HIV Medicine

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.

High‐risk human papillomavirus prevalence and serostatus in a cohort of cisgender women and people with a cervix living with perinatally acquired HIV

Abstract Objectives Human papillomavirus (HPV)‐associated cervical cancer risk is greater in people with HIV, although this has been at least partially attenuated by antiretroviral medication, enhanced cervical screening and HPV vaccination. People with perinatally acquired HIV may remain at higher risk due to lifelong immunosuppression and potentially reduced vaccine effectiveness. In this study in people with a cervix with perinatally acquired HIV, we explored cervical high‐risk HPV (hrHPV) prevalence and HPV serostatus. Methods Participants were recruited from a London HIV service between 2020 and 2022. Cervical samples from those sexually active were analysed for hrHPV (Cepheid GeneXpert) and cytology, and, if abnormal, a referral was made to colposcopy. Serum samples were tested for antibodies against HPV6/11/16/18/31/33/45/52/58. A self‐reported questionnaire including HPV vaccination history was completed. Results Fifty‐seven people were recruited with a median age of 25 years (range 18–34). Of those providing a cervical sample, 15/47 (32%) were hrHPV‐positive and 12/40 (30%) had abnormal cytology; 1/17 referred for colposcopy had CIN2 (6%); 7/15 (47%) with hrHPV were below the national screening age of 24.5 years (range 19–23), and 9/15 (60%) reported previous HPV vaccination. No vaccinated participants had hrHPV16/18. Of those vaccinated, 37/39 (95%) were seropositive for HPV16 and 30/39 (77%) for HPV18. Two vaccinated participants were seronegative for HPV16/18; both had detectable HIV viral loads and CD4 counts <200 cells/μL at recruitment. Conclusion In this small observational study we identified a 32% prevalence of cervical hrHPV. Cervical screening and HPV vaccination remain vital in this group, with further data required to inform screening guidelines for this population.

Risk factors, management, and HPV genotyping of vulvar intraepithelial neoplasia ( VIN ) in women living with HIV : A comparison with women without HIV and a case control study

Abstract Background Literature on vulvar cancer (VC) and vulvar intraepithelial neoplasia (VIN) in women living with HIV (WLWH) is scarce with no data on human papillomavirus (HPV) genotyping. Methods We compared disease characteristics and HPV genotyping on biopsies from WLWH and HIV‐negative women (HNW) followed for VIN2+ (VIN2/3 and VC) at Saint‐Pierre Hospital between 2000 and 2022. Then, a case control study identified VIN2+ risk factors among WLWH with VIN2+ (cases) and WLWH without VIN followed at the same period (controls), matched for age, ethnicity, and HIV follow‐up duration. Results Compared to 65 HNW (28 VC/37 VIN), 25 WLWH (4 VC/21 VIN) were younger at time of VIN2+ diagnosis (48 vs. 58.7 years, p  < 0.001), had more frequently cervical or anal (multicentric) dysplasia (52% vs. 22%, p  = 0.02) and non‐excisional treatments, and less often healthy margins in excisions (14% vs. 43%, p  = 0.02). In WLWH, high‐risk HPV was found in 100% (vs. 85% in HNW) with more multiple genotype infections (40% vs. 13%); HPV16 was found in 80% of VC and 73% of VIN in WLWH versus 91% and 79% in HNW. Compared to 75 controls, 25 cases had significantly more frequently prior cervical high‐grade intraepithelial lesion (HSIL) (40%), lower median CD4‐lymphocyte count (382/μL), and shorter duration of undetectable HIV viremia (4.8 years) than controls (respectively 0%, p  = 0.001; 770 CD4/μL, p  = 0.021; 10.6 years, p  = 0.04). Conclusions WLWH develop VIN2+ younger than HNW, with more multiple HPV infections but less HPV 16, more multicentric lesions, and less excisions with negative margins. Risk factors for developing VIN2+ in WLWH include lack of viremia control and immunosuppression.

Screening and prevention of HPV‐related anogenital cancers in women living with HIV in Europe: Results from a systematic review

AbstractBackgroundWomen living with HIV (WLWH) are at increased risk of human papillomavirus (HPV)‐related cancers. Throughout Europe, there is great heterogeneity among guidelines for screening programmes, access to HPV testing and HPV vaccination. The aim of this systematic review is to summarize available data on screening and prevention measures for HPV‐related anogenital cancers in WLWH across the WHO European Region (WER).MethodsThe systematic review followed the PRISMA guidelines and was registered on Prospero. PubMed, Embase and Web of Science databases were searched to identify available studies, written in English and published between 2011 and 2022. A metanalysis was conducted using random‐effects models to calculate pooled prevalence of HPV. Subgroup analyses were conducted according to country and HPV testing.ResultsThirty‐four articles involving 10 336 WLWH met the inclusion criteria. Studies were heterogenous in their methodology and presentation of results: 73.5% of studies focused on cervical cancer prevention, and only 4.4% on anal cancer; 76.5% of studies conducted HPV testing as a routine part of screening. The prevalence of high‐risk HPV was 30.5–33.9% depending on the detection method used. A total of 77% of WLWH had cervical cytology results reported. Six studies reported the positive association of CD4 cell count <200 cells/μL with HPV prevalence and cervical abnormalities. Anal HPV testing was conducted in <8% of participants. HPV vaccination was completed in 5.6% of women (106/1902) with known vaccination status. There was no information about the vaccination status of the majority of women in the analysed studies (8434/10336).ConclusionData about screening of HPV‐related anogenital cancer in WLWH in Europe are heterogenous and lacking, especially in relation to anal cancer. HPV DNA testing is not routinely done as part of screening for HPV‐related cancer; guidelines should include indications for when to use this test. Low CD4 count is a risk factor for HPV infection and cytological abnormalities. HPV vaccination data are poor and, when available, vaccination rates are very low among WLWH in Europe. This review concludes that significant improvements are required for data and also consistency on guidelines for HPV screening, prevention and vaccination in WLWH.

Re‐valuation of annual cytology using HPV self‐sampling to upgrade prevention (REACH UP): A feasibility study in women living with HIV in the UK

AbstractIntroductionCurrent UK guidelines for cervical cancer screening are based on the assumption that most women living with HIV (WLWH) are also high‐risk (HR) human papillomavirus (HPV)‐positive. We aimed to provide data on prevalence of HR‐HPV in WLWH in the UK and to assess feasibility and acceptability of HR‐HPV self‐sampling in this group.MethodsWomen living with HIV attending six HIV services in London/south of England, with no history of cervical cancer, were enrolled. Participants self‐collected a vaginal swab for the detection of HR‐HPV, completed a survey about sexual/gynaecological history, attitudes towards annual screening and perception of HR‐HPV self‐sampling, and were asked to have their annual cervical smear.ResultsIn all, 67 women were included: 86.5% were of black ethnicity, the median (range) age was 47 (24–60) years, median CD4 T‐cell count was 683 cells/µL [interquartile range (IQR): 527–910], and 95.4% had viral load ≤ 50 copies/mL. All performed the vaginal swab. Eighteen (27%) had no cervical smear results; none of these women attended HIV services where this was routinely offered. No cervical samples were positive for HR‐HPV. Three‐quarters (75.8%) of participants reported adherence to annual screening, with only one woman (1.5%) attending irregularly. On visual analogue scales (from 0 to 100), median (IQR) acceptability and necessity of smear tests were 100 (75–100) and 100 (85–100), respectively.ConclusionsOur results suggest that the prevalence of HR‐HPV in WLWH in the UK may be low. Self‐sampling seems to be acceptable, suggesting, if validated, its potential role in supporting less frequent smear testing and improving screening uptake in WLWH.