Cervical Cancer Risk Linked to HPV and Poor Immune Status

SAN DIEGO—AIDS experts have long worried that human immunodeficiency virus (HIV) infection might increase a woman’s risk of cervical cancer, particularly in the presence of concurrent human papillomavirus (HPV) infection.

Results of the Women’s Interagency HIV study, reported at the 31^st annual meeting of the Society of Gynecologic Oncologists (SGO), show that although most HIV-positive women have some abnormal cervical cytology, progression to cancer is not necessarily accelerated.

Progression is more likely in patients who also have HPV infection and/or poor immune status, such as CD4 cell counts less than 200 cells/mm³, said L. Stewart Massad, MD, of the Department of Gynecologic Oncology, Cook County Hospital, Chicago.

“Risk is related to HPV and degree of immunosuppression,” Dr. Massad told ONI in an interview. “HIV-positive women with good immune status and no HPV do as well as HIV-negative women, but HIV-positive women with poor immune status and no HPV do worse. Similarly, women with HPV do worse than women without HPV across all groups of HIV status.”

The study included data from 2,390 women at six US sites (1,860 HIV-positive women and 530 HIV-negative comparison women). The investigators obtained cervical Pap smears, CD4 counts, and HIV RNA measurements every 6 months over 3.5 years.

The cumulative risk of having an abnormal Pap smear during the study period was significantly higher among the HIV-positive women than the HIV-negative women (66.4% vs 33.4%, P < .01), but only eight women, all of them HIV positive, developed cancer (see Table).

The adjusted relative risk of developing a low-grade squamous intraepithelial lesion (LSIL) or higher among women who were both HIV and HPV positive and whose CD4 counts were under 200 cells/mm³ was 12 (range, 6.5 to 22.2), compared to women with neither HIV nor HPV.

Multivariate analysis showed that HPV infection, HIV infection, low CD4 count, and high HIV RNA level increased the risk of progression (P <.01). Odds of progression were 4.1 times higher among HIV/HPV-positive women with CD4 counts less than 200 cells/mm³ than among HIV/HPV-negative women.

The researchers concluded that abnormal cytology occurs in most HIV-positive women followed for 3.5 years but that high-grade changes are uncommon.

“The most important clinical message from our study is that risk for abnormal Pap smear has to be determined on an individual basis. Women who are HIV positive with good immune status have an outlook as good as that of HIV-negative women with the same HPV status,” Dr. Massad said. “Clinicians should continue to stick with the CDC guidelines for cervical cancer screening and let HIV-positive women know that cervical disease is not a relentless, hopeless process leading to cancer.”