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High rate off pre-cancer anal lesions in US women with HIV.

One in 10 HIV-infected US women had abnormal cell growth in anal tissue that may develop into anal cancer, according to results from the Women's Interagency HIV Study (WIHS). (1) Older age, receptive anal intercourse, and infection with anal human papillomavirus (HPV) raised the risk of low-grade anal intraepithelial neoplasia (AIN), the less threatening type of abnormal anal cell growth studied. Anal HPV infection raised the risk of high-grade AIN, the more threatening type of abnormal anal cell growth studied.

* How the study worked. Researchers studied 470 women with HIV and 185 women without HIV but with a high risk of HIV infection. The women lived in or around Chicago, San Francisco, or Brooklyn, New York. All women were interviewed, received a gynecological exam, and had anal and cervical cells tested for HPV and for AIN. If the cell studies showed abnormal results, women had biopsies of anal lesions. Then WIHS investigators compared AIN rates in women with and without HIV. Finally, the researchers used standard statistical methods to pinpoint factors that raise the risk of low-grade AIN and high-grade AIN.


* What the study found. Compared with the 185 women without HIV, the 470 HIV-infected women were older, poorer, less likely to have a job, and more likely to inject illegal drugs. Women with HIV drank less alcohol than women without HIV. About half of both the HIV group and the non-HIV group had anal intercourse. Higher proportions of women with HIV had abnormal findings in anal and cervical cells, and higher proportions of the HIV group had anal HPV infection (80% versus 50c/c of the non-HIV group) and cervical HPV infection (45% versus 15%).

When the researchers looked at the combined HIV and non-HIV group, 52% of women with normal cervical or anal findings smoked, compared will) 639? of women with low-grade AIN and 64% of women with high-grade AIN. Looking only at women with HIV. the researchers found that 51% with normal cervical or anal findings smoked, compared with 68% of women with low-grade AIN and 65% of women with high-grade AIN.

The researchers detected low-grade AIN in 12% of women with HIV versus 5% of women without HIV. High-grade AIN occurred in 9% of women with HIV versus 1% of women without HIV.

Statistical analysis that considered numerous risk factors for low-grade or high-grade AIN in the HIV-infected women found that the following factors raised or lowered the risk regardless of the other risk factors analyzed (Figure 8 on page 28):


Low-grade AIN In women with HIV

* Every fewer 10 years of age lowered the risk 41%

* Receptive anal intercourse raised the risk 3.2 limes

* Cancer-causing types of anal HPV raised the risk 11 times

* Cancer-causing plus non-cancer-causing types of anal HPV raised the risk 1 1 times

* Cancer-causing plus non-cancer-causing types of cervical HPV raised the risk 3.5 times

High-grade AIN in women with HIV

* Cancer-causing types of anal HPV raised the risk 7 times

* Cancer-causing plus non-cancer-causing types of anal HPV raised the risk 10 times

In these analyses, factors that did not affect the risk of low-grade or high-grade AIN were HIV infection, race or ethnicity (black, white, or Hispanic), education level, marital status, household income, employment, number of years smoking, current alcohol use, or history of injecting drugs. In the high-grade AIN analysis, other factors that did not affect the risk of AIN were current antiretro-viral therapy, CD4 count, and viral load.

* What the findings mean /or you. This study shows that older age, ever having receptive anal intercourse, or having anal or cervical HPV infection make AIN more likely in women with HIV. Although the study involved women from only three US cities, the results probably hold true for women with similar social, economic, and health backgrounds throughout the United States and other developed countries.

Because HPV, like HIV, is a sexually transmitted virus, the results underline the dangers of unprotected intercourse for both women and men. Other studies show a higher risk of HPV-related anal cancer in men and women with HIV than in those without HIV, and a higher risk of cervical cancer in HIV-infected women than in women without HIV-Researchers have known for some time that receptive anal intercourse contributes to the high risk of cancer-related anal lesions and anal cancer among gay men with and without HIV infection. (3-5) The WIHS study shows that receptive anal intercourse triples the risk of low-grade AIN in women with HIV and so may raise the risk of anal cancer in women as well as men.

A longer history of smoking cigarettes did not, by itself, raise the risk of AIN in this study. However, two thirds of women with low-grade or high-grade AIN smoked, compared with half of women with normal cervical or anal findings, In addition, some (but not all) earlier research linked smoking with a higher risk of anal cancer. (3), (5) These findings add to the many reasons why people with and without HIV should not smoke.

It is also important to know that other research suggests taking strong antiretroviral combinations does not protect against anal cancer. (6-7)

The US National Cancer Institute recommends a yearly cervical Pap test for all women at least once every 3 years, starting about 3 years after a woman begins sexual intercourse and no later than age 21. Pap tests can detect cervical cancer or abnormal cells that lead to cervical cancer.

To prevent anal cancer, the American Cancer Society recommends avoiding sexual practices that "carry a high risk of HPV infection and HIV infection, particularly having multiple partners and having unprotected anal sex." (8) A vaccine against certain types of HPV is recommended for young women before they become sexually active, and it is being studied in men. Young women who get the HPV vaccine should still have regular Pap tests.

To learn more about AIN and anal cancer, see the following University of California, San Francisco Web site: Joel Palefsky from the University of California, San Francisco, one of the authors of the new study, (1) recommends that HIV-infected women discuss their risk of anal and cervical cancer with their doctors. He believes all HIV-infected women should have an annual digital rectal exam. If they are having any-anal symptoms--such as bleeding or pain--or if they have a history of warts in or around the anus, Palefsky thinks women should consider being evaluated for AIN. They should also consider being evaluated for AIN if they have a history of cervical intraepithelial neoplasia or vulvar intraepithelial neoplasia. Finally, Palefsky recommends that women with a history of receptive anal intercourse should consider being evaluated for AIN.


(1.) Hessol NA, Holly EA, Efird JT, el al. Anal intraepithelial neoplasia in a multisite study of HIV-infected and high-risk HIV-uninfected women. AIDS. 2009;23:59-70.

(2.) Frisch M, Biggar RJ, Goederi JJ. Human papillomavirus-associated cancers in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome., J Natl Cancer Inst. 2000;92:1500-1510.

(3.) Dating JR, Madeleine MM. Johnson LG, et al. Human papillomavirus, smoking, and sexual practices in the etiology of anal cancer. Cancer. 2004;101:270-280.

(4.) Chin-Hong FV, Vittinghoff E, Cranston RD, et al. Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study./ Natl Cancer Inst. 2005;97:896-905.

(5.) Tseng HE, Morgenstern H. Mack TM, Peters RK. Risk factors for anal cancer: results of a populalion-based case-control study. Cancer Causes Control. 2003;14:837-846.

(6.) Piketty C. Selinger-Leneman H. Grabar S, ct al. Marked increase in the incidence of invasive anal cancel among HIV-infected patients despite treatment with combination antiretroviral therapy. AIDS. 2008;22:1203-1211.

(7.) Clifford CM, Polesel J, Rickenbach M, et al. Cancer risk in the Swiss HIV Cohort Study: associations with immunodeficiency, smoking, and highly active aniiretrovirai therapy. J Natl Cancer Inst. 2005;97:425-432. 8. American Cancer Society. Can anal cancer be prevented? April 25, 2007.
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Title Annotation:Study 11
Publication:HIV Treatment: ALERTS!
Date:Mar 1, 2009
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