AT CROI
SEATTLE (FRONTLINE MEDICAL NEWS) – HIV-positive women treated with cryotherapy for cervical intraepithelial neoplasia (CIN) 2/3 were 52% more likely than women treated with loop excision to have a recurrence within 2 years, according to a randomized trial in Kenya.
The investigators called on the World Health Organization and other groups to support loop excision as the first-line option for HIV-positive women in sub-Saharan Africa and other low-resource settings, but the findings also support its use, when possible, in Western countries.
Women with HIV have a higher prevalence of high-risk cervical lesions, and the lesions are more likely to recur. Those who “screen positive for cervical precancer should be managed with LEEP [loop electrosurgical excision procedure],” said lead investigator Sharon Greene, a PhD candidate at the University of Washington, Seattle.
For the study, 200 HIV-positive women were randomized to cryotherapy and 200 to LEEP for treatment of CIN 2/3 at the Coptic Hope Center for Infectious Diseases in Nairobi, with follow-up Pap smears every 6 months afterwards for 2 years.
At 12 months, 36 women in the LEEP group (18%) had recurrent high-grade squamous intraepithelial lesions (HSIL), versus 54 women (27%) in the cryotherapy arm. At 24 months, HSIL was detected in 52 women who had LEEP (26%), versus 74 who had cryotherapy (37%).
Overall, the rate of recurrence of HSIL was 21.1 per 100 woman-years after cryotherapy and 14.0 per 100 woman-years after LEEP.
It’s unclear how those results would have played out in the United States, Mr. Green said, noting that LEEP failure rates are far lower among women who do not have HIV, but the success of LEEP in HIV-positive women in the United States has not been well studied.
The World Health Organization “recommends posttreatment follow-up at 12 months, regardless of HIV status. Our findings indicate that women should be screened at more frequent intervals, particularly following cryotherapy,” she said at the Conference on Retroviruses & Opportunistic Infections in partnership with the International Antiviral Society.
Women were excluded from the study if they were pregnant. The median age was 37 years, and almost all the subjects were on antiretroviral therapy at the time of intervention, with a median CD4 count of 380 cells/mcL. Median follow-up was 2.1 years in both arms; most of the women completed all four follow-up visits. The majority in both groups had CIN 3; about 10 in each arm had carcinoma in situ.
“Cervical screening and treatment using visual inspection with acetic acid and cryotherapy is often implemented in resource-limited settings with high HIV-1 endemicity; however … HIV testing and referral for LEEP may be more effective” and cost effective if it prevents later hysterectomy, Ms. Greene said.
Ms. Greene had no disclosures. The work was funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Centers for Disease Control and Prevention.
