Should the management of high grade cervical squamous intraepithelial lesion (HSIL) be different in HIV-positive women?

Christine Gilles,Déborah Konopnicki,Maude Velghe-Lenelle,Serge Rozenberg,Yannick Manigart

doi:10.1186/s12981-021-00371-x

Abstract

BackgroundThis study compares the management and outcome of high grade squamous intraepithelial lesions (HSIL) in HIV-positive and -negative women and identifies risk factors for treatment failure.MethodsThis retrospective, controlled study includes 146 HIV-positive women, matched for HSIL, age and year of diagnosis, with 146 HIV-negative women. Differences were analysed using parametric and non-parametric tests and Kaplan–Meier survival curves. A binary logistic regression was used to assess risk factors for treatment failure.ResultsPersistence of cervical disease was observed most frequently in HIV-positive women (42 versus 17%) (p < 0.001) and the cone biopsy margins were more often invaded in HIV-positive-women than in HIV-negative ones. (37 versus 16%; p < 0.05).HIV-positive women, with successful cervical treatment had better HIV disease control: with significantly longer periods of undetectable HIV viral loads (VL) (19 versus 5 months; p < 0.001) and higher CD4 counts (491 versus 320 cells/mm3; p < 0.001). HIV-positive women with detectable VL at the time of dysplasia had 3.5 times (95% IC: 1.5–8.3) increased risk of treatment failure. Being treated through ablative therapy was associated with a 7.4, four-fold (95% IC: 3.2–17.3) increased risk of treatment failure compared to conizationConclusionHIV-positive women have a higher risk of treatment failure of HSIL than do HIV-negative women, especially when ablative therapy is used and in women with poor control of their HIV infection. The management and the follow- up of HSIL’s guidelines in this high-risk population should be adapted consequently: for HIV-positive women with uncontrolled viral load, excisional treatment should be the preferred therapy, whereas for women with undetectable viral load, CD4 + lymphocytes higher than 500 cells/mm3 and with a desire of pregnancy, ablative therapy may be considered.

Highlights

This study compares the management and outcome of high grade squamous intraepithelial lesions (HSIL) in HIV-positive and -negative women and identifies risk factors for treatment failure
HIV-positive women have a higher risk of treatment failure of HSIL than do HIV-negative women, espe‐ cially when ablative therapy is used and in women with poor control of their HIV infection
There were no differences between the two groups in terms of HSIL management: respectively 53% of HIVpositive and 64% of HIV-negative women underwent a cone biopsy and 33% of HIV positive and 25% of HIV negative women were treated by topical therapy

Summary

Introduction

This study compares the management and outcome of high grade squamous intraepithelial lesions (HSIL) in HIV-positive and -negative women and identifies risk factors for treatment failure. It was estimated in 2018, that 40 million people worldwide were living with HIV, of which about half were women [1]. In 2005, we compared HIV-positive and negative women after treatment of CIN 2 and CIN 3 [CIN2 + or high grade intraepithelial squamous lesions (HSIL)] and reported that HIV positive women had higher rates of recurrence of CIN after a median follow-up of 22 months [7], which was confirmed in a systematic review [8]. Compliance friendly cART (including one pill per day) has become widely available [9]

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