VULVOVAGINAL WARTS AND NEOPLASIA IN HIV-POSITIVE WOMEN

Abstract

BACKGROUND Several reports indicate higher rates of vulvar wats and vulvar intraepithelial neoplasia (IN) in HIV-seropositive women than in HIV-seronegative women. In this study, our goal was to determine the prevalence of vaginal and vulvar warts and neoplasia as defined by colposcopy and to evaluate the course of vaginal and vulvar warts and neoplasia on follow-up. METHODS: From 1991 to 1994, 285 HIV-seropositive women were enrolled in a study of the natural history of HIV disease and its gynecologic manifestations. At entry, the lower genital tract was evaluated by colposcopy and cytology. Vaginal and vulvar lesions were biopsied if suspicious for IN. Women were followed by pelvic exams and cytology every 6 months and by annual colposcopy. RESULTS: At study entry, 273 women had colposcopic evaluation of the lower genital tract. Four women (2%) had vaginal IN (VAIN) and 14 (5%) had vaginal warts. The prevalence of VAIN/warts in women with CD4 counts below 200 was 10% compared to 5% above 200 (p=0.15). One patient developed VAIN3 and two developed vaginal warts during follow-up. Mean CD4 count of VAIN patients was 200 and of patients with vaginal warts was 290. At baseline colposcopy, 2 women (1%) had vulvar IN (VIN) and 42 (15%) had vulvar warts. The prevalence of vulvar warts/VIN was 17% at CD4 counts < 200 compared to 15% > 200. Eight women developed vulvar warts on follow-up. Mean CD4 count of VIN patients was 289 and of patients with vulvar warts was 318. One patient with VAIN 3 treated by vaginectomy had no recurrence after 22 mos. Three of 4 patients with VAIN 1 treated by vaginal 5-fluorouracil cream, had persistent mild warts, but no evidence of VAIN (mean follow-up: 16 months). Three women had vaginal warts which persisted more than 12 months, while 9 had no further evidence of warts. One patient with untreated VIN 2 had persistent VIN2 more than 25 months after diagnosis. One patient with VIN 1 treated by LEEP had no recurrent VIN after 30 months. Of 9 patients with CD4 counts < 200, vulvar warts persisted in 33%, and in 30 patients with CD4 count > 200 vulvar warts persisted in 30%. CONCLUSION In HIV-seropositive women vulvovaginal IN and warts are more prevalent than reported in immunocompetent populations. However, with limited numbers, we observed no differences by severity of immunodeficiency. Meticulous surveillance of the entire lower genital tract including vagina, vulva and perineum should be a routine part of care for HIV-seropositive women.