Date Published: April 4, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Peter Memiah, Wangeci Mbuthia, Grace Kiiru, Solomon Agbor, Francesca Odhiambo, Sylvia Ojoo, Sibhatu Biadgilign.
Objective. To assess the prevalence and identified associated risk factors for precancerous cervical cancer lesions among HIV-infected women in resource-limited settings in Kenya. Methods. HIV-infected women attending the ART clinic at the Nazareth Hospital ART clinic between June 2009 and September 2010. Multivariate logistic regression model with odds ratios and 95% confidence intervals (CI) were estimated after controlling for important covariates. Result. A total of 715 women were screened for cervical cancer. The median age of the participants was 40 years (range 18–69 years). The prevalence of precancerous lesions (CINI, CINII, CIN III, ICC) was 191 (26.7%). After controlling for other variables in logistic regression analysis, cervical precancerous lesions were associated with not being on ART therapy; whereby non-ART were 2.21 times more likely to have precancerous lesions than ART patients [(aOR) = 2.21, 95% CI (1.28–3.83)].
Conclusion. The prevalence of precancerous cervical lesions was lower than other similar settings. It is recommended that cancer screening of HIV-infected women should be an established practice. Availability and accessibility of these services can be done through their integration into HIV. Prompt initiation of HAART through an early enrollment into care has an impact on reducing the prevalence and progression of cervical precancerous lesions.
Cervical cancer is the second most common malignancy and accounts for the greatest number of deaths from cancer in women worldwide . Human immunodeficiency virus (HIV) infection also represents a tremendous health burden worldwide. Cervical cancer was made an acquired immunodeficiency syndrome (AIDS-) defining illness in 1993 . In 2005, there were almost 260,000 deaths from cervical cancer and more than 500,000 new cases worldwide. Women in developing countries are at greater risk of death from cervical cancer primarily because few have access to the screening and treatment services that have greatly reduced mortality in the industrialized world over the past four decades. About 75% of women in industrialized countries has been screened for cervical cancer in the previous five years, compared to less than 5% in developing countries . According to WHO (1986), it has been estimated that only about 5% of women in developing countries has been screened for cervical dysplasia in the past 5 years, compared with 40% to 50% of women in developed countries . Research findings suggest that HIV-induced immunodeficiency predisposes to cervical intraepithelial neoplasia (CIN) or cervical carcinoma by facilitating the expression of a causal agent [5–8]. The public health importance of assessing the interaction between HIV and HPV infection with respect to cervical disease is suggested by increased rates of dysplasia persistence and recurrence among HIV-positive women and shorter survival for women with HIV infection and cervical cancer .
The study site was a faith-based hospital offering comprehensive care and treatment to approximately 4,000 HIV-infected patients. The study site was located in Central Kenya, Kiambu district which has a HIV prevalence of 4%. The study population constituted eligible women attending the ART treatment clinics. None of the patients had evidence of Kaposi sarcoma or non-Hodgkin lymphoma. Eligibility criteria included being aged 18–69 years and having no current or past history of cervical disease. Women, eighteen years and older, who were on followup for their HIV-positive status, were screened for cervical cancer using the Visual Inspection with Lugol’s Iodine (VILI) technique.
According to the World Health Organization (WHO), invasive cervical cancer (ICC) is the second most common cancer in women worldwide and is more frequent in low-income countries . Recent guidelines recommend that, following two initial normal Pap-smears at a 6-month interval, all HIV-positive women should undergo annual cervical cytologic examination. In addition, it is recommended that all immunosuppressed women with atypical squamous cells undergo colposcopy . In our study the prevalence of precancerous lesions was 26.7% (191). In other studies among HIV-infected women in Lusaka, Zambia was 79% prevalence of high-grade squamous intraepithelial lesions (HSIL) of the cervix  and the high prevalence of HPV-DNA in Zambia study (97.2% for any HPV and 90.3% for any HR-HPV) . In Guinea, overall human papillomavirus prevalence was 50.8% (78.5% and 47.9% among women with and without cervical abnormalities, resp.) . A recent meta-analysis shows that the HPV prevalence was 56.6% in Africa, 31.1% in Asia, 32.4% in Europe, 31.4% in North America, and 57.3% in South/Central America . Although the mechanism by which HIV increases risk of cervical cancer is not completely understood, studies suggest that HIV-induced immunosuppression leads to an inability to control the expression of HPV and the production of HPV oncoproteins E6 and E7 [25, 26] and the risk appears to be associated with increased HPV persistence that may result from immunosuppression related to HIV. Furthermore, the risk is greater in women with CD4 counts less than 200 cells per microliter and in those with high plasma HIV RNA levels . Studies have shown that HIV-1 infection is associated with an increased rate of HPV infection, mainly restricted to HR-HPV types which are the cause of invasive cancer of the cervix [28–30]. Several studies conducted in sub-Saharan Africa indicate that among African women, being HIV infected was associated with a high risk of presenting squamous intraepithelial lesions of the cervix, with ORs ranging from 4.4 to 17 depending on the grade of the lesion and other factors [28, 30–33]. Yet, many case-referent studies conducted in Uganda, Rwanda, and Côte d’Ivoire failed to demonstrate any significant association between HIV and ICC, with ORs ranging from 1.1 to 1.6 [34–37]. Case-referent studies in South Africa also found a significant association with ORs of 1.6 and 1.6 [38, 39]. In another case-referent study conducted in Kenya, HIV-positive women were also more likely to be HPV infected compared to HIV-negative women (OR = 3.1) . A cross-sectional study determined the prevalence of HPV infection, HIV infection, and cervical cytological abnormalities in Ugandan women presenting to a sexually transmitted infection clinic  and found 49 cases of HPV infection among 106 women with cervical swabs adequate for HPV testing (46.2%). Similarly, a study realized in Zambia among 145 HIV-infected women of which 93.8% had abnormal Pap smears . In other study of women initiating ARV therapy recorded an exceptionally high prevalence of cervical abnormalities (66%) . This finding has implications for future interventions in the implementation of prophylactic HPV vaccines to be the part of care and support programme for HIV-infected women.
In this study, the prevalence of CIN was 26.7 percent (191) which is lower than other findings reported in Africa. Those patients who were not on antiretroviral therapy were more likely to have CIN diagnosis than who were on antiretroviral therapy. Therefore regular screening of HIV-infected women is of paramount importance. Starting ART acts as leverage for cancer screening and majority of ART patients are likely not to progress to cervical cancer as demonstrated by this study. Conducting well-designed prospective cohort study to study natural history of cervical neoplasia among HIV-infected women in developing country settings is warranted.