Progression and regression of pre-malignant cervical lesions in HIV-positive women from Soweto
Polly Clayden, HIV i-Base
A poster authored by Tanvier Omar and coworkers reported progression and regression of pre-malignant lesions in a prospective cohort of HIV-positive women in Soweto, South Africa.
HIV-positive women >18 years, receiving ART or in pre-ART care, were offered cervical smears as part of a comprehensive package of primary care. Smears were assessed using the Bethesda system. Women with high-grade squamous intraepithelial lesions (ASC-H or HSIL), or worse were referred for colposcopy, treatment, and possible loop excision of the transformation zone.
In this study, women who had a least one smear were included in the prevalence analysis. Women with at least two smears were included in the assessment of incidence, progression and regression. The progression analysis included smears at least 5.5 months apart and regression at least 11 months apart.
Using Cox proportional hazard regression the investigators estimated predictors of incident events of either:
- HSIL in women with baseline normal, atypical squamous cells of undetermined significance (ASCUS); or low-grade squamous intraepithelial lesions (LSIL) smears; or
- Regression to normal in women with baseline LSIL smears.
1951/2533 (76.8%) of women had at least one cervical smear and 763 (30%) women had more than one smear 5.5 months apart.
At the time of their baseline smear their median age was 32.6 years and median CD4 count was 328 cells/mm3.
Baseline prevalence rates were: 59.2% (95% CI 57.0-61.3); 18.8% (95% CI 17.1-20.5), 17.1% (95% CI 14.4-18.8), for normal, LSIL and HSIL smears respectively. Based on 161 cases of progression among those with normal, ASCUS or LSIL smears, the investigators reported overall progression rates of 11.4/100 person years (95% CI 9.7- 13.3, n=927).
In multivariate analysis CD4 <200 cells/mm3 (with >500 CD4 cells/mm3 as reference), HR 2.27 (95% CI 1.38-3.72) and younger age (for every increase of 5 years), HR 0.83 (95% CI 0.74-0.94) were predictors of progression. ART did not appear to offer protection but there was insufficient time on ART to predict progression.
The investigators found rates of regression to be low in this analysis; 106/191 (55.5%) women with baseline LSIL remained LSIL and 38 (19.9%) women progressed at their second visit >1 year later.
The investigators reported 83/682 (12.2%) of women with normal, ASCUS or LSIL smears at baseline progressed to incident HSIL. Additionally, 157/544 had incident LSIL or worse after normal at baseline.
They wrote: “Earlier initiation of screening, shorter screening intervals in women with CD4 counts <200, and more proactive management of LSIL should be tested.”
“Our results add urgency to improving access to an affordable, effective HPV vaccine.” They added.
It is hard to develop recommendations for a package of services that are evidence based for use in this setting.
Ref. Omar et al. Progression and regression of pre-malignant cervical lesions in HIV-infected women from Soweto: A prospective cohort. 16th CROI, February 2009, Montreal, Canada. Poster abstract 974.