Minimally Abnormal Pap Testing and Cervical Histology in HIV-Infected Women

Abstract

Objective:

To assess the underlying histology of HIV-infected women with minimally abnormal Pap tests compared to HIV-uninfected women by evaluating their colposcopic and histologic outcomes.

Methods:

Retrospective analysis was performed to identify HIV-infected women who had at least one cervical Pap test from 2002 through 2008 at Boston Medical Center. We identified women who underwent colposcopy within 6 months of a minimally abnormal Pap test (atypical squamous cells of undetermined significance with positive high-risk human papillomavirus testing [ASCUS/HPV+] or low-grade squamous intraepithelial lesion (LSIL)). Our outcome was the proportion of HIV-infected women with histologic cervical intraepithelial neoplasia 2 or worse (CIN2+). We then compared these outcomes to those of a cohort of HIV-uninfected women from the same institution.

Results:

There were 655 HIV-infected women who had Pap testing in the study time frame, and 146 (22%) had a minimally abnormal Pap test (ASCUS/HPV+ or LSIL). Of the 90 HIV-infected women who had subsequent colposcopy within 6 months, colposcopy was negative for 20 (22%), CIN1 for 41 (46%), and CIN2+ for the remaining 29 (32%). During the same time period, there were 747 HIV-uninfected women who underwent colposcopy within 6 months of a minimally abnormal Pap test. Colposcopy was negative for 336 (45%), CIN1 for 254 (34%), and CIN2+ for 157 (21%). After adjusting for differences in age and race, the HIV-infected women were more likely to have CIN2+ after a minimally abnormal Pap test (p=0.002) (adjusted odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.62). There were no diagnosed cases of cervical cancer.

Conclusions:

HIV-infected women have higher rates of underlying CIN2+ for minimally abnormal Pap tests compared with HIV-uninfected women.

Introduction

HIV-infected women are more likely than HIV-uninfected women to be infected with human papillomavirus (HPV), the etiologic agent of cervical cancer, and to have abnormal cervical cytology, including minimally abnormal Pap testing.^1
–3 The decreased incidence of cervical cancer in HIV-uninfected women in countries with screening programs is likely due to treatment of precancerous lesions, making it important to understand the histologic diagnosis underlying a minimally abnormal Pap test.^4
–6 HIV-infected women are more frequently diagnosed with atypical squamous cells of undetermined significance (ASCUS) Pap tests, and a correlation has been found between low CD4 cell counts and progression to squamous intraepithelial lesions (SIL).^7,8 In these HIV-infected women, the HPV infections are more likely to be persistent infections.^9,10 The association between SIL and HIV seropositivity has been recognized since early in the HIV epidemic.¹¹ The aim of the present study was investigation of the underlying histology of HIV-infected women who had a minimally abnormal Pap test (ASCUS/HPV+ or low-grade squamous intraepithelial lesion [LSIL]) compared to HIV-uninfected women.

Materials and Methods

After receiving Institutional Review Board approval, we reviewed electronic medical records (EMR) at Boston Medical Center between January 2002 and June 2008 and searched for HIV-infected women who had at least one Pap test during that period. All Pap tests were collected in BD SurePath^™ (Becton Dickinson, Franklin Lakes, NJ) transport media. HPV testing was performed with the high-risk HPV probe of Hybrid Capture 2 (HC2) (Qiagen Inc., Gaithersburg, MD) with a relative light unit threshold of 1.0 for positivity. Pap test results were interpreted based on the 2001 Bethesda classification systems. All Pap testing was screened by a cytotechnologist, and a cytology supervisor reviewed approximately 15% of the tests. When the cytology supervisor disagreed with the initial interpretation or when the initial finding was ASCUS or higher a cytopathologist reviewed the case (approximately 35% of cases annually). Subjects for further study included HIV-infected women who had a cervical cytology Pap test that was minimally abnormal, which we defined as a Pap test result of ASCUS with detection of HPV, that is, ASCUS/HPV+, or LSIL.

We then reviewed the EMR and identified those HIV-infected women who underwent colposcopic evaluation within 6 months of a minimally abnormal cervical cytology result. Women who were pregnant at the time of colposcopy were excluded from the dataset. Colposcopic results were defined by the histology of the worst grade lesion. Women who had colposcopy where no lesions were biopsied were included in the analysis and considered to have a normal colposcopic examination result. Demographic data extracted included age and race. Clinical data included reported smoking status, CD4 count, and whether the patient was on highly active antiretroviral therapy (HAART) at the time of the colposcopy. We then compared these colposcopic results to those of a population cohort from our institution during the same time frame who were not known to be HIV-infected and underwent colposcopic evaluation within 6 months of a minimally abnormal cervical cytology result.¹²

Data were analyzed using Statistical Analysis Software (SAS, version 9, SAS Institute, Inc., Cary, NC). Descriptive values were expressed as means and as proportions. The chi-square test (for categorical data) and t test or analysis of variance (ANOVA) (for continuous data) were used to analyze differences between groups. Multiple logistic regression analysis was performed to verify the association between the main outcome (colposcopy with cervical intraepithelial neoplasia 2 or worse [CIN2+]) and the variables, as well as to adjust for confounders, and the odds ratios (OR) were calculated. A Spearman rank correlation analysis was performed to evaluate the relationship among CD4 count, being on HAART, and the colposcopy diagnosis.

Results

Of 655 HIV-infected women, a total of 146 HIV-infected women were identified who had a minimally abnormal Pap test (ASCUS/HPV+ or LSIL) during the time frame of the study. Within 6 months of Pap testing, 90 of these women (62%) had a colposcopic examination. For these 90 women, the average age was 36 years (range 13–56), the average CD4 count was 376 cells/μL, 60% of the women reported being on HAART, and the racial distribution was 62 (69%) women identified as black, 9 (10%) as white, 9 (10%) as Hispanic, and the remaining 10 (11%) as other (Table 1). Of these 90 women, colposcopy was negative for 20 (22%), CIN1 for 41 (46%), and CIN2+ for the remaining 29 (32%). Twenty-six of the 29 women (90%) with CIN2+ had CIN2, 3 (10%) had CIN3, and no women were diagnosed with cancer (Table 2). Our study was not powered to evaluate CIN3 alone as an outcome after a minimally abnormal Pap test. Smoking status, being on HAART, and mean CD4 counts were not significantly different among the different colposcopic outcome groups, including those without follow-up within 6 months (Table 3). A Spearman rank correlation analysis found no significant relationship among smoking status, CD4 count or being on HAART medication, and the colposcopy diagnosis. The colposcopy outcomes based on CD4 values are presented in Table 4. Our study was not powered to determine if there was a statistically significant difference in colposcopy results based on CD4 values.

Table 1.

Demographic Data

	HIV-infected (n=90)	HIV-uninfected (n=747)	p value
Age, years	36±9	27±10	<0.0001^*
Race
Black	62 (69%)	373 (50%)	<0.002^**
White	9 (10%)	179 (24%)
Hispanic	9 (10%)	105 (14%)
Other	10 (11%)	90 (12%)

Demographic data were extracted from the electronic medical records during chart review. There was a significant difference between age (^* p<0.0001, t test) and racial demographics (^** p<0.002, chi-square test) in the HIV-infected vs. the HIV-uninfected groups, which was adjusted for in the final analysis.

Table 2.

Colposcopy Results

Colposcopy result	HIV-infected	HIV-uninfected
Negative	20 (22%)	336 (45%)
CIN1	41 (46%)	254 (34%)
CIN2	26 (29%)	120 (16%)
CIN3	3 (3%)	37 (5%)
CIN2+	29 (32%)^a	157 (21%)^a
Cancer	0 (0%)	0 (0%)

Colposcopy results for HIV-infected and HIV-uninfected women who had a minimally abnormal Pap test and subsequent colposcopy within 6 months. The outcome of interest was the percentage of patients with cervical intraepithelial neoplasia 2 or worse (CIN2+). There was a higher percentage of HIV-infected women with underlying CIN2+ compared to HIV-uninfected women after adjusting for differences in age and race.

Adjusted odds-ratio [OR] 2.17, 95% confidence interval (CI) 1.33-3.62.

Table 3.

Characterization of HIV-Infected Women

Colposcopy result	Negative	CIN1	CIN2+	No follow-up	p value
Current smoker	4 (20%)	12 (29%)	6 (31%)	16 (30%)	0.69^a
Current HAART	12 (60%)	25 (61%)	12 (60%)	30 (54%)	0.38^a
Mean CD4 count, cells/μL (range)	346 (61–676)	375 (2–1680)	383 (20–993)	376 (11–619)	0.71^b

Smoking status, being on highly active antiretroviral therapy (HAART) (^achi-square test) and mean CD4 counts (^bANOVA) were not significantly different among the different colposcopic outcome groups, including those without follow-up within 6 months. A Spearman rank correlation analysis found no significant relationship between smoking status, CD4 count, or being on HAART medication and the colposcopy diagnosis.

Table 4.

Colposcopy Results Based on CD4+ Counts

CD4 Count	Negative	CIN1	CIN2	CIN3
<200	7 (25%)	11 (39%)	9 (32%)	1 (4%)
≥200 <350	4 (17%)	15 (65%)	4 (17%)	0 (0%)
≥350	9 (23%)	15 (38%)	13 (33%)	2 (5%)

Our study was not powered to determine if there was a statistically significant difference in colposcopy results based on CD4 values.

There were 747 HIV-uninfected women at the same institution within the same time period who underwent colposcopy within 6 months of a minimally abnormal Pap test. Of these women, 373 (50%) identified as black, 179 (24%) identified as white, 105 (14%) identified as Hispanic, and 90 (12%) identified as other (Table 1). Colposcopy was negative for 336 (45%), CIN1 for 254 (34%), and CIN2+ for 157 (21%). Of the women with CIN2+, 120 of the 157 had CIN2 (76%), 37 (24%) had CIN3, and no women were diagnosed with cancer (Table 2). After adjusting for differences in age and race, HIV-infected women were twice as likely to be diagnosed with CIN2+ after a minimally abnormal Pap test than HIV-uninfected women (p=0.002, adjusted OR 2.17, 95% CI 1.33-3.62). If we consider differences in rates of CIN2 only, excluding CIN3, there remains a higher risk of underlying CIN2 in HIV-infected patients (p=0.0001, OR 2.45, 95% CI 1.45-4.13). There were no cases of cervical cancer diagnosed in either group.

Discussion

Our study demonstrates that in the setting of a minimally abnormal Pap test, HIV-infected women are more likely to have underlying CIN2+ as diagnosed by histologic study within 6 months of Pap testing compared to HIV-uninfected women. Other studies have detected coincident CIN more frequently in HIV-infected women with minimally abnormal Pap testing. Wright et al.¹³ found in a cross-sectional analysis that of HIV-infected women with mild cytologic atypia, 38% had concomitant CIN compared to 9% of HIV-uninfected women. Our findings are in contrast to a cross-sectional cohort study by Boardman et al.,¹⁴ which did not note an increased risk of high-grade cervical histology (CIN2 or worse) in HIV-infected as compared to HIV-uninfected women with minimally abnormal Pap testing. Massad et al.,¹⁵ in a multicenter cohort study found that only 4% of HIV-infected women with ASCUS/HPV+ had underlying CIN2+; however only 270 (21%) of the 1281 HIV-infected women with ASCUS/HPV+ Pap tests in the cohort could be included in this analysis. Kirby et al.,¹⁶ in a secondary analysis of a prospective HPV natural history study of HIV-infected women, found CIN2+ in 5 (31%) HIV-infected women who underwent colposocpy within 6 months of an ASCUS/HPV+ Pap test; however, timely colposcopy was performed in only 16 (48%) of the 33 HIV-infected women with ASCUS/HPV+ cytology.

Minimally abnormal Pap tests continue to be common in HIV-infected women, although there is variation in the distribution of Pap test abnormalities. Of 120 women who participated in the Study to Understand the Natural history of HIV/AIDS in the era of effective therapy (The SUN Study), 14 (12%) had ASCUS, 24 (20%) had LSIL, and 2 (2%) had a high-grade squamous intraepithelial lesion (HSIL) as the baseline cervical cytology.¹⁷ Another study of HIV-infected women followed up to 7 years found that 222 (32%) of 700 cervical cytology specimens were abnormal; 108 (49%) were ASCUS, 83 (37%) were LSIL, and 14 (6%) were HSIL. An additional II were reported as dysplasia not otherwise specified, 2 with atypical cells of endocervical orgin, 2 with parakeratosis, one with endometrial adenocarcinoma and endometrial cells.¹⁸ Duerr et al.,¹⁹ demonstrated that women with HIV were more frequently diagnosed with ASCUS, with a cumulative incidence of 78% ASCUS Pap tests among HIV-infected women over a 5-year period compared to 38% among HIV-uninfected women. Similarly, a large cohort study that followed HIV-infected and uninfected women for a median of 8.4 years found an overall incidence of any abnormal Pap test result of 179 in 1000 person-years for HIV-infected and 75 in 1000 person-years for HIV-uninfected women. In the HIV-infected women with abnormal Pap testing, 19% had ASCUS, 13% had LSIL, 1% had HSIL, and 0.5% were diagnosed with cancer.²⁰

There is disagreement about the optimal management of a minimally abnormal Pap test in HIV-infected women. The American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) recommend colposcopy and directed biopsies for all HIV-infected women, regardless of CD4 count, viral load, or use of HAART, who have ASCUS or LSIL Pap testing.^21,22 In contrast, the American Society for Colposcopy and Cervical Pathology (ASCCP) recommends managing HIV-infected women with minimally abnormal Pap tests in the same manner as the general population by using HPV testing for triage of ASCUS and colposcopy for those with LSIL.²³ Because our current study evaluates only the HIV-infected women who were HPV+ and had colposcopy, our study does not provide data about the need for colposcopy for all HIV-infected patients with minimally abnormal Pap testing regardless of HPV status.

There are conflicting data regarding whether HIV infection is associated with an increased risk of progression to CIN2+. One prospective trial followed HIV-infected and uninfected women for 3 years after a diagnosis of CIN1 on colposcopy and found infrequent progression in both groups.²⁴ Another prospective study included HIV-infected and uninfected women who initially had a minimally abnormal Pap test and subsequent negative colposcopy. The women were followed with cytology every 6 months and colposcopy if abnormalities were detected. The authors found an increase in the risk of progression in HIV-infected women that was not statistically significant when controlled for HPV type, ethnicity, and colposcopy findings.²⁵ A nearly 3-year prospective cohort study evaluated the development of SIL, finding that 20% of HIV-infected women were diagnosed with histologically confirmed SIL compared to 5% of HIV-uninfected women. Interestingly, 9% of the SIL in HIV-infected women was HSIL, whereas 25% of the SIL in HIV-uninfected was HSIL.²⁶ This study did not, however, specifically focus on minimally abnormal Pap testing. When evaluating the incidence of invasive cervical cancer (ICC), long-term prospective studies have suggested that when enrolled in regular screening programs, HIV-infected women do not have a higher rate of ICC.^27,28

Our study has several limitations. It is retrospective in design and follows each patient during a 6-month window that links a minimally abnormal Pap test with colposcopy and histologic data. There is the possibility of selection bias, given that a subset of the HIV-infected women did not follow up for colposcopic examination. The data available suggest that the baseline characteristics of being on HAART, smoking status, and CD4 counts were not different between the groups; however, we cannot account for differences in other clinical parameters that may affect interpretation. It may be that the rates of CIN2+ would differ if data from the women who did not undergo a timely colposcopic evaluation could be included. Similarly, the rates of CIN2+ could also differ if cytologic and histologic outcomes at a longer time interval from the index Pap test were included in the analysis. It is possible that HIV-infected women have a higher progression to CIN2+ during the 6-month study interval, although several studies with long-term cytologic follow-up have not demonstrated the development of significant HSIL. Additionally, several studies have noted low risk of progression to ICC over longer study intervals, making a rapid progression less likely.^23

–26 Our small sample size does not allow us to draw statistically significant conclusions about relationships between immune status as noted by CD4 count and colposcopic results.

Conclusions

Our data suggest that in the HAART era, HIV-infected women with a minimally abnormal Pap test are at a significantly higher risk of having underlying CIN2+ compared with HIV-uninfected women. This demonstrates the importance of colposcopic and histologic evaluation for minimally abnormal cytology in the HIV-infected patient.

Footnotes

Disclosure Statement

The authors report that no competing financial interests exist.

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