Impact of timing of antiretroviral therapy initiation on survival of cervical squamous intraepithelial lesions: a cohort analysis from South Africa

Abstract

To determine factors that influence excision treatment outcome and recurrence of cervical squamous intraepithelial lesions (SIL) in women living with HIV infection, we analysed 1848 women who underwent excision treatment of cervical SIL at Tygerberg Hospital, Cape Town, South Africa. We compared treatment failure defined as presence of cervical intraepithelial neoplasia (CIN) I (presence of CIN I or higher at first follow-up after excision treatment) and post-excision recurrence of lesions (at one year or later) between women of HIV-positive, -negative or unknown status and examined factors associated with excision treatment outcome and recurrence. HIV-infected women experienced higher treatment failure than uninfected women (53.8% versus 26.9%, P < 0.001). At treatment failure, more HIV-infected women had low-grade squamous intraepithelial lesion (LSIL) compared with uninfected women (64.9% versus 37.3%, P < 0.001). Treatment failure did not differ with the type of excision used in HIV-infected women. HIV-infected women were more likely to experience recurrence of lesions after excision treatment than uninfected women (hazard ratio 1.95, 95% confidence interval [CI] 1.59-2.39; P < 0.001). Antiretroviral therapy (ART) initiated before excision biopsy had a strong protective effect against recurrence (hazard ratio 0.70, 95% CI 0.55-0.89; P = 0.006). Our data suggest that women with cervical SIL initiated on ART earlier may be expected to have better long-term excision treatment outcome. Close follow-up should be maintained after cervical excision treatment, especially in a setting of high HIV prevalence.

Assessing cervical intraepithelial neoplasia as an indicator disease for HIV in a low endemic setting: a population‐based register study

“…Persistence and recurrence of CIN2 + after treatment is more common among WLWH and the most important risk factor seems to be a low CD4 + T‐cell count . ART is associated with reduction of the incidence and progression of cervical dysplasia among WLWH, further stressing the importance of identifying women with cervical dysplasia who are unaware of their HIV status …”

Suppressive antiretroviral therapy associates with effective treatment of high-grade cervical intraepithelial neoplasia

“…Additionally, several studies have not adjusted for CD4 nadir, current CD4 count, or time on ART, which may explain why the association between ART and progression/regression of cervical lesion has remained uncertain for so long 107,108 . There are studies, however, adjusting for CD4 count and time on ART that have shown an association between ART and outcome of CIN and recently a meta-analysis confirmed reduced incidence of HSIL/CIN2+, decreased progression of SIL, increased SIL/CIN regression and reduced incidence of ICC among women on ART 78,103,[109][110][111] .…”

“…Persistence and recurrence of CIN2/3 after treatment with conization is more common in WLWH and increases with the level of immunosuppression 104,110,113,114 . It is unclear if WLWH on ART have better outcome after conization than those not on ART as data is limited.…”

Factors Associated With Recurrence of Cervical Intraepithelial Neoplasia 2+ After Treatment Among HIV-Infected Women in Western Kenya

“…9,10 Although access to highly active antiretroviral therapy (HAART) in many countries has dramatically increased over the past decade, the impact of HAART on the development of cervical precancer and recurrence after treatment remain unclear. 1115 This means that an increasing number of HIV-infected women are living longer with a potentially higher risk for cervical cancer.…”