Girls with HIV at higher risk for cervical abnormalities

Reproductive health services and surveillance are needed for sexually active girls born with HIV.

Issue: June 2007

Girls born with HIV who become sexually active are at higher risk for developing cervical abnormalities compared with girls with HIV who do not become sexually active, according to study results published in the American Journal of Public Health.

Researchers analyzed 638 girls aged 13 and older who were born with HIV and enrolled in the Pediatric AIDS Clinical Trials Group protocol 219C between September 2000 and December 2005. The data obtained included test results, previous clinical diagnoses, pregnancies and pregnancy outcomes, antiretroviral therapy (ART) use, CD4-positive T lymphocyte number, percentage and plasma HIV viral load copy number, pelvic exam test results, cervical Papanicolaou test results and whether the girls were sexually active. The researchers considered the results of sexually active patients as preliminary because the data were based on disclosure, pregnancy and/or STD diagnosis.

One hundred seventy-four of the participants (27.3%) were sexually active and more likely to be older, Hispanic, have a higher HIV RNA copy number (>10,000 copies/mL) and a lower CD4 percentage compared with patients who were not sexually active. Also, sexually active patients were less likely to be on ART than non-sexually active patients.

“Clinicians caring for perinatal adolescents with HIV have to discuss sexuality issues with them, including safer sexual practices, need for contraception and, if they are sexually active, screening for STDs and cervical abnormalities,” said researcher D. Heather Watts, MD, a medical officer from the pediatric, adolescent and maternal AIDS branch of the NIH.

Abnormal results

Thirty-eight patients were pregnant between 13 years of age and their last follow-up visit. Overall incidence rate of first pregnancy was 18.8 per 1,000 person-years (95% CI, 13.3-25.7), and pregnancy among patients aged 15 to 19 was 33.5 per 1,000 person-years (95% CI, 22.8-47.6). At age 19 years, pregnancy was 17.2% (95% CI, 11.1-23.2) among the 638 patients. Patients who were pregnant were more likely to have abnormal cervical cytology during follow-up compared with patients who were sexually active but not pregnant.

All patients received an HIV treatment regimen during pregnancy resulting in 32 live births, with one child with HIV infection. Regimens included highly active antiretroviral therapy with protease inhibitor and non-nucleoside reverse transcriptase inhibitor (NNRTI), HAART with protease inhibitor, HAART with NNRTI, more than three nucleoside reverse transcriptase inhibitors (NRTI) or other ART. The infant with HIV infection was born to a mother who received two NRTIs and an NNRTI.

Of the 174 reported sexually active patients, 101 (58.1%) had a Pap test and 165 (94.8%) had a pelvic examination. Thirty of the 101 patients who had a Pap test had abnormal cervical cytology at the first examination with a prevalence of 29.7% (95% CI, 20-42.4), and 18 patients had abnormal cervical cytology at follow-up.

The first abnormal cytological diagnosis was classified as atypical squamous cell of undetermined significance (ASCUS) for 18 patients, low-grade squamous intraepithelial lesions (SIL) for 27 patients and high-grade SIL for three patients. Patients with abnormal cervical cytology were more likely to have a genital infection at follow-up than patients with normal cervical cytology. However, some abnormalities continued despite interventions.

“Twenty-one girls with abnormal Pap smears had documented intervention and at least one follow-up Pap smear examination. In some girls, ASCUS progressed to low-grade SIL, low-grade SIL progressed to high-grade SIL or low-grade SIL persisted,” said Susan B. Brogly, PhD, a research scientist of epidemiology at the Harvard School of Public Health Center for Biostatistics in AIDS Research.

The researchers suggested a need for enhanced provision of reproductive health services, such as contraceptive counseling and cervical cytological screening, since 17% of the patients were pregnant by age 19, only 50% of the sexually active patients had Pap tests and almost half of the patients had abnormal cervical cytology. Other recommendations include regularly getting Pap smears, closely managing cervical lesions and screening for genital infections, Brogly said.

Additionally, the researchers also suggested that girls with HIV should receive the human papillomavirus vaccine depending upon immune functions.

“If the HPV vaccine is found to be immunogenic in adolescents with HIV, the vaccine should provide some protection against certain HPV strains and related cervical abnormalities,” Watts said. – by Pam Rothman

For more information:

Brogly SB, Watts DH, Ylitalo N, et al. Reproductive health of adolescent girls perinatally infected with HIV. Am J Public Health. 2007;97:e1047-e1052.