The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study.

Allen C. Bateman,Jeffrey S. A. Stringer,Vikrant V. Sahasrabuddhe,Benjamin H. Chi,Katundu Katundu,Groesbeck P. Parham,Carla J. Chibwesha,Sharon Kapambwe,Mulindi H. Mwanahamuntu,Michael L. Hicks

doi:10.1186/s12885-015-1558-5

Abstract

BackgroundHIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC.MethodsWe conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia’s most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally.ResultsOver half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC.ConclusionsThe DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.

Highlights

HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC)
Over half (52 %; 161) of the study participants screened positive by digital cervicography (DC), while 45 % (138) had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse (HSIL+) (Fig. 1)
Using DC, cytology, and histologic evaluation of both abnormal and normal appearing areas of the cervix, we have demonstrated the large burden of high-grade cervical neoplasia among previously unscreened HIV positive women in Zambia

Summary

Introduction

HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. Cervical cancer is the most common cause of cancer death among women in sub-Saharan Africa [2], and Zambia has the second-highest incidence rate of ICC in the world [1]. HIV compounds the ICC burden, because HIV is associated with a higher prevalence of persistent infection with high-risk human papillomavirus (HPV) – an obligate cause of ICC [4,5,6]. HIV infection is associated with a higher incidence of precancerous cervical lesions and accelerated progression of these lesions to ICC [7]. The effect of antiretroviral therapy (ART) on the natural history of cervical precancerous lesions is unclear [7], with some studies showing no effect and other studies showing a modest beneficial effect of ART [8, 9]

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