Prevalence of Cervical Dysplasia in HIV-Positive and HIV-Negative Women at the Sihanouk Hospital Center of HOPE, Phnom Penh , Cambodia

Introduction: There is a high burden of cervical cancer in Cambodia, yet published data on the prevalence of cervical dysplasia and the risk factors contributing to the development of pre-cancerous lesions in Cambodian women is very limited. In addition, as it is well known that HIV positivity increases cervical cancer risk, it is important to quantify the prevalence of cervical dysplasia and carcinoma among Cambodian women living with HIV disease. Methods: A cross-sectional study was conducted with a sample of 499 HIV+ and 501 HIV- Cambodian women at the Sihanouk Hospital Center of HOPE. Visual inspection with 5% acetic acid was the method of screening. Colposcopy was performed on all VIA+ patients, and subsequent treatment followed WHO guidelines. Logistic regression models, stratified by both HIV+ and HIV- groups, were used to assess significant factors associated with having dysplasia. Results: VIA+ results were prevalent in both the HIV+ and HIV- arms of the study. The HIV+ patients were more likely to have a lower age at coitarche, lower weight, 2 or more lifetime sexual partners, two or greater pregnancies, or be unmarried. The estimated prevalence of VIA detected cervical dysplasia was 11% for the entire study sample, 13.4% in the HIV positive (HIV+) group and 8.6% in the HIV negative (HIV-) group (OR: 1.65; 95% CI: 1.10, 2.48; p=0.01). For the HIV+ group, having a history of 4 or more full-term pregnancies (OR: 3.42; 95% CI: 1.01-11.64; p=0.049) was found to be significantly associated with having an increased risk of developing cervical dysplasia in the multivariate model. Conclusion: Cervical dysplasia is prevalent in both HIV positive and negative Cambodian women and a VIA based national screening programs need to be developed and expanded to provide access to affordable and effective treatment for cervical dysplasia and cancers.

Prospective cohort study examining cervical cancer screening methods in HIV-positive and HIV-negative Cambodian Women: a comparison of human papilloma virus testing, visualization with acetic acid and digital colposcopy.

OBJECTIVES: Logistical and economic issues make traditional cytology-based cervical cancer screening challenging in developing countries. Alternative, cost-effective, screening strategies must be developed to screen millions of women in resource-poor countries such as Cambodia. DESIGN: A prospective cohort study during which all women underwent four cervical cancer screening methods: (1) self-sampled human papilloma virus (HPV) testing (careHPV system), (2) clinician-collected HPV testing, (3) visualization with acetic acid (VIA) and (4) digital colposcopy (DC) with the Enhanced Visual Assessment System (EVA). SETTING: A referral hospital in Phnom Penh, Cambodia. PARTICIPANTS: Two hundred and fifty Cambodian women (129 HIV+, 121 HIV-). Subjects were recruited from the National Center for HIV/AIDS Dermatology and sexually transmitted disease (STD) cohort, the Sihanouk Hospital Center of Hope's Rural Outreach Teams and the Pochentong Medical Center. RESULTS: Fifty six of the 250 (22.4%) patients tested positive for high-risk HPV (hrHPV+). Thirty seven of the 129 HIV+ women were hrHPV+ (28.6%) whereas 19/121 HIV- women were hrHPV+ (15.7%) p=0.0154. Self-sampling HPV specimens identified 50/56 (89%) whereas physician-collected specimens identified 45/56 (80%) p=0.174. 95.2% of the patients felt comfortable obtaining HPV self-samples. Thirty seven of 250 women were VIA+. Thirty of 37 VIA+ women underwent confirmatory biopsies for cervical intraepithelial neoplasia (CIN) (26 CIN1, 4 CIN2+). The rate of confirmed dysplasia in the HIV+ group was 20/129 (15.5%) compared with 10/121 (8.26%) in HIV- women p=0.0291. The contemporaneous physician impressions of the DC images accurately differentiated between CIN1 and CIN2+ lesions in all 30 women having confirmatory biopsies. CONCLUSIONS: The results of this study suggest potential modifications of the current cervical screening strategy that is currently being employed in Cambodia. The first step in this new strategy would be self-swabbing for hrHPV. Subsequently, hrHPV+ patients would have DC and immediate treatment based on colposcopic findings: cryotherapy for suspected CIN1 and loop electrosurgical excision procedure (LEEP) for suspected CIN2+.

Comparing Visual Inspection with Acetic Acid to Cytology in Detection of Precancerous Lesions of the Cervix in HIV-Infected Cambodian Women.

PURPOSE: To compare Papanicolaou (Pap) smear readings to visual inspection with acetic acid (VIA) findings among HIV-infected women in Phnom Penh, Cambodia. METHODS: A total of 304 HIV-infected women presenting to the women's clinic at the Community Resource Center in Phnom Penh, Cambodia, were screened for cervical cancer by both Pap smear and VIA. The results of the 2 tests were compared. RESULTS: Complete data were available on 293 women. In all, 55 (19%) women screened positive on VIA; 25 (8.5%) women screened positive by Pap. Visual inspection with acetic acid detected 18 of the 25 patients with abnormal cytology and was normal in 7 women with abnormal cytology. A total of 37 (67%) women with positive VIA were negative by cytology. CONCLUSIONS: Our study shows a reasonable correlation between VIA and Pap smear, with VIA detecting more abnormalities than cytology. In the absence of Pap smear availability, VIA may be a reasonable cervical cancer screening method for HIV-infected women in Cambodia.