NEW YORK (Reuters Health) – In women with HIV, a loop electrosurgical excision procedure (LEEP) was 40% more likely than cryotherapy to clear high-risk human papillomavirus (hrHPV) in a secondary analysis of a randomized trial in Africa.
The analysis also found that persistent hrHPV was associated with recurrent cervical intraepithelial neoplasia grade 2 or higher (CIN2+) in these women.
“Cryotherapy is commonly used in resource-limited settings to treat pre-cancerous cervical lesions,” Dr. Michael Chung of Emory University in Atlanta told Reuters Health by email. “However, in places like sub-Saharan Africa, infection with HPV often intersects with HIV, since both diseases are sexually transmitted and are common in this setting. As a result, many women co-infected with both are being treated with cryotherapy when a pre-cancerous lesion is detected during cervical cancer screening.”
“We wanted to better understand whether this was the best treatment to use, especially when other options like LEEP are available,” he said. “LEEP is commonly used in high-income countries as well, so this will help inform our understanding of how effectively this excisional procedure will clear HPV infection among HIV-infected women here.”
“This is important,” he noted, “because HPV testing is being recommended more widely after cervical treatment in high-income countries to determine the need for further follow-up.”
As reported in JAMA Oncology, Dr. Chung and colleagues randomized 354 HIV-positive women (mean age, about 37.5) with CIN2+ to cryotherapy or LEEP and followed them for 24 months. The main outcomes were hrHPV positivity, defined as having 1 of 12 hrHPV types, and disease recurrence, defined as CIN2+, as determined with cervical biopsy.
Baseline hrHPV prevalence was 90% in the cryotherapy arm and 94% in the LEEP arm; the most common hrHPV types detected were 16 (27%), 58 (27%), 35 (26%), 52 (20%), and 18 (17%).
Over 24 months, hrHPV clearance was significantly higher among those who underwent LEEP versus cryotherapy (hazard ratio, 1.40).
In multivariable analysis, hrHPV type-specific persistence at 12-months was significantly associated with CIN2+ recurrence from 12 months to 24 months (adjusted hazard ratio, 4.70).
Specifically, at 12 months, type-specific persistence of baseline hrHPV was significantly higher after cryotherapy versus LEEP for any hrHPV (61% vs. 49%); hrHPV type 16 (69% vs. 48%); and hrHPV type 51 (44% vs. 12%).
At 12 months, hrHPV testing for recurrent CIN2+ had 93% sensitivity, 46% specificity, 38% positive predictive value, and 95% negative predictive value.
The authors conclude, “Persistent hrHPV was significantly associated with recurrent CIN2+, suggesting that LEEP’s benefits may be related in part to its ability to clear hrHPV infection. Screening for hrHPV infection after treatment among HIV-positive women may be used to rule out recurrent CIN disease given its high sensitivity and negative predictive value.”
Dr. Chung added, “Clinicians should understand that clearing HPV infection among HIV-infected women is difficult even when using an excisional therapy like LEEP. As a result, they should follow HIV-infected women more closely after treatment and not necessarily assume they have been successfully cured. Persistent HPV infection may result in cervical cancer years later.”
Dr. Rowena Johnston, amfAR VP and Director of Research, commented in an email to Reuters Health, “This study will help policymakers and public health officials ensure that best medical practices follow the evidence. Treatment of CIN saves lives, and LEEP does this better than cryotherapy, whether in in wealthy or low-income settings, in women living with or without HIV.”
SOURCE: https://bit.ly/37CV1Pb JAMA Oncology, online August 5, 2021.