Efficacy of human papillomavirus-based screen-and-treat for cervical cancer prevention among HIV-infected women.A

Comorbidity

Efficacy of human papillomavirus-based screen-and-treat for cervical cancer prevention among HIV-infected women.

Cervical cancer prevention should be provided as part of primary healthcare services for HIV-infected women but conventional screening programs are difficult to implement in low-resource settings. Here, Kuhn and colleagues evaluate the efficacy among HIV-infected women of a simpler, screen-and-treat strategy in which all women with a positive screening test are treated with cryotherapy. The authors conducted a randomized clinical trial of two screen-and-treat strategies among 6555 women in Cape Town, South Africa, among whom 956 were HIV-positive. Women were randomized to screen-and-treat utilizing either human papillomavirus DNA testing or visual inspection with acetic acid as the screening method or to a control group. Women were followed for up to 36 months after randomization with colposcopy and biopsy to determine the study endpoint of cervical intraepithelial neoplasia grade 2 or higher. In the control group, HIV-positive women had higher rates of cervical intraepithelial neoplasia grade 2 or higher detected by 36 months (14.9%) than HIV-negative women (4.6%) (P = 0.0006). Screen-and-treat utilizing human papillomavirus DNA testing significantly reduced cervical intraepithelial neoplasia grade 2 or higher through 36 months in both HIV-positive (relative risk = 0.20, 95% confidence interval 0.06-0.69) and HIV-negative women (relative risk = 0.31, 95% confidence interval 0.20-0.50). Reductions in the visual inspection with acetic acid-and-treat group were less marked. Complications of cryotherapy were mostly minor and did not differ in frequency between HIV-positive and HIV-negative women. Screen-and-treat using human papillomavirus testing is a simple and effective method to reduce high-grade cervical cancer precursors in HIV-infected women.

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Editors’ note: This trial was not designed to test the efficacy of a screen-and-treat approach to cervical cancer prevention in women living with HIV, but the findings are very promising. Trial participants were recruited from ambulatory women’s health clinics in Khayelitsha at a time when antiretroviral treatment was not routinely available in the public sector in South Africa (2000-2002). For the 956 women who were diagnosed as HIV-positive at some point in the study, no information was collected on CD4 count, viral load, or treatment status. It is likely that most of these women were not profoundly immunosuppressed. With these provisos, the trial provides proof of concept that human papilloma virus (HPV)-based screen-and-treat is safe and effective in HIV-positive women. Conventional screening methods (cytology or Pap smears, colposcopy, and biopsies for pathology) require considerable infrastructure and clinical expertise. The less expensive, easy to use new generation HPV DNA tests are a new screening approach that could greatly expand access to cervical cancer prevention for all women, but particularly those living with HIV who are at greatly elevated risk for cervical disease.