Management of abnormal cytology in HIV-1-infected women

Lynette Denny1, Sonata Walraven1, Landon Meyer1, Bruce Allan1,

Anna-Lise Williamson1, Henry Kitchener2
1
University of Cape Town, Cape Town, South Africa; 2University of Manchester, Manchester, UK

Introduction Results – Genotyping detected 275 HPV types in 78 women,

with multiple infections observed in the majority
● One of the risk factors for human papillomavirus ● Patient population (n=400): of women (Figure 3)
(HPV) infection and subsequent cervical cancer is
impaired cell-mediated immunity – Mean age at Visit 1 was 29 (range 18–52) years
AMPLICOR hc2 test
● HIV-positive women with severe immuno- – Median CD4 count was 248 (range 4–1200) HPV Test
suppression are almost twice as likely to have cells/µL
cervical intraepithelial neoplasia than HIV-negative 2
4 0
women,1 but the exact risk of invasive carcinoma is – Median HIV viral load was 21,000 copies/mL
unclear 59
– The prevalence of HR HPV types, using hc2, was 7 1
● Highly active antiretroviral therapy may reduce the
68% overall
development of cervical intraepithelial neoplasia
in HIV-positive women by reversing immuno- ● Cytological diagnoses at baseline were: 49% normal; 6
deficiency,2 although this effect has not been proven
37% low-grade squamous intraepithelial lesion;
● A better understanding of the natural history of 14% high-grade squamous intraepithelial lesion;
disease is needed in patients co-infected with HIV one cancer Roche line blot assay
and HPV, in order to define management protocols
in this population ● HR HPV detection by hc2 at baseline was
Figure 2. Concordance between the AMPLICOR
associated with a decreased baseline CD4 count and HPV Test, the hc2 test and the Roche line
an increased viral load; 88% of patients infected
Objective blot assay
with HPV at baseline had persistent HPV infection
● To study the natural history of cervical infection by hc2 testing at 6 months, and 88% of women
16
with HPV and cervical cancer precursors in infected at 6 months were also infected at 12 months
untreated, HIV-positive women recruited from two 14

sites in Cape Town, South Africa ● Low baseline CD4 count, but not age, sexual activity 12
or baseline HIV viral load, was associated with
Women (n)
10
persistence
Materials and methods 8

● 28% of women acquired a new HPV infection, as 6

● HIV-positive women (n=400) were recruited for
6-monthly visits over 3 years, from a primary detected by hc2 testing, during Months 1–6 4

healthcare clinic and a colposcopy clinic in 2

● Sub-analysis (n=78):
Cape Town. At each visit, the following analyses were 0
carried out: conventional cytology; HPV DNA testing – The AMPLICOR HPV Test demonstrated 1 2 3 4 5 6 7 8 9 10 11 12

for high-risk (HR) types using the Digene Hybrid HPV infections (n)
extremely high sensitivity; 71/78 women (91%)
Capture® 2 (hc2) test; colposcopy; and histological
were HR HPV-positive, compared with 61/78 Figure 3. Multiple HPV infections are common in
sampling if a lesion was identified. Blood samples
were obtained for assessment of CD4 count and women (78%) by hc2 HIV-positive women
viral load
– Concordance was good between all three assays
● Subsequently, the Roche AMPLICOR® HPV Test (Figure 2):
(Figure 1), assessment of CD4 count and viral load,
Conclusions
colposcopy and histological sampling (if a lesion • Of six samples testing negative by both the
was noted) were performed on 78 women. HPV AMPLICOR HPV Test and the hc2 test, geno- ● The sensitivity of the AMPLICOR HPV
genotyping was performed by the Roche prototype typing confirmed that any types identified were Test is greater than that of the hc2 test
line blot assay (91% vs 78%)
not included in the 13 HR target genotype
spectrum ● Most HIV-infected women have con-
Native HPV Denature and comitant HR HPV infection; multiple
genome UNG
digestion hybridize
• One sample was AMPLICOR-negative and
concurrent HPV infections are common
Wash, add
avidin-HRP
hc2-positive; genotyping identified types
PCR conjugate
Biotinylated
primers
66 and 72 (types not included in the ● The most significant predictor of HPV
target genotype spectrum) in this sample persistence was a low CD4 count
HPV
probe

Hybridization
• 11 samples were AMPLICOR-positive and hc2-
Oxidized Oxidized
TMB TMB
negative: four samples tested negative with the
Add stop solution,
read absorbance
TMB TMB

Roche line blot assay; target genotype(s) were References

HRP produces color upon
addition of TMB substrate
Immobilized hybrids react
with avidin-HRP confirmed in three samples; and four samples 1. Chin KM, Sidhu JS, Janssen RS et al. Obstet Gynecol
HPV: Human papillomavirus; UNG: Uracil-N-glycosylase; PCR: Polymerase chain reaction; HRP: Horseradish peroxidase;
contained non-target genotype(s) (co- 1998;92:83–7
TMB: 3,3',5,5'-tetramethylbenzidene
infection with two types [n=2] and three types 2. Minkoff H, Ahdieh L, Massad LS et al. AIDS 2001;
Figure 1. The AMPLICOR HPV Test [n=2]) 15:2157–64