examined
by colposcopy had vulvar lesions in the absence of cervical lesions.[27]

Although the rate of multifocal disease has been found to range
between 28% to 50% in women with HIV,[30] some of these small studies
probably exaggerated the prevalence of multifocal disease due to
selection bias. In a large, well-controlled study, vulvar and/or
vaginal condyloma acuminata were detected in 5.6% (22/396) of the
HIV-positive women but in only 0.8% (3/375) of the HIV-negative
women.[31] High-grade SILs were found only in the HIV-positive women
(N = 2).

In comparison to HIV-negative women, the prevalence of vulvar and
vaginal lesions appears to be higher among HIV-positive women. We
found that HIV-positive women were 27 times more likely to have
vulvar intraepithelial neoplasia (VIN) than were HIV-negative women.[32]

This increased risk for VIN among HIV-infected women raises concern
about the potential development of vulvar cancer. In fact, cases of
invasive vulvar carcinoma have been documented in women with HIV.[33]
Since VIN is more common among women with HIV and may occur in the
absence of CIN, Pap smears alone may not be adequate as a screening
method. Colposcopy may be the most efficient method of detecting
these lesions and may be especially warranted in HIV-positive women
with a history of dysplasia or with vaginal or vulvar condylomata.

The finding of anal cancers in homosexual men with HIV[34] has led to
the screening of HIV-infected women for anal intraepithelial
neoplasia (AIN). In most cases, the performance of anal Pap smears
has been done in conjunction with studies of the natural history of
HIV. These studies have revealed that women with HIV are also at
increased risk for anal dysplasia.[35] Cytologic abnormalities of the
anus were detected in 26% of 27 HIV-infected women and 6% of 6
uninfected women.[36] Of the smears in the HIV-infected women, 5%
were low-grade AIN. These data point to the need for increased
vigilance in the detection of SILs throughout the lower anogenital tract.

Recurrence or Persistence of Neoplasia After Therapy

Lower genital tract neoplasia is more likely to recur or persist
after treatment in HIV-positive than in HIV-negative women. Maiman
and colleagues reported a 39% rate of recurrence of CIN following
ablative or excisional therapy in HIV-infected women, as compared
with a 9% recurrence rate in HIV-uninfected women.[37]

Wright et al found that 56% (19/34) of women with HIV who underwent
loop electrosurgical excision had recurrent or persistent CIN, as
opposed to 13% (10/80) of women with unknown HIV status.[38] In
addition, the rate of recurrence/persistence was greater in the women
who had CD4 counts < 200 cells/mm³, although this difference
was not statistically significant.

In a prospective study that followed HIV-infected women for 18
months, persistent CIN was noted in 95% (18/19) of the women who did
not receive treatment and in 61% (8/13) of the women who were
treated.[39] Among women who had initially presented with low-grade
CIN, cervical dysplasia persisted in 60% of the cases, which is twice
the rate reported for the general population.[40]

We found that HIV-positive women who had VIN had a relative risk of
recurrence or persistence of vulvar dysplasia of 3.3 (95% CI, 1.4 to
7.4; P = .01) after therapy, as compared with women who said that
they were not HIV-infected.[32] The type of treatment, laser or
excision, did not affect the rate of recurrence or persistence of VIN
in either group.

Despite the common recurrence of intraepithelial neoplasia after
treatment, reports of the development of invasive cancer in
HIV-infected women receiving treatment are quite rare.

Therapy and Monitoring for Intraepithelial Neoplasia

Few studies have explored the effectiveness of treatment of
intraepithelial neoplasia in women who are immunocompromised. More
information is needed about the long-term effectiveness of various
treatments, as well as the effect of the new combination therapies on
the progression or regression of SILs. Additional therapies are
needed that are effective against multifocal disease, are more
effective against recurrent or persistent disease, do not affect
future fertility, and are not disfiguring.

Little is known about how often women with HIV should be monitored
for intraepithelial neoplasia with Pap smears or colposcopy.
Long-term monitoring can be burdensome for some women and may affect
follow-up.[P. D. Abercrombie, unpublished dissertation, 1997] As
women live longer with HIV, noncervical lower anogenital tract
cancers (especially vulvar and anal cancers) may become increasingly
common. In women with iatrogenic immunosuppression after organ
transplantation, a 100-fold increase in vulvar cancer has been
reported, occurring after an average of 107 months.[41]

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