Follow CIN Closely in HIV-Positive Women : Treatment of CIN I has a high failure rate in these women, but it has a relatively low rate of progression.


SAN FRANCISCO — Women who are HIV positive are at enhanced risk of cervical intraepithelial neoplasia and must be followed closely, according to Meg Newman, M.D.

Furthermore, treatment of squamous intraepithelial lesions (SIL) or cervical intraepithelial neoplasia (CIN) is less effective, and there's a very high risk of recurrence in women with the virus. HIV-positive women should be warned of this possibility, so they'll be prepared for any necessary retreatment, she said at a meeting on HIV management sponsored by the University of California, San Francisco.

Despite the risk of SIL/CIN recurrence in HIV-positive women, it is possible to avoid invasive cervical carcinoma, said Dr. Newman of the University of California, San Francisco, and San Francisco General Hospital. She said her hospital has developed the following treatment guidelines for SIL/CIN in patients with HIV infection:

▸ While treatment of CIN I (mild dysplasia) has a high failure rate in HIV-positive women, it appears to have a relatively low rate of progression. At San Francisco General Hospital, women with CD4 counts more than 200 cells/μL who can commit to follow-up are treated only with close observation.

▸ Cryotherapy is appropriate for a woman with CIN I if her CD4 count is less than 200 cells/μL or if she has a higher CD4 count but is likely to be lost to follow-up.

▸ Appropriate treatment for HIV-infected women with CIN II (moderate to marked dysplasia) or CIN III (severe dysplasia) requires an ablative or excisional procedure.

▸ Cryotherapy is appropriate for CIN II or III if there is a satisfactory colposcopy; the patient has had no previous cervical treatment; and the lesion is completely visible, less than 2 cm in diameter, and affects only one or two quadrants.

▸ Laser ablation is better when the lesion is greater than 2 cm in diameter or involves three or four quadrants.

▸ The loop electrosurgical excision procedure (LEEP) is helpful when cryotherapy is inappropriate due to lesion size, or if the lesion is located high in the endocervix.

▸ LEEP can't be done when the cervical architecture is disrupted secondary to a prior LEEP or to a cone biopsy.

▸ A cold-knife cone biopsy requires an operating room. This procedure is best used for a high-grade lesion when malignancy is detected on Pap smear and microinvasive disease or a glandular lesion is present.

▸ After excisional or ablative treatment of CIN II or III, topical 5-fluorouracil appears to be useful as an adjunctive treatment.

Finally, Dr. Newman noted that cigarette smoking is one behavior that may play an important role in the acquisition and recurrence of SIL/CIN, and women should be counseled to quit.

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