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Cervical cancer prevention and
HIV positive women
International policy perspectives
Fiona Hale
Definitions
• Primary prevention = immunity to HPV
(through vaccination).
• Secondary prevention = screening for precancerous lesions which are then removed.
• Treatment = interventions to treat cervical
cancer such as surgery, radiotherapy,
chemotherapy.
Primary prevention: what is
recommended?
WHO (2006) recommends HPV vaccination of:
• Primary target group – girls 9-13
• Secondary (catch-up) target group – girls 1426
Compare with HIV prevalence in girls and
women of the same age-ranges, and consider ….
Is HPV vaccination safe for HIV+
women?
• Probably yes - it’s not a live vaccine…
BUT
• No data yet – GSK Phase II trials in progress.
http://clinicaltrialsfeeds.org/clinicaltrials/show/NCT00586339
Is HPV vaccination effective in HIV+
women?
Probably less effective than in HIV- women:
• Data on efficacy of HPV vaccination in HIV
positive women lacking (FIGO, 2009, p. 19).
• HPV types other than 16 and 18 often
associated with cervical cancer in HIV positive
women (McKenzie et al, 2010; Moodley et al,
2009; Sahasrabuddhe et al, 2007; Clifford et
al, 2006).
Is HPV vaccination effective in HIV+
women… cont
• In HIV+ women, HPV vaccination may be more
effective once HAART has been successfully
initiated (Palefsky, Gillison and Strickler, 2006).
• So, even if HPV vaccination is possible given
costs and logistics, screening (secondary
prevention) will continue to be vital.
Secondary prevention and HIV
• Precancerous cervical lesions tend to be more
prevalent, persistent and likely to recur in HIV
positive women. Outpatient treatments less
likely to be effective – regular follow-up care is
needed.
• Annual cytology screening (pap smear)
recommended for HIV+ women (eg US CDC
guidelines, UK BHIVA guidelines).
Secondary prevention and HIV cont…
• Effective cytology screening programmes have
been hard to implement in low-resource settings
(WHO 2007). Many women never screened.
• Alternatives sorely needed, eg
– HPV DNA testing, ‘screen and treat’ approaches,
Visual inspection with acetic acid (VIA), visual
inspection using Lugol’s iodine (VIL) (ACCP, 2004; Path,
2007).
Secondary prevention – pilot
programmes
• Pilot cervical cancer screening programmes
using new approaches are ongoing in more
than 40 countries
(http://screening.iarc.fr/activ/activity.php).
• As well as assessing how effective they are
generally, these must be assessed in terms of
of how effective they are for HIV positive
women.
Conclusions
• The burden of disease makes cervical cancer
prevention and treatment vital for HIV
positive women.
• Effectiveness of any screening programme
may be reduced if HIV is not taken into
account.
Conclusions
• Advocacy messages on HPV vaccination, HPV
DNA testing (and new developments like
therapeutic HPV16 long peptide vaccination),
should be aware that HPV types other than 16
and 18 are associated with cancer in HIV+
women.
Conclusions
• Pilot screening programme evaluations should
take into account the decreased effectiveness
in HIV positive women of cryotherapy and
LEEP, and the importance of regular follow-up
and repeat interventions.
• In summary: HIV positive women must be
specifically considered in all cervical cancer
prevention efforts (primary and secondary).