Correlating Pap Smear Results and Colposcopy-Directed Large Loop Excision of the Transformation Zone Histopathology in HIV-Infected and HIV-Uninfected Women: A Case-Control Study in South Africa
Background. In low-resource settings (LRS) with high HIV/AIDS and cervical cancer rates, new screening strategies face many logistic hurdles. Since cytology is there to stay, at least in the median-term future, it is important to assess to what extent HIV-HPV coinfection impacts the accuracy of screening methods and strategies. Methods. We audited the correlation between cytological diagnosis of minimal abnormality ( CIN1), CIN2+, or cancer and the histological diagnosis of colposcopy-directed large loop excision of the transformation zone of 399 HIV-uninfected controls and 389 HIV-infected cases. Results. The average age at diagnosis of CIN2+ of the cases was 4.2 years younger than controls ( ). The endpoint used to assess the accuracy of cytology was minimal cytological abnormality (≤CIN1/LGSIL). The sensitivity, specificity, and negative and positive predictive values were 92.7, 18.5, 45.1, and 77.9%, respectively. The overall ratio of discordance/concordance between cytology and histology was similar in both groups. Conclusion. In LRS, where rapid-HPV testing is not yet part of screening algorithms, a cytological diagnosis of minimal abnormality requires visual inspection and treatment of visualized lesions especially in HIV-infected women aged 30 years. The cytological endpoint of accuracy should be set low to avoid false negative smears. 1. Introduction It is often stated that more stringent follow-up by means of Pap smears is warranted in HIV-infected than uninfected women [1–3]. The rationale is based on the assumption that cervical cancer is an AIDS-defining illness [4]. However, this assumption is debatable since there is no convincing evidence indicating that the incidence of cervical cancer increased with the spread of HIV/AIDS, be it in the developing or the developed world [5–8]. This being said, the question remains whether preventative strategies should be tailor-made for HIV-infected women. The prevention of cervical cancer encompasses primary (HPV vaccination and life style) and secondary (screening) measures. In low-resource settings (LRS), HPV vaccination is not yet practiced because of a wide array of logistical hurdles, and cytological screening is mostly either absent or limited to opportunistic testing [9, 10]. Cervical cytology has been the mainstay of prevention for many decades. Because of its wide range of sensitivity and specificity and the availability of low-cost/low-technology HPV-DNA test kits, there is a slowly growing paradigm shift favoring alternatives based on cytology, rapid-HPV testing, visual inspection,
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