Recurrence of cervical intraepithelial lesions after thermo-coagulation in HIV-positive and HIV-negative Nigerian women

Abstract

BackgroundThe burden of cervical cancer remains huge globally, more so in sub-Saharan Africa. Effectiveness of screening, rates of recurrence following treatment and factors driving these in Africans have not been sufficiently studied. The purpose of this study therefore was to investigate factors associated with recurrence of cervical intraepithelial lesions following thermo-coagulation in HIV-positive and HIV-negative Nigerian women using Visual Inspection with Acetic Acid (VIA) or Lugol’s Iodine (VILI) for diagnosis.MethodsA retrospective cohort study was conducted, recruiting participants from the cervical cancer “see and treat” program of IHVN. Data from 6 sites collected over a 4-year period was used. Inclusion criteria were: age ≥18 years, baseline HIV status known, VIA or VILI positive and thermo-coagulation done. Logistic regression was performed to examine the proportion of women with recurrence and to examine factors associated with recurrence.ResultsOut of 177 women included in study, 67.8 % (120/177) were HIV-positive and 32.2 % (57/177) were HIV-negative. Recurrence occurred in 16.4 % (29/177) of participants; this was 18.3 % (22/120) in HIV-positive women compared to 12.3 % (7/57) in HIV-negative women but this difference was not statistically significant (p-value 0.31). Women aged ≥30 years were much less likely to develop recurrence, adjusted OR = 0.34 (95 % CI = 0.13, 0.92). Among HIV-positive women, CD4 count <200cells/mm3 was associated with recurrence, adjusted OR = 5.47 (95 % CI = 1.24, 24.18).ConclusionRecurrence of VIA or VILI positive lesions after thermo-coagulation occurs in a significant proportion of women. HIV-positive women with low CD4 counts are at increased risk of recurrent lesions and may be related to immunosuppression.

Treatment of cervical intraepithelial lesions

“…A recent systematic review, and subsequent publications, suggest that HIV‐infected women are more likely to have treatment failures/recurrent disease, but the evidence for each treatment modality is very limited. The most likely explanation is that HIV‐infected women have larger lesions due to immune suppression and therefore the lesion margins are not clear, leading to failure/recurrence. Does the healed epithelium following ablation allow for effective monitoring and diagnosis of recurrent (untreated) disease? Placed into context, if a treatment is 90% effective in treating CIN 2–3, the treated cohort has a prevalence of 10% CIN 2–3, which is several fold higher risk than the general population from which they were screened.…”

“…The authors reported no serious adverse effects, and pain was reported as minor by most women—a single woman reported significant pain. Oga et al . reviewed studies that had used thermal coagulation in VIA‐based screen‐and‐treat programs at six sites in Nigeria, which included both HIV‐positive and HIV‐negative women.…”

Malignancies in women with HIV infection

“…In SSA, the six most common types of HPV are oncogenic types 16, 18, 35, 45, 33, and 52 [14]. Immunologic and virologic HIV control are significant co-factors in the persistence, and progression of HPV infection to pre-malignant lesions and ICC [11, 15, 16]. The use of cART, however, may not completely reverse the oncogenic potential of HPV especially if early malignant changes begin to take place while CD4 counts are low [15].…”

Human papillomavirus-associated anal and cervical cancers in HIV-infected individuals

“…In a meta-analysis of the performance of VIA, recurrence after treatment was higher among HIV-infected compared with HIV-uninfected women but morbidity from treatment was similar (19). Among Nigerian HIV-infected women participating in a see-and-treat program and treated for cervical disease with thermal coagulation, there was no statistically significant difference in recurrence between HIV-infected and HIV-uninfected women (20). However among HIV-infected women the risk of recurrence was highest among those with lower CD4 levels.…”