HPV Cotesting Safe for HIV+ Women

A cohort of HIV-infected women had no cases of histologically confirmed high-risk cervical neoplasia during follow-up after negative cotesting for human papillomavirus (HPV) infection, investigators reported.

Of 245 patients with paired negative cotests (Pap smear and HPV DNA), none developed cervical intraepithelial neoplasia grade 2+ (CIN2+) during follow-up as long as 42 months. One woman had a high-grade intraepithelial squamous lesion (HSIL).

The findings are consistent with the clinical experience among populations of HIV-negative women and support less frequent HPV screening when cotesting is used, according to a brief report in the July 9 issue of Archives of Internal Medicine.

“These findings are consistent with our understanding of the natural history of HPV and cervical cancer, in which CIN2+ only develops several years after a newly detected HPV infection,” Philip E. Castle, PhD, of the American Society for Clinical Pathology Institute in Washington, and co-authors wrote in conclusion.

“While more data are needed, these results suggest that it may be acceptable and safe to extend cervical cancer screening intervals by including HPV testing, hereby minimizing the harms of screening.”

The American Cancer Society has recommended cotesting for a decade as an alternative to routine cytologic screening for HPV. The ACS has determined that women who are negative for both tests can defer follow-up screening for as long as 3 years.

HIV is a known risk for cervical cancer and precancerous lesions, and cervical cancer is an AIDS-defining malignancy, the authors wrote. Current screening guidelines recommend screening with a Pap test twice in the first year after diagnosis of HIV infection. If both tests are negative, follow-up screening should continue annually.

But whether cotesting for HPV has a similar safety profile in HIV-positive women has not been determined. To address the question, Castle and colleagues reviewed medical records of members of Kaiser Permanente Northern California. In 2003 the health system introduced HPV cotesting at 3-year intervals as an alternative to annual Pap testing.

For women who tested HPV positive but had negative Pap tests, colposcopy was recommended after two consecutive mixed results, beginning in 2006. Two years later, colposcopy was made mandatory after two HPV+/Pap- tests.

The investigators identified 245 HIV-infected women 30 and older who had a negative cotest and underwent a cotesting a second time during follow-up. The second cotest occurred an average of 24.4 months after the first.

In 202 of 245 cases, the second cotest was negative. Additionally, 16 patients tested HPV+/Pap-, 11 tested positive, and nine were HPV- with atypical squamous cells of undetermined significance. The remaining patients had indeterminate or incomplete results.

The mean and median CD4 cell counts determined nearest to the second cotesting were 519.7 and 475/µL. Data on HIV viral load for 95 patients showed mean and median values of 20,274.5 and 7,552.5 copies/mL.

Pap test results for 241 women showed that 21 (8.7%) tested positive for HPV, and HPV DNA testing yielded positive results in 27 of 240 (11.3%) women.

Subsequently, 236 women underwent a third round of cotesting at least 12 months after the second. None of the women had histologically confirmed CIN2+. One patient had HSIL during the third cotest as a follow-up to a second cotest that had been HPV+/Pap-, resulting a 0.4% risk of HSIL cytology.

Of 78 women followed for at least 30 months after a first negative cotest, none developed CIN2+.

The study was supported in part by the American Cancer Society.

Castle disclosed relationships with Merck, Qiagen, and Roche.

Primary source: Archives of Internal Medicine
Source reference: Castle PE, et al “Safety against cervical precancer and cancer following negative human papillomavirus and Papanicolaou test results in human immunodeficiency virus-infected women” Arch Intern Med 2012; 172: 1041-1043.


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