Elsevier

The Lancet

Volume 359, Issue 9301, 12 January 2002, Pages 108-113
The Lancet

Articles
HIV-1 infection and risk of vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia: a prospective cohort study

https://doi.org/10.1016/S0140-6736(02)07368-3Get rights and content

Summary

Background

Information about vulvovaginal and perianal condylomata acuminata and intraepithelial neoplasia in women infected with HIV-1 is needed to develop guidelines for clinical care. Our aim was to investigate the incidence of these lesions in HIV-1-positive and HIV-1-negative women and to examine risk factors for disease.

Methods

In a prospective cohort study, 925 women had a gynaecological examination twice yearly—including colposcopy and tests for human papillomavirus DNA in cervicovaginal lavage—for a median follow-up of 3·2 years (IQR 0·98–4·87).

Findings

Vulvovaginal and perianal condylomata acuminata or intraepithelial neoplasia were present in 30 (6%) of 481 HIV-1-positive and four (1%) of 437 HIV-1-negative women (p<0·0001) at enrolment. Women without lesions at enrolment were included in an incidence analysis. 33 (9%) of 385 HIV-1-positive and two (1%) of 341 HIV-1-negative women developed vulvovaginal or perianal lesions, resulting in an incidence of 2·6 and 0·16 cases per 100 person-years, respectively (relative risk 16, 95% CI 12·9–20·5; p<0·0001). Risk factors for incident lesions included HIV-1 infection (p=0·013), human papillomavirus infection (p=0·0013), lower CD4 T lymphocyte count (p=0·0395), and history of frequent injection of drugs (p=0·0199).

Interpretation

Our results suggest that HIV-1-positive women are at increased risk of development of invasive vulvar carcinoma. Thus, we recommend that, as part of every gynaecological examination, HIV-1-positive women should have a thorough inspection of the vulva and perianal region, and women with abnormalities—except for typical, exophytic condylomata acuminata—should undergo colposcopy and biopsy.

Introduction

In the USA, about 110000–155000 women are infected with HIV-1.1, 2 Women infected with HIV-1 are at increased risk of developing pre-invasive cervical lesions and invasive cervical cancer.3, 4, 5, 6, 7, 8, 9 As a result, in 1993, invasive cervical cancer was designated an AIDS-defining disorder by the US Centers for Disease Control and Prevention.10 Results of several reports suggest that women with HIV-1 infection are at increased risk of developing vulvar, vaginal, and perianal lesions associated with human papillomavirus;11, 12, 13, 14, 15, 16, 17 these lesions include condylomata acuminata, intraepithelial neoplasia (which are pre-invasive lesions), and invasive cancers. Findings of an AIDS-cancer match registry study showed increased rates of in-situ and invasive vulvovaginal lesions associated with human papillomavirus in HIV-1-positive women in the USA.17 However, little is known about the natural history of these lesions in women infected with HIV-1. This information is needed to develop guidelines for clinical care. We did a prospective cohort study to investigate gynaecological disorders associated with HIV-1 infection.

Section snippets

Study population

From October, 1991, to September, 1998, we enrolled 925 women from the New York City area. Participants included 481 HIV-1-positive women, 437 HIV-1-negative women, and seven women with unknown HIV serostatus. Women infected with HIV-1 were followed up and treated for the disease at local HIV and infectious disease clinics. The cohort and the recruitment protocol are described elsewhere.5, 6

Study participants included 319 women from HIV-AIDS clinics, 142 from methadone maintenance clinics, 282

Results

Age, race and ethnic origin, income, age at first sexual intercourse, and history of cigarette smoking did not differ by much between women infected and not infected with HIV-1 (table 1). However, HIV-1-positive women were significantly more likely to have had human papillomavirus DNA detected in a cervicovaginal lavage sample at enrolment and to have had a history of prostitution, intravenous drug use, and a sexually transmitted disease. At enrolment, CD4 T lymphocyte counts were <200 cells/μL

Discussion

Our study is a comprehensive analysis of the incidence of vulvovaginal and perianal lesions, including intraepithelial neoplasia, in HIV-1-positive women. The incidence of vulvovaginal or perianal lesions was 16 times higher in HIV-1-positive than in HIV-1-negative women, at 2·6 and 0·16 cases per 100 person-years, respectively. Of 33 incident lesions identified in 385 HIV-1-positive women in the incidence analysis, five were high-grade vulvar intraepithelial neoplasia. Additionally, two

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