For other malignancies in HIV the main predisposing factor is immune deficiency; however, the relationship between squamous cell neoplasia of the cervix and HIV is unique because of common sexual behaviour risk factors.
Viral DNA from high-risk types of the human papilloma virus (HPV16, 18, 31, 33, and 45) is found in 90% of all cervical cancers irrespective of HIV status. Not every woman with HPV infection develops cervical carcinoma and HPV infection alone is not sufficient for tumour development. Persistence of infection is probably important and other risk factors include smoking, oral contraceptive use and early pregnancy. HPV infection in HIV-infected women may represent reactivation of HPV types acquired in the past rather than recent acquisition of new types.
HIV positive women have a high rate of vulvo-vaginal infection which may make screening unreliable, regular Pap smears are therefore critical. Cervical intraepithelial neoplasia (CIN) is more commonly of a higher grade in HIV positive women and if invasive carcinoma ensues it is also more aggressive. A low threshold for referral for colposcopy is essential. Standard treatment strategies of ablation and excision have yielded disappointing levels of recurrence and patients need to be followed up very closely. If invasive disease ensues treatment is as for immunocompetent patients with surgery, radiotherapy and chemotherapy. Unfortunately treatment reactions are often severe with patients suffering severe vaginal mucositis.
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