studies of anal cytologic screening of HIV-infected women.

Comorbidity

Human papillomavirus infection and cytologic abnormalities of the anus and cervix, among HIV-infected women in the study to understand the natural history of HIV in the era of effective therapy (the SUN study)

Kojic EM, Cu-Uvin S, Conley L, Bush T, Onyekwuluje J, Swan DC, Unger ER, Henry K, Hammer JH, Overton ET, Darragh TM, Palefsky JM, Vellozzi C, Patel P, Brooks JT. Sex Transm Dis. 2010 Oct 14. [Epub ahead of print]

Human papillomavirus (HPV) infection of the cervix and related abnormal cervical cytology in HIV-infected women has been well described. Little is known about anal HPV infection in HIV-infected women. The SUN Study is a prospective cohort study of 700 HIV-infected patients including 167 women. At baseline, patients completed a behavioural questionnaire and provided, among other samples, cervical and anal swabs for HPV detection and genotyping and for cytologic examination. Here, Kojic and colleagues present the available baseline data for 120 of the 167 women in the SUN study: median age: 38 years, 57% non-Hispanic black, median CD4 cell count 444.5 cells/mm, of whom, 77% were taking antiretroviral therapy. The prevalences in the anus and cervix of any HPV were 90% and 83%, respectively (P = 0.039), and of high-risk (HR) types 85% and 70%, respectively, (P = 0.001). There was no significant difference in the prevalences of abnormal cytology between the anus and cervix: 38% and 33%, respectively (P = 0.217). Although the presence of abnormal cervical cytology was associated with the presence of abnormal anal cytology (relative risk: 1.7, P = 0.024), its sensitivity (52.5%) and positive predictive value positive (45.6%) for identifying women with abnormal anal cytology were poor. A history of anal sex was not associated with anal HPV infection or abnormal anal cytology. In this cohort of HIV-infected women, anal HPV infection was more prevalent and diverse than cervical HPV infection. Anal cytologic abnormalities were as prevalent as cervical cytologic abnormalities, and although abnormal cervical cytology was predictive of abnormal anal cytology, results were not highly concordant. These data support the need for studies of anal cytologic screening of HIV-infected women.

Editors’ note: Cervical cancer has always been a concern for women living with HIV, whether or not they are on antiretroviral therapy, but now a watching brief on anal cancer in women is warranted. Although this is a relatively small study (120 women living with HIV), the findings are striking: a higher likelihood of anal HPV than cervical HPV, with a higher diversity of high- and low-risk types found at the anal site. The proportion of women with anal HPV is higher than ever reported, possibly due to improvements in PCR (polymerase chain reaction) methodologies. There was no association of anal HPV with self-reported anal intercourse. Higher anal HPV prevalence than cervical HPV prevalence may possibly reflect previous treatment for cervical HPV-related disease. Aside from the clear need for screening for anal dysplasia, there are two conclusions of interest for prevention of anal cancer in women living with HIV. First, smoking increased the number of HPV types found at both the anal and cervical sites – this is consistent with a study of over 10,000 women that found a dose-dependent increased risk of HPV prevalence in smokers. Second, none of the women had all 4 types targeted by the quadrivalent vaccine (6, 11, 16, and 18) in either cervix or anus. Advice to women living with HIV: stop smoking or don’t start and get vaccinated for HPV.