Priya Batra1, Louise Kuhn2 and Lynette Denny3

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Excisional therapy outcomes for cervical
intraepithelial neoplasia (CIN) in a South
African population with high HIV prevalence

• Priya Batra1, Louise Kuhn2 and Lynette Denny3
• 1College of Physicians and Surgeons, Columbia
  University
• 2Mailman School of Public Health, Columbia
  University 3Faculty of Health Sciences -
  Department of Obstetrics and Gynaecology,
  University of Cape Town

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HIV/cervical cancer in South Africa

• Most common cancer in South African women
  relatively high mortality
• Compounded by HIV (2008 adult prevalence 18.1)
• Annual incidence of CIN is four to five times
  greater in HIV-positive women

WHO/ICO HPV Information Centre, 2007
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Excisional therapy for CIN
Normal cervical epithelium
Cellular atypia with HPV infection
non-invasive CIN
HPV-induced nuclear changes invasive carcinoma
Large Loop Excision of the Transformation Zone
(LLETZ)
William J. Mann, Jr., MD, for UTDOL
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Objectives

• Describing women undergoing LLETZ in Cape Towns
  public health system
• Evaluating the impact of HIV status on LLETZ
  outcomes

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Methods

• Design/setting
• Retrospective chart review
• Groote Schuur Hospital, Cape Town
  (primary referral center, Western Cape)
• Sample
• All new patients gt16 years of age undergoing
  LLETZ between 01/01/06 and 12/31/08 (n778)
• Data time points

Index visit
LLETZ visit
4-month post-LLETZ visit
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Results
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Demographics - women undergoing LLETZ (N778)
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No difference in LLETZ histology by HIV status
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Excision margins positive for residual CIN

• 55.1 of specimens had gt1 excision margins
  positive for CIN
• Women with gt1 positive margins more likely to be
  HIV-positive (plt0.0001)

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Post-LLETZ treatment outcomes
Incomplete treatment LSIL or more severe lesion
by Pap smear at 4 months post-LLETZ
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HIV-positive women significantly more likely to
have abnormal Pap at 4 months

• plt0.0001 for effect of HIV status on post-LLETZ
  Pap smear result
• No protective effect of ART use

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Findings summary

• Post-LLETZ loss to follow-up rate of over 20
• HIV-positive women significantly more likely to
  default
• HIV-positive women significantly more likely to
• Have cervical disease by Pap smear after LLETZ
• Have excision margins positive for residual CIN
• No protective effect of ART therapy
• ART use self-reported data on duration of
  therapy/CD4 count unavailable

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Interpretation and conclusions

• Suboptimal LLETZ treatment outcomes in
  HIV-positive women (Adam et al. 2008, Lima et al.
  2009, Massad et al. 2007)
• Poor follow-up in HIV-positive women
• Unclear cervix-specific treatment benefit of ART
  (Ahdieh-Grant et al. 2004, Heard et al. 2005,
  Soncini et al. 2007)

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Interpretation and conclusions

• Suboptimal LLETZ treatment outcomes in
  HIV-positive women (Adam et al. 2008, Lima et al.
  2009, Massad et al. 2007)
• Poor follow-up in HIV-positive women
• Unclear cervix-specific treatment benefit of ART
  (Ahdieh-Grant et al. 2004, Heard et al. 2005,
  Soncini et al. 2007)

Cervical surveillance should be emphasized for
HIV-positive women in South Africa
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Acknowledgements
University of Cape Town Dr. R. Soeters Dr. N.
Mbatani Dr. P. Van Greunen Dr. R. Boa Colposcopy
clinic staff
Columbia University Dr. M. Sobieszczyk Dr. J.
Rubin
Western Cape Department of Health The Doris Duke
Charitable Foundation
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