1 / 16

Cervical Cancer and HIV: Interactions and Interventions

Cervical Cancer and HIV: Interactions and Interventions. Jean R. Anderson, M.D. Jhpiego, an affiliate of Johns Hopkins University The Johns Hopkins University School of Medicine. Cervical Cancer. Latest data on cervical cancer incidence and mortality (GLOBOCAN 2008, IARC*):

saddam
Download Presentation

Cervical Cancer and HIV: Interactions and Interventions

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Cervical Cancer and HIV:Interactions and Interventions Jean R. Anderson, M.D. Jhpiego, an affiliate of Johns Hopkins University The Johns Hopkins University School of Medicine

  2. Cervical Cancer • Latest data on cervical cancer incidence and mortality (GLOBOCAN 2008, IARC*): • Globally 529,512 cases diagnosed per year: • 86% of all cases (n=453,032) in developing world • Globally 274,967 deaths: • 88% of all deaths (n=241,818) in developing world • Mortality to incidence ratio: • Developed countries: 36–43% • Developing countries: 54–80% *www.iarc.fr/globocan2008

  3. Globocan 2008—Most Frequent Cancers in Women in Africa* *www.iarc.fr/globocan2008

  4. Additional Burden in Africa: HIV/AIDS HIV incidence in Africa (UNAIDS 2010) Cervical cancer incidence in Africa (Globocan 2008, IARC)

  5. HIV and Cervical Cancer • Studies have shown that among HIV-positive women, there is a consistently higher incidence of: • Human papillomavirus (HPV) infection • Persistent HPV infection with high-risk types • Infection with multiple types of HPV • Cervical cancer precursors (cervical intraepithelial neoplasia [CIN] or squamous intraepithelial lesion [SIL]) • Cervical dysplasia tends to involve a larger area of the cervix in the setting of HIV infection • Cancer registry linkage studies have shown significant increase in cervical cancer, particularly where women live longer due to access to ART

  6. +++ ++ +/- Source: Palefsky.Curr Opin Oncol 2003.

  7. Alternatives to Cytology: Visual Inspection with Acetic Acid (VIA) • Meta-analysis of 26 studies(Int J Gynecol Obstet 2011;113:14) in which VIA was performed on asymptomatic women who underwent confirmatory testing with a disease threshold of CIN 2 plus reported: • Sensitivity of 80% (range 79–82%) • Specificity of 92% (range 91–92%) • Positive predictive value of 10% • Cluster-randomized trial in India (Lancet 2007;370:398): • 31,343 screened with VIA vs. 30,958 controls, 30–59 years old, 7-year follow-up • VIA-positive received colposcopy/biopsy and cryotherapy at same visit with colposcopy impression low-grade SIL/high-grade SIL • VIA associated with 24% reduction in cervical cancer (Stage II or worse) incidence and 35% reduction in cervical cancer mortality • Safe, feasible and acceptable in multiple studies • Can be done by trained nurses/midwives • Inexpensive • Allows treatment at same visit

  8. Alternatives To Cytology: HPV Testing • Cluster randomized trial in India • 4 arms: HPV (hybrid capture), VIA, cytology, standard of care (no screening); >2,700 women 30–59 years in each arm with 8-year follow-up • Positive results: colposcopy/biopsy, treatment (cryotherapy or loop electrosurgical excision procedure [LEEP]) • HPV testing associated with approximately 50% reduction in detection of advanced cervical cancer and cervical cancer deaths vs controls; no significant difference for VIA, cytology • Source: NEJM 2009;360:1385.

  9. VIA 30–50 Years HIV-Positive—at Any Age FP/MNCH, OPD, Gyn, ART Clinic Negative Positive Follow-Up 3–5 Years (HIV-) Follow-Up 1 Year (HIV+) Treat Immediately Cryotherapy Refer/Treat with LEEP Repeat VIA after 1 Year Target for Screening and Flow Pattern

  10. VIA by Total and HIV-Infected Women and Treatment Rates

  11. Cervical Cancer VIA Screening and Treatment Outcomes for 3 Countries, January 2009–March 2012* New women screened 7,538 Côte d’Ivoire 19,934 Guyana 7,449 Tanzania • Suspect cancer cases detected and referred • 50 (0.7%) Côte d’Ivoire • 108 (0.5%) Guyana • 178 (2%) Tanzania VIA screen positive* 519 (7%)Côte d’Ivoire 2,529 (13%) Guyana 532 (7%) Tanzania VIA screen negative 6969 (92%) Côte d’Ivoire 17,297 (87%) Guyana 6,739 (90%) Tanzania • Cryotherapy treatment postponed • 81 (23%) Côte d’Ivoire • 336 (16%) Guyana • 34 (8%) Tanzania • Treated with cryotherapy on same day as screening (SVA) • 279 (78%) Côte d’Ivoire • 1,813 (84%) Guyana • 416 (92%) Tanzania • Referred for large lesions • 159 (31%) Côte d’Ivoire • 381 (15%) Guyana • 82 (15%) Tanzania • LEEP performed • 45 (28%) Côte d’Ivoire • 239 (63%) Guyana • 6 (7%) Tanzania • Lost to advanced care follow-up • 114 (72%) Côte d’Ivoire • 142 (37%) Guyana • 76 (93%) Tanzania • Lost to cryotherapy treatment • 39 (48%) Côte d’Ivoire • 150 (45%) Guyana • 28 (82%) Tanzania • Returned for cryotherapy after previously postponing • 42 (52%) Côte d’Ivoire • 186 (55%) Guyana • 6 (18%) Tanzania *Côte d’Ivoire began in October 2009 and Tanzania began in April 2010.

  12. Initial Results from a Multi-Country Cervical Cancer Screening Program for HIV-Infected Women • Summary of study: • VIA/SVA for cervical cancer prevention in Côte d’Ivoire (n=7,538), Guyana (n=19,934) and Tanzania (n=7,449) • Services provided by trained nurses/midwives at HIV care and treatment sites and general health facilities • Key results: • In all 3 countries, HIV-positive women were more likely to be VIA-positive than HIV-negative/unknown women • In all 3 countries, HIV-positive women who were VIA-positive were more likely to have large lesions (occupying >75% cervix) and therefore ineligible for cryotherapy • 85% of eligible women had same-day treatment with cryotherapy; of those who postponed, 48% did not return for treatment Source: Anderson J, Lu E, Wysong M, Kibwana S, Estep D, Varallo J, Toure K, Giattas M, for Jhpiego.

  13. Lessons Learned • Promote country ownership • Implement sustainable, organized screening for scale-up • Conduct monitoring and assessment • Build capacity • Maintain quality of care

  14. Research Priorities • What are the optimal screening strategies for cervical cancer precursors in setting of HIV? • Potential role of self-collection • Role of HPV-DNA testing • What are the optimal treatment methods for cervical cancer precursors in setting of HIV? • Does screening or treatment effectiveness vary by CD4/CD4 nadir or ART status? • What are the determinants of recurrence and what are best strategies to identify recurrences?

  15. Research Priorities (cont.) • How can recurrences be prevented? • What is the role of male circumcision in cervical cancer prevention (and programmatic implications)? • What are effects of treatment (cryotherapy vs. LEEP, others?) on HIV shedding and what are the determinants? • What are the most effective strategies to incorporate cervical screening and treatment into HIV care? • Models of integration • Systems issues • Quality control: training, pathology, etc.

  16. Summary • Cervical cancer is a leading cause of morbidity and mortality in limited-resource countries • HIV infection is associated with higher incidence of cervical cancer and its precursors and this association persists in the era of effective ART • Alternatives to cytology, such as VIA, are critical to ensure adequate coverage and appropriate interventions for cervical cancer screening and prevention in the setting of HIV, but several key research questions remain

More Related