ZIMBABWE AIDS CARE FOUNDATION NEWLANDS CLINIC Is Cervical Cancer Screening a necessary part of HIV care in Zimbabwe? ZIMA Congress Friday 29 th August

Presentation Outline Newlands Clinic and WHS Case studies HPV and HIV Methodology and results Conclusion Recommendations 2

The Newlands Clinic (NC) A Public Private Partnership with AIDS & TB unit in MOHCC Commenced operations in 2004 offering free, comprehensive HIV care & treatment for over 5000 patients: lab & pharmacy, diagnosis & management of OIs including TB, women’s health service (WHS), pyscho-social programme, adolescent corner & a nutrition programme Nurse-led model of care 3

The Newlands Clinic (NC) Training school: o National Advanced HIV Management for Adults & Children o Visual Inspection with Acetic Acid & Cryotherapy (VIAC) training Partner in the National VIAC programme 4

The Newlands Clinic WHS Launched in January 2011 to offer cervical cancer screening, STI diagnosis & treatment for all sexually active female patients registered at NC Currently 2550 females > 18 years of age in care Nurse-led service supervised by Dr Magure (UZ Dept O&G) 5

The Newlands Clinic WHS ‘See & treat’ approach – VIAC & cryotherapy Loop Electrosurgical Excision Procedure (LEEP) for more advanced lesions Referral system for patient’s requiring complicated surgical procedures eg TAH 6

The NC WHS Equipment Gynae couch Light Cryogun Gas cylinder and stand + spare Camera plus accessories Monitor Trolley Sterile packs Stool Patient information Vinegar Computer + software

Screening for Cervical Abnormality Cytology (pap smear) Visual methods (VIAC, VILI) HPV DNA testing – screen for high risk HPV types, not recommended for routine practise

Normal Cervix

VIA Positive

VIAC Positive

Invasive cervical cancer

Case Study 1 – Mrs EC 49 years old Commenced ART in January 2005 (9½ years) On 1 st line (TDF/3TC/NVP) Baseline CD4 count 83, June Viral load undetectable since April

Mrs EC - routine VIAC screening in April LEEP:histology - koilocytosis VIAC positive: eligible for LEEP

Mrs EC – VIAC screening April VIAC positive - eligible for LEEP Histology – micro-invasive carcinoma of the cervix

Mrs EC - outcome TAH done at Karanda Mission Hospital in Dec 2013 Histology confirmed micro-invasive carcinoma of the cervix Reviewed in WHS June 2014 – all well For repeat VIAC (vaginal vault Dec 2014) 18

Case study 2 – Ms MM 19 year old Commenced ART in March 2005 (at 10 years of age) Baseline CD4 was 224, June 2014 was 710 Viral load undetectable 19

Ms MM – routine VIAC screening August VIAC positive – eligible for LEEP LEEP done 13/08/2014 – CIN I

HIV, HPV and Cervical Cancer >140 HPV types identified, 40 infect female genital tract & 18 (incl types 16 & 18) are high risk for oncogenesis Pre-existing HPV infection is associated with a 2-fold increase in the risk of HIV acquisition in women (1) It has been recognized that HIV+ve people: - more likely to have HPV - carry ↑ number of HPV types - less likely to spontaneously clear HPV infection

HIV changes the natural history of HPV infection → 10 fold ↑ incidence of cervical dysplasia & 5 fold ↑ incidence of cervical neoplasia HIV causes chronic inflammation – markers present in blood and urine (2) Recurrence rates of HPV infection are higher in HIV+ve women than in HIV-ve women HIV+ve women with a low CD4 count are more likely to experience progression of cervical cancer ARV’s will prolong the life of women infected with HPV & allow the development of cervical cancer HPV infection in HIV+ve Women

The most common types of lower genital tract disease caused by HPV infection in HIV+ve women: Cervical intraepithelial neoplasia (CIN) Genital warts Vulval intraepithelial neoplasia Anal intraepithelial neoplasia Vaginal intraepithelial neoplasia Cervical cancer Anal cancer 23

Purpose of the record review The purpose of this review was: To establish the prevalence of VIAC positive lesions at initial screening in women registered in care at NC To determine the histological diagnosis in women with VIAC positive lesions undergoing the LEEP procedure 24

Methodology A record review of patients undergoing initial cervical screening from January 2011 to December 2013 was done The percentage of VIAC positive lesions was assessed Histological specimens obtained from 235 LEEP procedures were analysed 25

Results The age range of women with VIAC positive lesions screened was 18 – 63 years The % of women with VIAC positive lesions was: % (314/899) % (269/895) % (126/406) The mean over the 3 years was 32.0% 26

Results Histological diagnosis for 235 LEEP specimens confirmed pre-cancerous lesions in 69% CIN I - 12% CIN II - 27% CIN III - 30% Cervical cancer in 2% 27

Histological Diagnosis 28 CIN I 12% CIN II 27% CIN III 30% HPV-related changes 17% Cervical Cancer 2% Other 12%

Conclusions These data illustrate a 32% prevalence of VIAC positive lesions Histological diagnosis confirmed moderate to severe dysplasia (CIN II and III) in 57% and invasive cancer in 2% Cervical screening, plus appropriate treatment, is an essential component of care for HIV-infected women in care at Newlands Clinic 29

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Recommendations VIAC must be introduced as standard of care for all HIV+ve women in Zimbabwe In order to prevent HPV infection & consequent cervical disease, pre-adolescent girls must be vaccinated (3) Due to the parallel epidemics of HPV & HIV in Zimbabwe, we should consider HPV vaccination as a additional preventive strategy for pre-adolescent girls, in an attempt to reduce the acquisition of HIV in this key population (3)

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References 1. CF Houlihan, NL Larke, D Watson-Jones, et al. HPV infection and increased risk of HIV acquisition: a systematic review and meta-analysis. XIX International AIDS Conference (AIDS 2012). Washington, DC, July 22-27, Poster WEPE258.Poster WEPE The effect of HIV and HPV coinfection on cervical COX-2 expression and systemic prostaglandin E2 levels. Fitzgerald DWFitzgerald DW, Bezak K, Ocheretina O, Riviere C, Wright TC, Milne GL, Zhou XK, Du B, Subbaramaiah K, Byrt E, Goodwin ML, Rafii A,Dannenberg AJ.Bezak KOcheretina ORiviere CWright TCMilne GLZhou XKDu BSubbaramaiah KByrt EGoodwin MLRafii ADannenberg AJ 3. J Brotherton, M Fridman, CL May, et al. Early effect of the HPV vaccination programme on cervical abnormalities in Victoria, Australia: an ecological study. Lancet 377(9783): (abstract). June 18, 2011.abstract

Thank you The women in care at NC The staff in the NC WHS Dr Magure Prof Luethy To you all for listening! 34