The battleground of two Infections and a cancer: Human Papilloma Virus, premalignant lesions of the cervix and their interaction with Human Immunodeficiency Virus in southwestern Nigeria

Abstract

Background: The highest numbers of HIV-infected women are in sub-

Saharan Africa, where the natural progression of HIV disease in the

absence of treatment results in death before the onset of invasive cervical cancer. With improved access to treatment, several studies outside West Africa demonstrated an increased risk of pre-invasive cervical lesions among HIV-infected women and the positive impact of treatment on the outcome. Given the various HIV strains in Nigeria and other West African countries, a different outcome may be expected. Unfortunately, limited information exists on the subject in the sub-region.

Aim: To study the effect of HIV infection on the burden of premalignant lesions of the cervix; assess the diagnostic accuracy of direct visual inspection of the cervix; and contribute to policy formulation and the development and implementation of effective cervical cancer prevention and control programme in Nigeria.

Method: The studies (I-V) were conducted among adult women of known

HIV status in south-western Nigerian (2011- 2012). Study I, a randomised control study among 1140 women, determined the effect of HIV infection on the test performance of direct visual inspection of the cervix in detecting cytology - diagnosed squamous intraepithelial lesions. Studies II and III utilised data generated in Study I to determine the interaction between HIV infection, antiretroviral therapy, and precancerous lesions of the cervix. Study IV, a cross-sectional study, assessed the acceptability of cervical cancer screening among 1517 HIV- positive women. Study V prospectively determined the outcome of follow- up after a positive cervical cancer screening test.

Results: Visual inspection with Lugol’s iodine was found to be inferior to visual inspection with acetic acid and inadequate as a cervical cancer screening tool in cases of severe immune deficiency (specificity of 66.9% and negative predictive value of 50.0%). The prevalence of high risk HPV and squamous intraepithelial lesions were 19.6% and 8.4%, respectively. HPV 16 (3.9%), 35 (3.5%) and 58 (3.5%) were most frequently found. HIV positive women were found to be at increased risk of high risk HPV infection (OR: 1.8; 95% CI: 1.4 - 2.2) and squamous intraepithelial lesion (OR: 5.4; 95% CI: 2.9 - 8.8). Antiretroviral drugs was found to protect against high risk HPV infection (OR: 0.4; 95% CI: 0.3- 0.5) and development of squamous intraepithelial lesions. Although only 56.2% of HIV positive women were aware of cervical cancer screening, the test was acceptable

to 79.8% of them. Among the 108 women who screened positive during

outreach cervical cancer screening, 47.2% defaulted from follow -up as a result of transportation and cost- related issues and an anticipated long waiting time at the referral centre. Poorly educated women (OR: 3.1, CI:2.0 – 5.2) and those residing more than 10 km from the clinic (OR: 2.0, CI:1.0 – 4.1) were most likely to default.

Conclusion. Precancerous lesions of the cervix were found to be higher in HIV positive women, especially severely immuno-compromised ones and those not on treatment. Cervical cancer screening is acceptable to women but default from follow - up after positive screening was high, especially among poorly educated rural women. Visual inspection with Lugol’s iodine was found to be inadequate for cervical cancer screening in cases of severe immune deficiency. The current strategy needs to be changed to one that will integrate cervical cancer prevention into HIV care as well as to improve access services for poorly educated rural women.

Abstract (Swedish)

Popular Abstract in English

An increased risk of pre-cancer lesions of the cervix among HIV-infected women, and the positive impact of HIV treatment on its outcome has been reported globally. However there is paucity of information from west Africa with genetically distinct viral strains. Considering that HIV strains differ in the rate and pattern of HIV disease progression, a different outcome is expected. This study was conducted to determine the effect of HIV infection on the burden of pre-cancer lesions of the cervix; assess the diagnostic accuracy of visual inspection of the cervix; and contribute inform that is necessary for cervical cancer prevention and control programme in Nigeria. The study was conducted in southwest Nigeria among adult women of known HIV status(2011- 2012). In study I, the effect of HIV infection on the test performance of visual inspection of the cervix in detecting cervical pre-cancer lesions in 1140 women was determined. The effect of HIV infection and antiretroviral therapy on precancerous lesions of the cervix was determined in studies II and III. The acceptability of cervical cancer screening among 1517 HIV- positive women were determine in study IV and in study V we followed up women who tested positive at cervical cancer screening to determine rate and reason for default from follow- up .

This study demonstrates that cervical screening using visual inspection with Lugol’s iodine was inferior to screening with visual inspection with acetic acid in HIV positive women. The prevalence of high risk HPV and pre-cancerous lesions of the cervix were 19.6% and 8.4%, respectively. HPV 16 (3.9%), 35 (3.5%) and 58 (3.5%) were most frequently found high risk HPV type. HIV positive women were found to be at greater risk of high risk HPV infection and pre-cancer lesions of the cervix. The risk of infection with high risk HPV and development of precancerous lesions of cervix were reduced in those on HIV treatment compared to those not on treat. Although only 56.2% of HIV positive women were aware of cervical cancer screening, the test acceptable to over two-third of the women(79.8%). Among the 108 women who screened positive during community cervical cancer screening, 47.2% defaulted from follow -up as a result of transportation and cost- related issues and an anticipated long waiting time at the referral centre. Poorly educated women residing in the were most likely to default. Pre-cancer lesions of the cervix were found to be higher in HIV positive women, especially severely immuno-compromised ones and those not on treatment. Cervical cancer screening is acceptable to women but default from follow - up after positive screening was high, especially among poorly educated rural women.

The current strategy therefore needs to be changed to one that will integrate cervical cancer prevention into HIV care as well as to improve access to services for poorly educated women in rural communities.

• author: Ezechi, Oliver
• supervisor: Karen Odberg Pettersson; Per-Olof Östergren
• opponent: Professor Weiderpass Vaino, Elisabete, Karolinska Institute, Sweden
• organization: Social Medicine and Global Health (research group); Social Medicine and Global Health-lup-obsolete (research group)
• publishing date: 2014
• type: Thesis
• publication status: published
• subject: Environmental Health and Occupational Health
• keywords: antiretroviral drugs, Human papilloma virus, cervical cancer, HIV/AIDS, pre-cancerous lesions, Nigeria
• in: Lund University Faculty of Medicine Doctoral Dissertation Series
• volume: 2014:86
• pages: 129 pages
• defense location: CRC Aula, ingång 72, Jan Waldenströmsgata 35, Skånes Unviersitetssjukhus i Malmö
• defense date: 2014-10-24 09:00:00
• ISSN: 1652-8220
• ISBN: 978-91-7619-015-9
• language: English
• LU publication?: yes
• id: 7d4f6f2b-3e9e-47a0-a41b-6321801c8b5c (old id 4689657)
• date added to LUP: 2016-04-01 14:12:37
• date last changed: 2023-04-18 20:19:42