Cervical Abnormalities in South African Women Living With HIV With High Screening and Referral Rates

Abstract

Background: Access to antiretroviral therapy (ART) has improved in South Africa (SA), enabling HIV-infected women to live longer and healthier lives. However, they remain at increased risk of mortality from cervical cancer, the leading cause of cancer-related deaths. This study aims to advance our understanding of the prevalence of screening, cervical dysplasia, and histologic diagnoses from colposcopy and large loop excision of the transformation zone (LLETZ) in a high HIV prevalence region of SA. Methodology: We performed a retrospective cohort study to determine the prevalence of cervical dysplasia and malignancy among HIV-infected women attending an urban ART clinic in KwaZulu-Natal (KZN), SA over a five-year period (2004-2009). A random sample of eligible women_defined as HIV-infected, >18 years old, and attending the clinic for > 3 months--enrolled in HIV-care was included from each study year. Data were abstracted from electronic records and paper charts, including date of birth, CD4+ count, viral load (VL), initial Pap smear results, colposcopy and LLETZ results. Per clinic guidelines, colposcopy/LLETZ was indicated for women with two consecutive LSIL's or a single HSIL Pap smear. We also tracked time to colposcopy among women with abnormal Pap smears. Results: We reviewed charts of 462 women with median age 33.7 years (IQR 29.0-39.2 years), median baseline CD4 117.5 (IQR 55-177), median baseline VL 49 (IQR 24-61). 432 (93.3%) had at least one evaluable Pap smear over the study period and 330 (76%) had two or more Pap smears (median=3, IQR 2-4). At baseline, 237 (54.9%) women had an abnormal Pap smear (see Table). 103 women were referred for colposcopy, of whom 89/103 (86.4%) had documentation of completed colposcopy within a median of 39 days (IQR 20-119 days) of referral yielding 57/89 (64.0%) evaluable samples of which 21.1%, 28.1%, 26.3%, and 1.8% had cervical intraepithelial neoplasia (CIN) I, CIN 2, CIN 3, and invasive cervical cancer, respectively. Conclusions: Among a sample of HIV-infected women in an urban clinic in KZN, SA where Pap smear coverage and rates of referral for colposcopy/ LLETZ were very high, we observed a prevalence of >75% cervical dysplasia and malignancy among those referred. These findings support the importance of cervical screening upon entry into care, and suggest that all HIV-infected women with cytological abnormalities on Pap smear should undergo early evaluation with colposcopy to minimize loss to care and optimize chances for survival.