HIV-Positive Women at Greater Risk for Genital Lesions and Vulvar Cancer, Study Says

Women infected with HIV are at greater risk of developing genital lesions and invasive vulvar cancer than women who are HIV-negative, according to a study published in the Jan. 12 issue of the Lancet. Researchers from the CDC's National Center for HIV, STD and TB Prevention and colleagues examined the incidence of vulvovaginal and perianal condylomata acuminata -- genital warts typically associated with human papillomavirus -- and intraepithelial neoplasia -- pre-invasive lesions -- in HIV-positive and HIV-negative women. Women infected with HIV are at increased risk of developing pre-invasive cervical lesions and invasive cervical cancer, and several studies suggest that HIV-positive women are at greater risk of developing vulvar, vaginal and perianal lesions associated with HPV, which can lead to cervical cancer. These genital lesions include condylomata acuminata, intraepithelial neoplasia and invasive cancers. The researchers enrolled 925 women from the New York City area in the study. The participants, who were enrolled between October 1991 and September 1998, represented three groups: 481 HIV-positive women, 437 HIV-negative women and seven women with unknown HIV serostatus. Women received a gynecological exam at enrollment and were examined every six months thereafter. The study's findings include the following:

• Participants who were infected with HIV were 16 times more likely to have vulvovaginal or perianal lesions than participants who were HIV-negative.
• HIV-positive women were more likely than HIV-negative women to develop vulvovaginal or perianal lesions during the study. Among women who had no vulvovaginal lesions at enrollment and who did not seroconvert during the study follow-up period, 9% of HIV-positive participants and 1% of HIV-negative participants developed vulvovaginal or perianal lesions during the study.
• Further analysis indicated that 8% of HIV-positive and 0.4% of HIV-negative women would develop a vulvovaginal or perianal lesion within four years.
• HIV-positive women were also more likely to be infected with HPV. Among women who provided cervicovaginal lavage samples, 55% of HIV-positive women tested positive for HPV, compared to 32% of HIV-negative women.
• After 48 months of follow-up, 15% of HIV-positive women who had tested positive for HPV had developed vulvovaginal or perianal lesions.
• Of the 33 lesions developed by HIV-positive participants during the study, five were identified as high-grade vulvar intraepithelial neoplasia.
• Overall, 15% of incident vulvovaginal or perianal lesions in HIV-positive participants were histologically classified as high-grade intraepithelial neoplasia.

Link Between HIV and Pre-Cancerous Lesions
The researchers conclude that the high number of HIV-positive participants who had high-grade vulvar intraepithelial neoplasia and the one HIV-positive participant who went on to develop invasive cancer supports the theory that "malignancies associated with HPV occur at increased rates in people with HIV." These findings suggest that the "natural history of HPV might be different in HIV-positive women," the study authors note, adding that the similarity between HIV-positive individuals' increased risk for vulvar and cervical disease "lends support to the hypothesis that changes in viral-host interactions occur in HIV-positive women and affect the natural history of HPV infection." HIV infection, HPV infection, low CD4+ T cell count and a history of injection drug use were "significantly associated with the development of a vulvovaginal or perianal lesion," the authors write. The study states that "[s]ubstantial information suggests an association between immunosuppression and development of vulvar neoplasia." Although antiretroviral therapy did not seem to affect the incidence of vulvovaginal or perianal lesions among study participants, the authors note that the study was conducted before the advent of triple-drug antiretroviral treatment. The authors recommend that doctors conduct a "thorough examination of the vulva and perianal region" during gynecological exams of HIV-positive patients. Women with "any degree of abnormality" should be referred for colposcopy and biopsy, they conclude (Conley et al., Lancet, 1/12).