Research Article: Prevalence and Predictors of Colposcopic-Histopathologically Confirmed Cervical Intraepithelial Neoplasia in HIV-Infected Women in India

Date Published: January 8, 2010

Publisher: Public Library of Science

Author(s): Vikrant V. Sahasrabuddhe, Ramesh A. Bhosale, Smita N. Joshi, Anita N. Kavatkar, Chandraprabha A. Nagwanshi, Rohini S. Kelkar, Cathy A. Jenkins, Bryan E. Shepherd, Seema Sahay, Arun R. Risbud, Sten H. Vermund, Sanjay M. Mehendale, Landon Myer.

Abstract: Prevalence estimates of cervical intraepithelial neoplasia (CIN) among HIV-infected women in India have been based on cervical cytology, which may have underestimated true disease burden. We sought to better establish prevalence estimates and evaluate risk factors of CIN among HIV-infected women in Pune, India using colposcopy and histopathology as diagnostic tools.

Partial Text: Women living with human immunodeficiency virus (HIV) infection have a higher risk of human papillomavirus (HPV)-associated cervical intraepithelial neoplasia (CIN) as compared to HIV-uninfected women. [1], [2] India has some of the highest case burdens of both HIV/AIDS (estimated 2.4 million individuals, including 1 million women) and cervical cancer (estimated 130,000 new cases and 74,000 deaths annually) of any single nation.[3]–[5] The life span of HIV-infected women in India is increasing due to improved access to affordable antiretroviral therapy (ART). [6] Before the introduction of ART, the lack of cervical cancer prevention services probably had little influence on the life expectancy of HIV-infected women due to high competing mortality associated with other opportunistic infections. [7], [8] As HIV-infected women continue to live longer with ART support, albeit in a moderately immunosuppressed state, they may be at increased risk for CIN and invasive cervical cancer.[1], [7]

Our study is the first report from India on CIN disease prevalence in HIV-infected women confirmed by a composite colposcopic-histopathological assessment. Previous studies have relied on the use of cytology to report prevalence of CIN in HIV-infected women.[9]–[12]. The cytology-derived prevalence estimates in these studies have varied according to the population being sampled, ranging from 6.3% (voluntary counseling and testing clinics, n = 287),[11] 14% (HIV and gynecology clinics, n = 75),[12] 19.2% (women attending STI clinics, n = 100),[9] to 30.7% (commercial sex workers, n = 137),[9]. However, cervical cytology (Pap smear) has only moderate sensitivity in detecting CIN and may miss many lesions.[13], [14] Besides, ‘true’ CIN disease estimation is only done by standardized diagnostic confirmatory colposcopy followed by histopathological confirmation as may be indicated clinically. [15], [16] All participants in our study received a standardized diagnostic colposcopic examination. Additional invasive confirmatory diagnostic procedures (biopsy, LEEP, ECC) were restricted only for consenting women with clinical evidence of CIN, as per internationally recommended clinical management guidelines.[24] This approach avoided unnecessary invasive diagnostic procedures yet increased the accuracy of CIN diagnosis more than from diagnostic colposcopy alone.[24], [25] Thus, our study design represents the best effort for maximizing the precision of clinical-pathological prevalence estimates while balancing ethical concerns by avoiding unnecessary invasive procedures. The participant recruitment in this study was undertaken regardless of the baseline CD4+ cell counts or presence of symptoms of cervical cancer or HIV/AIDS. This, and the fact that none of the participants had been previously screened or treated for cervical neoplasia, has limited the selection bias in our study and increased the generalizability and representativeness of our findings for HIV-infected women in India.



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