Half of HIV+ Women in Zambia Positive for Cervical Cancer



ORLANDO – A first-of-its-kind program to screen and treat HIV-infected women for cervical cancer in Zambia was heralded as a potential platform for low-cost, human papillomavirus–based screening programs at this year’s annual meeting of the Society of Gynecologic Oncologists.

More than 20,000 residents of the impoverished, south-central African nation were screened in the first 3 years, according to a study. Just over half of the 6,572 women with known HIV infection at the time of presentation screened positive for cervical cancer, Dr. Groesbeck Parham said.

Although initially designed for HIV-positive women, the program expanded to generalized cervical cancer prevention when word of the services spread.

Dr. Groesbeck Parham

Dr. Parham and his colleagues analyzed data from 21,010 women who were screened for cervical cancer in 2006, 2007, and 2008. About one-third each were HIV positive (6,572), HIV negative (7,238 women), or of uncertain status at presentation (7,200).

In the HIV-positive cohort, 3,523 of the screened women (54%) had detectable cervical lesions that were seen via visual inspection with acetic acid (VIA). Of those with positive VIA findings, 2,061 were eligible for cryotherapy and about 70% of those underwent this treatment. "The remainder declined cryotherapy, saying they needed to confer with their families and husbands; [they] did not return. That is a problem," said Dr. Parham, a gynecologic oncologist at the University of Alabama at Birmingham.He is also affiliated with the Center for Infectious Disease Research in Zambia (CIDRZ).

A total of 1,462 women had complex lesions that clinicians felt required excision and histologic evaluation. In this group, 1,095 had histology done and 367 did not. "That [also] is a problem," Dr. Parham said.

An available 715 pathology reports revealed 151 women with benign histology (21%) and 449 with precancerous lesions (214 women with cervical intraepithelial neoplasia [CIN] 1 and 235 women with CIN 2 or 3). "We found 115 had invasive cancer. About 70% of the invasive cancers were early (stage IA, IB), almost the opposite of what we see when women do not come into the university through a cervical cancer–screening program."

VIA and cryotherapy-based, screen-and-treat programs "in a low-income African nation can prevent deaths from cervical cancer in HIV-infected women," Dr. Parham said.

The researchers used a "conditional probability model" to calculate mortality prevention. Dr. Parham said, "In our best estimate, we prevented 142 cervical cancer deaths, and thus one death was prevented for every 46 HIV-positive women we screened – a high intervention-to-impact ratio."

This "demonstrates how a small group of people committed to a single cause – even with very few resources, if [they are] willing to make personal sacrifices – can have profound impact on improving the care of women with gynecologic cancers," said Dr. Robert E. Bristow, director of gynecologic oncology services at the University of California, Irvine, Medical Center.

Rationale and funding for the program stemmed from previous research by Dr. Parham and his colleagues (Gynecol. Oncol. 2006:103:1017-22). They found cytologic evidence of invasive cervical cancer in almost 20% of 150 consecutive, HIV-positive women who were screened in Zambia. The findings convinced the government to support screening.

Since the onset of the HIV/AIDS pandemic in 1985, the life expectancy of the 12 million people in Zambia has dropped from 52 years to 38 years. The HIV prevalence is 16% nationally and 22% in the capital city of Lusaka. The cervical cancer incidence is 52 per 100,000, and associated deaths are 38 per 100,000.

"According to the World Health Organization, Zambia has the second highest cervical cancer incidence and mortality rates in the world," Dr. Parham said.

The clinic programs began in Lusaka, where 24 public health clinics and one tertiary hospital serve 2 million residents. There are five gynecologists at the hospital and only 15 gynecologists in the entire country, Dr. Parham said.

"When you start making rounds on the gynecology unit, you quickly discover that about 80% of beds are occupied by women who have invasive cervical cancer, most with very advanced stages," Dr. Parham said. "You will also see a significant number of women [aged 20-30 years] who are HIV infected."

It is not uncommon to see unusual clinical manifestations of cervical cancer in this immunosuppressed population "because of this sordid relationship between HIV and cervical carcinogenesis," Dr. Parham said. Higher prevalence rates of human papillomavirus (HPV) infections, CIN, and invasive cancers result. These patients typically experience faster progression to advanced stages and grades of cancer, as well as higher recurrence and persistence rates.

The screening program faced some additional challenges. For example, the low socioeconomic status of women in Zambia prevented most from returning for multiple evaluations. "We decided to use the only alternative available at that time, which is visual inspection with acetic acid. We think it’s as good as colposcopy and much less expensive."

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