Eliane Rohner

Factors associated with uptake of gynaecological care and cervical cancer screening among women in the Swiss HIV Cohort Study

Abstract Objectives We assessed factors associated with attendance at gynaecological visits and cervical cancer screening, and estimated the incidence of cervical dysplasia and cancer among women with HIV (WWH) in Switzerland over two decades. Methods We used self‐reported gynaecological information, collected biannually, in the Swiss HIV Cohort Study between April 2001 and June 2022. We used mixed‐effects logistic regression to examine factors associated with attending yearly gynaecological visits and having cervical smears performed. We estimated cervical dysplasia and cancer incidence rates per 100 000 person‐years and used Cox regression to assess factors associated with incident dysplasia and cancer. Results Among 4052 included WWH, cervical smears were collected in 83% of 33 097 pregnancy‐unrelated visits. Gynaecological visits were less common among older women, among those with lower education, or with a history of intravenous drug use. If a gynaecological visit occurred, cervical smears were less common among women of Black than White ethnicity. Among 3970 women included in the incidence analysis, 218 cervical dysplasias (crude rate: 466/100 000 person‐years) and 14 cervical cancers (crude rate: 28/100 000 person‐years) were recorded. Women who had cervical smears documented in a higher proportion of time periods were more likely to have a cervical dysplasia diagnosis but less likely to have a cervical cancer diagnosis documented. Conclusions We found substantial disparities in the uptake of gynaecological visits and cervical smears by age, education level, ethnicity and intravenous drug use. Implementing more targeted and integrated cervical cancer screening and gynaecological care models may help reduce these disparities and improve prevention of cervical cancer among WWH in Switzerland.

Cervical intraepithelial neoplasia progression and regression among women living with HIV in Zambia

Abstract Objectives Cervical screening and precancer treatment are less effective in women living with HIV (WLWH) than in women without HIV. We assessed high‐risk human papillomavirus (HR‐HPV) infection and cervical disease progression among screened WLWH in Zambia. Methods Participants underwent visual inspection with acetic acid (VIA), HR‐HPV testing and cervical biopsies at baseline and at follow‐up 30–36 months later. Women with positive VIA results or high‐grade histology were offered treatment. We assessed HR‐HPV and cervical disease prevalence at both timepoints and used multivariable logistic regression to identify factors associated with cervical disease progression and regression. Results Among 241 included women, HR‐HPV prevalence declined from 44% (95% confidence interval [CI]: 39%–49%) at baseline to 24% (95% CI: 19%–31%) at follow‐up. High‐grade disease decreased from 25% (95% CI: 20%–31%) to 9% (95% CI: 5%–13%). In analyses adjusted for age, CD4 cell count, HIV RNA viral load, HR‐HPV infection and histological results at baseline, precancer treatment was associated with increased odds of disease regression (adjusted odds ratio [aOR]: 2.74, 95% CI: 1.08–7.06) and reduced odds of progression (aOR: 0.45, 95% CI: 0.11–1.64). One‐third of women with high‐grade disease at follow‐up (7/21) had previously undergone precancer treatment. Conclusions Cervical screening and precancer treatment are key to reducing cervical disease progression among WLWH and ultimately achieving cervical cancer elimination, but efforts to improve treatment effectiveness among WLWH must be balanced with the risk of overtreatment.

Cervical cancer risk in women living with HIV across four continents: A multicohort study

We compared invasive cervical cancer (ICC) incidence rates in Europe, South Africa, Latin and North America among women living with HIV who initiated antiretroviral therapy (ART) between 1996 and 2014. We analyzed cohort data from the International Epidemiology Databases to Evaluate AIDS (IeDEA) and the Collaboration of Observational HIV Epidemiological Research in Europe (COHERE) in EuroCoord. We used flexible parametric survival models to determine regional ICC rates and risk factors for incident ICC. We included 64,231 women from 45 countries. During 320,141 person‐years (pys), 356 incident ICC cases were diagnosed (Europe 164, South Africa 156, North America 19 and Latin America 17). Raw ICC incidence rates per 100,000 pys were 447 in South Africa (95% confidence interval [CI]: 382–523), 136 in Latin America (95% CI: 85–219), 76 in North America (95% CI: 48–119) and 66 in Europe (95% CI: 57–77). Compared to European women ICC rates at 5 years after ART initiation were more than double in Latin America (adjusted hazard ratio [aHR]: 2.43, 95% CI: 1.27–4.68) and 11 times higher in South Africa (aHR: 10.66, 95% CI: 6.73–16.88), but similar in North America (aHR: 0.79, 95% CI: 0.37–1.71). Overall, ICC rates increased with age (>50 years vs. 16–30 years, aHR: 1.57, 95% CI: 1.03–2.40) and lower CD4 cell counts at ART initiation (per 100 cell/μl decrease, aHR: 1.25, 95% CI: 1.15–1.36). Improving access to early ART initiation and effective cervical cancer screening in women living with HIV should be key parts of global efforts to reduce cancer‐related health inequities.

Gynaecologic and breast cancers in women living with HIV in South Africa: A record linkage study

AbstractBreast and gynaecologic cancers account for approximately half of all cancers diagnosed amongst women in South Africa, many of whom also live with HIV. We aimed to determine the incidence of and risk factors for developing breast and gynaecologic cancers in women living with HIV (WLHIV) in South Africa. This is a longitudinal analysis of the South African HIV Cancer Match study including women aged ≥15 years with two or more HIV‐related laboratory tests. We used Cox proportional hazard models to determine the association of Human Papilloma Virus (HPV)‐related and hormone‐related gynaecologic cancer with patient‐ and municipal‐level characteristics. From 3 447 908 women and 10.5 million years of follow‐up, we identified 11 384 incident and 7612 prevalent gynaecologic and breast cancers. The overall crude incidence rate was 108/1 00 000 person‐years (pyears) (95% confidence interval [CI]: 106‐110), with the highest incidence observed for cervical cancer (70/1 00 000 pyears; 95% CI: 68.5‐71.7). Low CD4 cell counts and high HIV RNA viral loads increased the risk of cervical and other HPV‐related cancers. Age was associated with both HPV‐related and hormone‐related cancers. Women accessing health facilities in high socioeconomic position (SEP) municipalities were more likely to be diagnosed with HPV‐related cancers and breast cancer than women accessing care in low SEP municipalities. It is important to improve the immunologic status of WLHIV as part of cancer prevention strategies in WLHIV. Cancer prevention and early detection programmes should be tailored to the needs of women ageing with HIV. In addition, SEP disparities in cancer diagnostic services have to be addressed.

Cervical precancer and cancer incidence among insured women with and without HIV in South Africa

AbstractHIV infection increases the risk of developing cervical cancer; however, longitudinal studies in sub‐Saharan Africa comparing cervical cancer rates between women living with HIV (WLWH) and women without HIV are scarce. To address this gap, we compared cervical precancer and cancer incidence rates between WLWH and women without HIV in South Africa using reimbursement claims data from a medical insurance scheme from January 2011 to June 2020. We used Royston‐Parmar flexible parametric survival models to estimate cervical precancer and cancer incidence rates as a continuous function of age, stratified by HIV status. Our study population consisted of 518 048 women, with exclusions based on the endpoint of interest. To analyse cervical cancer incidence, we included 517 312 women, of whom 564 developed cervical cancer. WLWH had an ~3‐fold higher risk of developing cervical precancer and cancer than women without HIV (adjusted hazard ratio for cervical cancer: 2.99; 95% confidence interval [CI]: 2.40‐3.73). For all endpoints of interest, the estimated incidence rates were higher in WLWH than women without HIV. Cervical cancer rates among WLWH increased at early ages and peaked at 49 years (122/100 000 person‐years; 95% CI: 100‐147), whereas, in women without HIV, incidence rates peaked at 56 years (40/100 000 person‐years; 95% CI: 36‐45). Cervical precancer rates peaked in women in their 30s. Analyses of age‐specific cervical cancer rates by HIV status are essential to inform the design of targeted cervical cancer prevention policies in Southern Africa and other regions with a double burden of HIV and cervical cancer.