Determinants of HPV infection among women living with HIV/AIDS (n = 291)

Determinants of Cervical Intraepithelial Neoplasia among Women Living with HIV/AIDS

The study shows that the participants with CIN II+ are significantly more likely to be currently unmarried (OR = 3.363, 95%-CI = 1.302–8.686). Nonsignificant positive associations were found between HPV occurrence and lower than primary level of education (OR = 1.557, 95%-CI = 0.684–3.546), being a housewife (OR = 2.115, 95%-CI = 0.769–5.819), age at marriage (OR = 3.211, 95%-CI = 0.935–11.031), getting pregnant more than two times (OR = 2.163, 95%-CI = 0.923–5.069), tobacco use (OR = 1.184, 95%-CI = 0.452–3.105), duration of HIV positivity less than 5 years (OR = 1.805, 95%-CI = 0.790–4.125), husband being HIV positive for more than 5 years (OR = 1.394, 95%-CI = 0.522–3.724), and instances of HIV being transmitted sexually (OR = 1.166, 95%-CI = 0.469–2.900) ([Table 2]).

Determinants of cervical intraepithelial neoplasia among women living with HIV/AIDS (n = 291)

Discussion

Studies have shown that HIV is a predisposing factor for HPV infection.[9] [10] The chances of acquiring HIV infection are also more than twice in women with a history of HPV infection of the cervix.[11] HIV decreases the immunity, thereby causing a lack of clearance of HPV infection, its persistence, and hence, causes cervical lesions. The prevalence of HPV in our study was found to be 34.4%. This prevalence is higher than reported among HIV-positive women in eastern India (26.85%) and that reported from a recent study in Africa (22.2%).[12] [13] Prevalence of high-risk (HR-HPV) HPV infection similar to our study was found in Brazil (31.1%).[14] However, a study in Pune and a systematic review by Bogale et al reported a higher prevalence of 41.7 and 51.0%, respectively.[15] [16] Analysis from studies suggests 30 to 80% of HIV-positive women suffer from HR-HPV.[17]

Histological lesions were present in 43 (14.7%) participants. Among these, CIN1 and CIN2+ were present in 18 (6.2%) and 25 (8.6%) participants, respectively. Prevalence comparable to our study was noted by Chakravarty et al where HSIL and cervical cancer were noted in 5.35 and 1.6% of females, respectively.[12] Daniel et al reported a slightly lower prevalence of HSIL and higher lesions in Nigeria (4.9%).[12] [18] Our prevalence is lower than that reported by Sahasrabuddhe et al in Pune (27.7%).[15] The review done by Patel et al found cervical precancer and invasive cancer of the cervix in 10 to 40% and 1.3 to 1.7% of the HIV-positive women.[17]

As the age increases, the risk of getting HR-HPV decreases.[9] In our study also, HPV DNA positivity was significantly more likely in HIV women aged younger than 35 years. The study done by Chakravarty et al showed younger women to be twice at risk for HPV infection (OR = 2.56, 95% CI = 1.26–5.19).[12] Some studies, however, have shown results contrary to our findings. In the study at Togo, HPV positivity was high among women aged older than 50 years.[13] The study in West Bengal showed an increased HPV prevalence till 40 years of age.[10]

Regarding sociodemographic factors such as literacy, our study shows a nonsignificant association between the lower level of education with HPV positivity and CIN. The study by Sahasrabuddhe et al and Chakravarty et al shows that women with education less than that of primary education level have increased CIN severity and HPV positivity, respectively.[12] [15] Our study shows that HIV-positive women with more than two pregnancies had twice the chances to develop CIN. Although the results in our study were nonsignificant, literature shows that multiparity increases the tendency to develop an intraepithelial lesion.[18] [19] Studies have shown that tobacco use is a significant predictor of intraepithelial neoplasia. In our study, although CIN II+ was more common among women who consumed tobacco, this association was nonsignificant. Similar results were seen in the study done by Daniel et al in Nigeria.[20]

Regarding CD4+ cell count, our analysis shows participants with HPV infection were more likely to have CD4+ cell count <500 OR = 1.12, CI = 0.54–2.33). class="i" xss=removed>p-value  =  0.62).[14] Chakravarty et al in West Bengal (OR = 2.46, 95% CI = 1.26–4.83), and systematic review by Bogale et al presented parallel results.[12] [16] However, Atashili et al demonstrated CIN more likely in participants with low CD4+ cell count.[19]

In our study, nonsignificant association was found between HPV positivity and starting ART within 1 year (OR = 1.40, 95% CI = 0.85–2.31). In the study done by Sahasrabuddhe et al, increasing severity of CIN was found with patients receiving ART treatment (adjusted OR = 2.24, 95% CI = [1.17–4.26]).[15] There is limited literature available on the impact of ART treatment on HPV infection and CIN. However, since life expectancy has increased with ART regimens, regular screening for cervical cancer is recommended to prevent mortality.

It has been observed that non-16 and non-18 HPV genotypes are more common among HIV-positive women.[10] In the study done at Togo, the genotype 16 prevalence was found to be low.[13] This may have implications on cervical cancer control using HPV vaccination programs, where these vaccines may only have a limited role to play among HIV-infected women.

Our study does suffer from a few limitations. Complete information regarding husband's HIV infection duration, details regarding the method of HIV transmission, and CD4 counts were unavailable for some participants. Details regarding sexual activity and tobacco intake were self-reported. Participants would have refrained from giving true responses to these questions due to their personal inhibitions and cultural barriers which could have led them under reporting. Our study also did not assess the different HPV genotypes.

Conclusion

A high prevalence of HPV and CIN was observed among women who were HIV positive. This calls for active screening and treatment of this susceptible population to prevent the further development of cervical cancer among them. The HIV/AIDS/ART outpatient clinics should include sensitization sessions, awareness programs, and routine cervical cancer screening for HIV-positive women to avoid the development of CIN and higher lesions and achieve the goal of global elimination of cervical cancer.

Conflict of Interest

None declared.

Acknowledgments

We are grateful to medical social workers, Ms. Parishi Majmudar, Mr. Ashok Patil, and Ms. Bhakti Kabre for providing counseling to HIV-positive women. We are thankful to Mr. Suresh Raibhatanavar and Ms. Nicole Aguirre for helping in data retrieval and analysis. We also thank Ms. Rupa Sarwaiya and Ms. Darshana Rane for data entry.

Authors' Contribution

S.A.P. had the initial idea and was responsible for the conduct of the study, and participated in its conception and design, monitoring, supervision, acquisition, and interpretation of the data and the provision of clinical services in the study. V.P. was responsible for monitoring, supervision, acquisition, and interpretation of the data. G.A.M. was responsible for the study design, conduct, monitoring and supervision of the study, acquisition, analysis, and interpretation of the data. K.V.A. participated in the conduct and monitoring of the study, acquisition, and interpretation of data. All authors were involved in drafting the manuscript and have read and approved the text as submitted to the journal.

S.A.P., as corresponding author, confirms that she had access to all data and had final responsibility for the decision to submit for publication.

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  • Address for correspondence

    Sharmila A. Pimple, MD, PSM
    Department of Preventive Oncology, Centre for Cancer Epidemiology, Tata Memorial Centre, Homi Bhabha National Institute
    3rd Floor, Service Block, E. Borges Marg, Parel, Mumbai 400 012, Maharashtra
    India   
    Email: drsharmilapatil@yahoo.com   
    Email: pimplesa@tmc.gov.in
    
    

    Publication History

    Article published online:
    17 February 2022
    

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