Human Papillomavirus Vaccination Prior to Loop Electroexcision Procedure Does Not Prevent Recurrent Cervical High-grade Squamous Intraepithelial Lesions in Women Living With Human Immunodeficiency Virus: A Randomized, Double-blind, Placebo-controlled Trial

2020 ◽  
Author(s):  
Cynthia Firnhaber ◽  
Avril Swarts ◽  
Vuyokazi Jezile ◽  
Masango Mulongo ◽  
Bridgette Goeieman ◽  
...  
Keyword(s):  
Cervical Cancer ◽  
Human Immunodeficiency Virus ◽  
Human Papillomavirus ◽  
Hpv Vaccination ◽  
High Grade ◽  
Double Blind ◽  
Women Living With Hiv ◽  
Immunodeficiency Virus ◽  
Living With Hiv ◽  
Intraepithelial Lesions

Abstract Background Women living with human immunodeficiency virus (HIV), especially in sub-Saharan Africa, are at high risk for cervical high-grade squamous intraepithelial lesions (HSIL) and cervical cancer. These women have high HSIL recurrence rates after loop electroexcision procedure (LEEP). Retrospective studies suggest that human papillomavirus (HPV) vaccination improves response to treatment of cervical HSIL. Methods We performed a double-blind, randomized clinical trial enrolling 180 women living with HIV in Johannesburg, South Africa, diagnosed with cervical HSIL by colposcopic biopsy. Women received quadrivalent HPV vaccine or placebo (1:1) at entry, week 4, and week 26. LEEP was performed at week 4. Colposcopic-directed biopsies and cervical cytology were performed at weeks 26 and 52. The primary endpoint, cervical HSIL by histology or cytology at either week 26 or 52, was compared between arms using χ 2 analysis. Results Participant characteristics included median age of 39 years and median CD4 count 489 cells/μL, and 94% had HIV suppression. One hundred seventy-four women completed the vaccine/placebo series and had evaluable results at week 26 or 52. The proportion experiencing the primary endpoint was similar in the vaccine and placebo groups (53% vs 45%; relative risk, 1.18 [95% confidence interval, .87–1.6]; P = .29). HSIL recurrence was associated with a LEEP biopsy result of HSIL and detection of HSIL at the margins of the LEEP sample. Conclusions This study did not support HPV vaccination to prevent recurrent HSIL after LEEP in women living with HIV. Recurrent HSIL was high despite virologic suppression. Improved treatments are needed for HSIL to reduce the burden of cervical cancer among women living with HIV.

scholarly journals Delivering Cervical Cancer Screening and Treatment to Women Living With Human Immunodeficiency Virus

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 227s-227s
Author(s):  
A. Kaneza ◽  
D. Uwimana ◽  
R. Mbonyindavyi
Keyword(s):  
Cervical Cancer ◽  
Human Immunodeficiency Virus ◽  
Vulnerable Populations ◽  
Cancer Information ◽  
Operational Experience ◽  
Resource Limited Settings ◽  
Women Living With Hiv ◽  
Resource Limited ◽  
Immunodeficiency Virus ◽  
Living With Hiv

Background: More than 80% of cervical cancer cases happens in the developing world. The same trend is seen in Burundi, where cervical cancer is the first gynecological cancer and the leading cause of female cancer deaths. In addition to this, Burundi presents high human immunodeficiency virus (HIV) prevalence rate. It is believed that there were 2200 new diagnosed clients in 2016. In spite of this, not all people can have access to desired services due to financial and geographical barriers. To increase access to cervical cancer information and screenings in resource-limited settings, Association Burundaise pour le Bien Etre Familiale (ABUBEF) introduces visual inspection of the cervix with acetic acid (VIA) and Lugol’s Iodine (VILI) plus cryotherapy to vulnerable populations, especially women living with HIV. Aim: To provide VIA/VILI and cryotherapy to women living with HIV in resource-limited settings. Methods: ABUBEF also conducted a training to ensure health providers can independently carry out VIA/VILI and cryotherapy. ABUBEF organized a campaign to raise people's awareness and deliver services to vulnerable populations. Results: Seventeen doctors were trained to perform VIA/VILI. They can also confidently make diagnosis and provide relevant treatment, such as cryotherapy or referral. 337 women were screened during the campaign and 4 of them received positive VIA/VILI results (1.1%). For women living with HIV, the VIA/VILI positivity rates was 4% and 2 of them presented suspicious cervical cancer lesions. All clients received essential treatments. This can be cryotherapy or be referred to specialists for further evaluation and cancer treatment. Conclusion: According to ABUBEF’s operational experience, VIA/VILI and cryotherapy is feasible in resource-limited settings. It is also noticed that women living with HIV has higher VIA/VILI-positive rate and even cancer lesions.

scholarly journals Diagnostic accuracy of cervical cancer screening and screening–triage strategies among women living with HIV-1 in Burkina Faso and South Africa: A cohort study

PLoS Medicine ◽  
2021 ◽  
Vol 18 (3) ◽  
pp. e1003528
Author(s):  
Helen A. Kelly ◽  
Admire Chikandiwa ◽  
Bernard Sawadogo ◽  
Clare Gilham ◽  
Pamela Michelow ◽  
...  
Keyword(s):  
South Africa ◽  
Cervical Cancer ◽  
Cohort Study ◽  
Human Papillomavirus ◽  
Cancer Screening ◽  
Cervical Cancer Screening ◽  
Visual Inspection ◽  
High Grade ◽  
Women Living With Hiv ◽  
Living With Hiv

Background Cervical cancer screening strategies using visual inspection or cytology may have suboptimal diagnostic accuracy for detection of precancer in women living with HIV (WLHIV). The optimal screen and screen–triage strategy, age to initiate, and frequency of screening for WLHIV remain unclear. This study evaluated the sensitivity, specificity, and positive predictive value of different cervical cancer strategies in WLHIV in Africa. Methods and findings WLHIV aged 25–50 years attending HIV treatment centres in Burkina Faso (BF) and South Africa (SA) from 5 December 2011 to 30 October 2012 were enrolled in a prospective evaluation study of visual inspection using acetic acid (VIA) or visual inspection using Lugol’s iodine (VILI), high-risk human papillomavirus DNA test (Hybrid Capture 2 [HC2] or careHPV), and cytology for histology-verified high-grade cervical intraepithelial neoplasia (CIN2+/CIN3+) at baseline and endline, a median 16 months later. Among 1,238 women (BF: 615; SA: 623), median age was 36 and 34 years (p < 0.001), 28.6% and 49.6% ever had prior cervical cancer screening (p < 0.001), and 69.9% and 64.2% were taking ART at enrolment (p = 0.045) in BF and SA, respectively. CIN2+ prevalence was 5.8% and 22.4% in BF and SA (p < 0.001), respectively. VIA had low sensitivity for CIN2+ (44.7%, 95% confidence interval [CI] 36.9%–52.7%) and CIN3+ (56.1%, 95% CI 43.3%–68.3%) in both countries, with specificity for ≤CIN1 of 78.7% (95% CI 76.0%–81.3%). HC2 had sensitivity of 88.8% (95% CI 82.9%–93.2%) for CIN2+ and 86.4% (95% CI 75.7%–93.6%) for CIN3+. Specificity for ≤CIN1 was 55.4% (95% CI 52.2%–58.6%), and screen positivity was 51.3%. Specificity was higher with a restricted genotype (HPV16/18/31/33/35/45/52/58) approach (73.5%, 95% CI 70.6%–76.2%), with lower screen positivity (33.7%), although there was lower sensitivity for CIN3+ (77.3%, 95% CI 65.3%–86.7%). In BF, HC2 was more sensitive for CIN2+/CIN3+ compared to VIA/VILI (relative sensitivity for CIN2+ = 1.72, 95% CI 1.28–2.32; CIN3+: 1.18, 95% CI 0.94–1.49). Triage of HC2-positive women with VIA/VILI reduced the number of colposcopy referrals, but with loss in sensitivity for CIN2+ (58.1%) but not for CIN3+ (84.6%). In SA, cytology high-grade squamous intraepithelial lesion or greater (HSIL+) had best combination of sensitivity (CIN2+: 70.1%, 95% CI 61.3%–77.9%; CIN3+: 80.8%, 95% CI 67.5%–90.4%) and specificity (81.6%, 95% CI 77.6%–85.1%). HC2 had similar sensitivity for CIN3+ (83.0%, 95% CI 70.2%–91.9%) but lower specificity compared to HSIL+ (42.7%, 95% CI 38.4%–47.1%; relative specificity = 0.57, 95% CI 0.52–0.63), resulting in almost twice as many referrals. Compared to HC2, triage of HC2-positive women with HSIL+ resulted in a 40% reduction in colposcopy referrals but was associated with some loss in sensitivity. CIN2+ incidence over a median 16 months was highest among VIA baseline screen-negative women (2.2%, 95% CI 1.3%–3.7%) and women who were baseline double-negative with HC2 and VIA (2.1%, 95% CI 1.3%–3.5%) and lowest among HC2 baseline screen-negative women (0.5%, 95% CI 0.1%–1.8%). Limitations of our study are that WLHIV included in the study may not reflect a contemporary cohort of WLHIV initiating ART in the universal ART era and that we did not evaluate HPV tests available in study settings today. Conclusions In this cohort study among WLHIV in Africa, a human papillomavirus (HPV) test targeting 14 high-risk (HR) types had higher sensitivity to detect CIN2+ compared to visual inspection but had low specificity, although a restricted genotype approach targeting 8 HR types decreased the number of unnecessary colposcopy referrals. Cytology HSIL+ had optimal performance for CIN2+/CIN3+ detection in SA. Triage of HPV-positive women with HSIL+ maintained high specificity but with some loss in sensitivity compared to HC2 alone.

scholarly journals Delivering Cost-Effective Cervical Cancer Screening Package to Women Living With Human Immunodeficiency Virus By Reproductive Health Uganda

2018 ◽  
Vol 4 (Supplement 2) ◽  
pp. 146s-146s
Author(s):  
A. Kyarimpa
Keyword(s):  
Public Health ◽  
Cervical Cancer ◽  
Human Immunodeficiency Virus ◽  
Cancer Screening ◽  
Reproductive Health ◽  
Cervical Cancer Screening ◽  
Cost Effective ◽  
Women Living With Hiv ◽  
Immunodeficiency Virus ◽  
Living With Hiv

Background and context: Uganda has one of the highest cervical cancer incidences in the world. Over 80% late diagnosis compounds the challenge. It is evident that women living with human immunodeficiency virus (HIV) have a higher prevalence of precancer lesions and have limited access to cervical cancer knowledge and relevant services especially women living with HIV, who are poor and marginalized. This results in a gap for first-line defense to cervical cancer. To bridge the gap and deliver services, Reproductive Health Uganda (RHU) introduced cost-effective “see and treat”, single visit approach (SVA), using combined visual inspection with acetic acid (VIA) and cryotherapy. Aim: To promote single visit approach in cervical cancer screening program in selected HIV clinics and assess the feasibility. Strategy: • Collaborate with HIV clinics, which enroll and provide counseling and services to women living with HIV • Integrate SVA into the current services package in HIV clinics and outreaches to break geographic barriers • Train RHU and public health clinic staff to perform VIA and cryotherapy if needed • Enable SVA in public antiretroviral therapy (ART) clinics through partnerships • Awareness creation through group health education and individual counseling Program: The project implemented in three high HIV prevalence rate districts targeted women 25-49 years of age. Partnered with public ART clinics and arranged training to ensure midwives and nurses in RHU and public health facilities are able to carry out VIA and cryotherapy if needed. Announcements and appointment posters were pinned up on the facility notice board providing details of dates and service package. RHU used this opportunity to promote contraception and STIs management. Health education and counseling session were conducted. Trained peer support mothers mobilized women seek cervical cancer screening when doing HIV follow-up. Quarterly support supervision, QOC assessments and DQAs were conducted to ensure quality and reliability of results and reports. Outcomes: Acceptability of cervical cancer screening was high. The project increased general awareness among rural community members, where cancer is generally stigmatized and associated with a lot of myths. Knowledge, skills and competencies of 54 midwives to screen for and treat with cryotherapy was built. 23,713 women were screened, with average VIA positivity rate 8%-11% across project districts. 98% of cryotherapy-eligible women treated during the same visit. Referral to Ugandan cancer institute was established to ensure timely cancer therapy. Integration and acceptability of family planning increased among women attending ART clinics. What was learned: With appropriate demand creation, acceptability of SVA was good among women attending the ART clinics, SVA is cost-effective and feasible. Integration of SRH package of services helps leverage resources. Strategic partnerships are critical in strengthening public–private partnership in services provision.

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