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HIV infection and invasive cervical cancer in South Africa. Patrick Lomalisa FCOG ,MPH (SA),Trudy Smith FCOG (SA) and Franco Guidozzi FCOG,PhD (SA). Johannesburg Hospital, Wits University (SA) Gaborone October 2007. Introduction.

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HIV infection and invasive cervical cancer in South Africa

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Hiv infection and invasive cervical cancer in south africa l.jpg

HIV infection and invasive cervical cancer in South Africa

Patrick Lomalisa FCOG ,MPH (SA),Trudy Smith FCOG (SA) and Franco Guidozzi FCOG,PhD (SA).

Johannesburg Hospital, Wits University (SA)

Gaborone

October 2007


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Introduction

  • 1993 :Center for diseases control (CDC,USA) adopted cancer of cervix as an AIDS-defined disease.

  • Developed countries : persistence of relation between cancer of cervix and HIV infection, HIV diagnosed before cancer of cervix, less immunosuppression than other opportunistic infections ,few cases and HAART available since 1996.

  • Developing countries :more cases of cancer of cervix (lack of national screening), increase prevalence of HIV infection, no relation between HIV infection and cancer of cervix (CD4 not available, no HAART,? Death due to opportunistic infections), HIV diagnosed after cancer of cervix .


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HIV infection and cancer of cervix in South Africa

  • No significant increase of incidence of cancer of cervix. From the cancer registry available since 1986 ,cancer of cervix represented 17.4% (1986),17.8% (1992),17%(1999) of total of cancer in women. Persistence of advanced lesions (stages 3&4) at the presentation; +/- 60% (Gordon Grant,1982; Cronje,1996).

  • From the antenatal surveys, there is a continuous increase of prevalence of HIV infection.

  • Studies by Sitas and al,1997 in Soweto, no relation HIV infection and cancer of cervix but relation with Kaposi and non-Hodgkin lymphoma (no CD4 determined), prevalence of HIV infection was 3.5% among cancer of cervix patients reported.


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Objectives

Determine if HIV(+) with invasive cervical

cancer had more advanced lesions

than HIV(-) women.

Determine if degree of immunity affects the stage of disease at presentation.


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Methodology

  • Review of all new cases of invasive cervical cancer at the combined gynecologic oncology unit of the Witwatersrand University from 01/01/1997 to 30/06/1998.

  • Demographic characteristics (age, parity), histology type, stage of the disease, HIV status and CD4 for HIV(+) women were reviewed.


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Results

  • Comparison of demographic characteristics and histology type

    60 HIV(+) 776 HIV(-) p-value

    Age

    Mean 44+9.8 53+12.7 <0.001

    Range 28-70 15-90

    <30 2(3.3) 9(1.1)

    >/=50 16(27.7) 450(68.2)

    Parity

    Median (range)

    3(0-9) 4(0-14) NS

    Histology type

    SCC 55(91.6) 725(93.4) NS

    Stages 3&4 39(65) 430(55.4) NS

  • HIV(+) :77% of CD4<200 and 56% CD4>/=200 had stages 3&4(p=0.109).

  • HIV(+) and CD4<200 77% and HIV(-) 55% had stages 3&4(p=0.041)


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Discussion

  • Prevalence of HIV infection among cancer of cervix women is

    variable.

    -Johannesburg ; Sitas et al 3.5%(1997) and lomalisa et

    al 7.2%(2000). Moodley et al (2006) in Durban found no increase

    of prevalence (21 % in 1999 and 21.8% in 2003) but a

    decrease of number of new cases of invasive cervical cancer (672 in 1999 to

    271 in 2003).

    -Moodley J R et al in Cape Town (2006) found an increase risk of cervical pre-

    cancer but no relation between HIV infection and invasive cervical cancer. HIV (+)

    women : 5 times high risk of HPV infection and HPV +HIV(+) :40 Times risk for SIL

  • Age of patients : all studies showed that HIV(+) women were younger than HIV(-) women.

  • Relation HIV and HPV: HIV alters the natural history of HPV infection with decrease regression rates and more rapid progression to HGSIL and ICC.(Clarke and Chetty ,2002 ;Durban, SA).


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Discussion (ctd)

  • Is cancer of cervix of cervix an AIDS –defined cancer (Bower et al,2006)?

    3 parameters : increase risk with decrease CD4 ,reduction of risk by HAART and improved survival by HAART.

    Since HAART in 1996,no evidence with cancer of cervix but good evidence for Kaposi Sarcoma and non-Hodgkin lymphoma.

    If good prevention program, no increase prevalence of ICC among HIV-infected women (Massad et al,2004;USA).


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Discussion (ctd)

  • If good screening program ;decrease prevalence of ICC +early lesions (developed countries). If no no good program : increase prevalence and advanced lesions (developing countries).

  • For HIV(+): No difference if CD4>200. If CD4 <200, depending of HAART availability and cervical screening program. HAART(+) +good program :no increase number of ICC (developed countries)

  • And if HAART(-) and no program :no relation because patients die of opportunistic infections (developing countries).


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Conclusion

  • No relation to date between cancer of cervix and HIV infection.

  • Abnormal pap smear (HGSIL): Counsel for HIV testing and manage according to CD4/Viral load.

  • SA Oncology group : 3 pap smears for population starting @ 30 years old.

  • HIV + : yearly pap smear if immunosuppression.

    THANX FOR YOUR ATTENTION


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