CASE REPORTS
Cervical cancer and HIV: the Bahia/Brazil situation
Conceição Queiroz
There are epidemiological evidences that persistent infection, with a high viral load of oncogenic types of human papiloma virus (HPV) plays a pivotal role in the development of uterine cervix cancer. Association of other co-factors seems to be necessary for oncogenesis, such as infection with human immunodeficiency virus (HIV). HIV related cervical intraepithelial neoplasias (CIN) show higher rates of progression and persistence, are more refractary to treatment and often recurrent than in HIV negative women. This is the reason why seropositive patients need more aggressive approach. HPV induced-lesions can be routinely diagnosed using tests such as colposcopy, cytology and histopathology. These tests do not allow identification of the viral type or its oncogenic potential, as molecular hybridization tests do. However, in Brazil, they are very restricted because they are very expensive, nevertheless, colposcopy is low cost and has high technical quality.
CIN prevalence in HIV patients in Brazil is quite variable. In São Paulo, Auge et al. (2000) found 15.2% (n=99) using colposcopy and cytology, much lower than the percentage of 72.1% (n=115) detected by Coelho et al. (2004) based on cytology only. In Rio de Janeiro, Fialho (2002) found 30% (n=130) using cytology and histopathology, similar to the 35.5% (n=354) detected by Oliveira and Silva (2003) using colposcopy and cytology. At the AIDS State Reference Center (CREAIDS), Bahia, we found 12.9% (n=833) of cytological atypia between 2002 and 2004, a much lower rate than the 37% detected between 1998 and 2000 at the same service. A possible explanation for this variation is the fact that some patients are being followed since 1998 and treated as soon as the lesion is diagnosed. Other possibility could be the very high prevalence of antiretroviral therapy.
Although there are no definitive results, some consensus about the co-infection HIV-HPV is under way: (1) The prevalence of HPV infection is higher among HIV patients than in other patient groups. Matos et al. (2003) found a prevalence of 42.9% versus 8.2% in HIV positive and negative patients, respectively and Auge et al. (2000) showed similarly 15.2% versus 3.8%. (2) There is a high rate of HPV-DNA in the cervical mucosa of HIV positive women. Levi et al. (2002) found 66% of positivity using hybridization (Digene) and 98% using PCR (LiPA). Souza et al. (2001) and Queiroz et al. (2004) detected 85.7% and 100% of HPV-DNA by PCR respectively. (3) CD4 counts under 350 cells/mL and high viral load counts are associated with higher CIN progression.
Highly active antiretroviral therapy has significantly modified the natural history of AIDS, but its relationship with cervical uterine lesions is not well established. At some Brazilian Centers there are Cervical Pathology outpatient clinics for HIV positive patients with well established protocols, but still there are a few. It is necessary to advise physicians about the importance of early investigation of all seropositive women. This could avoid the development of this invasive malignancy.
Publication Dates
-
Publication in this collection
06 Jan 2006 -
Date of issue
Oct 2005
