**6. Research questions and programmatic issues**

There remain a number of unanswered questions and challenges regarding the implementation and integration of effective cervical cancer screening programs into HIV care and treatment. Data regarding antiretroviral treatment and CD4 counts correlated with VIA results are important to further refine screening and treatment protocols and inform guidelines on appropriate screening strategies and intervals. Integration of cervical cancer screening for HIV+ women requires testing of different models for training, implementation and data collection. Given the information currently available of the interaction of HPV and HIV infections and the epidemiology of HIV:


244 Cancer Prevention – From Mechanisms to Translational Benefits

canal and is less effective with large lesions. This raises potential concerns in the management of HIV+ women, who may have lesions occupying a larger volume of the

One of the treatment effects with either cryotherapy or LEEP may be stimulation of the immune response, promoting clearance of HPV after treatment, even if the entire lesion or the entire transformation zone is not excised or ablated, although one small study failed to show an effect of cryotherapy on HPV clearance one year after treatment (Taylor 2010;

HIV-positive women have an increased incidence of persistence or recurrence after treatment, with some studies documenting >50% recurrence rate (Tebeu et al. 2006).

positive surgical margins with LEEP or cervical conization (present in >40% of HIV+

Most recurrences in HIV+ women appear to be low-grade disease, which may be associated with new HPV infections (Massad et al. 2007) but re-excision may be necessary in some cases (Holcomb et al. 1999; Gingelmaier et al. 2007). Follow-up with cervical cytology alone or cytology and colposcopy together at 6-month intervals over the first year after treatment

There remain limited data on the use of LEEP and cryotherapy in the setting of HIV, especially related to efficacy. A study of HIV-infected and –uninfected women in Zimbabwe, cryotherapy had a 40.5% failure rate among HIV+ women at one year of followup, compared to 15.8% failure rate among HIV- women; in the same study, LEEP had 14% and 0% failure rates, respectively, among HIV+ and HIV- women (CHirenje 2003). However, over 50% of failures were low-grade lesions. LEEP was associated with higher complication rates, including excessive bleeding,and discharge, than cryotherapy. A study from Zambia of cryotherapy-ineligible women (many of whom were HIV+), referred for further management, LEEP (performed by physicians) was feasible and safe, with low levels

Abstinence should be emphasized until complete healing has occurred after treatment for cervical dysplasia, since the treatment has been shown to dramatically increase genital tract HIV shedding (Wright 2001) and may increase risk of sexual transmission of HIV. However, a recent study from Kenya found no increase in detectable cervical HIV-1 RNA among HIV-

There remain a number of unanswered questions and challenges regarding the implementation and integration of effective cervical cancer screening programs into HIV care and treatment. Data regarding antiretroviral treatment and CD4 counts correlated with

women) (Boardman et al. 1999; Gilles et al. 2005; Lima et al. 2009).

greater immunosuppression (Holcomb et al. 1999; Shah et al. 2008)

of complications that can be managed locally (Pfaendler et al. 2008).

positive women (most on ART) after cryotherapy. (Chung et al. 2011).

**6. Research questions and programmatic issues** 

cervix.

Chumworathayi et al. 2010).

Recurrence rates are increased in the following situations:

glandular involvement (Lima et al. 2009).

lack of suppressive ART (Robinson et al. 2001).

is recommended (CDC 2009; Wright et al. 2007).

