zimbabwe aids care foundation newlands clinic is cervical cancer screening a necessary part of hiv...
TRANSCRIPT
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ZIMBABWE AIDS CARE FOUNDATION
NEWLANDS CLINICIs Cervical Cancer Screening a necessary
part of HIV care in Zimbabwe?
ZIMA CongressFriday 29th August 2014
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Presentation Outline
• Newlands Clinic and WHS• Case studies• HPV and HIV• Methodology and results• Conclusion• Recommendations
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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 care3
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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
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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)
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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
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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
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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
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Normal Cervix
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Normal Cervix
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VIA Positive
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VIAC Positive
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VIAC Positive
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Invasive cervical cancer
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Case Study 1 – Mrs EC
• 49 years old• Commenced ART in January 2005 (9½ years)• On 1st line (TDF/3TC/NVP)• Baseline CD4 count 83, June 2014 573
• Viral load undetectable since April 200515
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Mrs EC - routine VIAC screening in April 2012
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LEEP:histology - koilocytosis
VIAC positive: eligible for LEEP
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Mrs EC – VIAC screening April 2013
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VIAC positive - eligible for LEEP
Histology – micro-invasive carcinoma of the cervix
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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)
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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 undetectable19
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Ms MM – routine VIAC screening August 2014
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VIAC positive – eligible for LEEP
LEEP done 13/08/2014 – CIN I
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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
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• 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
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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
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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
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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
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Results
• The age range of women with VIAC positive lesions screened was 18 – 63 years
• The % of women with VIAC positive lesions was:
- 2011 - 34.9% (314/899) - 2012 - 30.1% (269/895) - 2013 - 31.0% (126/406)• The mean over the 3 years was 32.0% 26
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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%
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Histological Diagnosis
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CIN I 12%
CIN II 27%
CIN III 30%
HPV-related changes 17%
Cervical Cancer 2%
Other 12%
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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
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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, 2012. Poster WEPE258.2. The effect of HIV and HPV coinfection on cervical COX-2 expression and systemic prostaglandin E2 levels.Fitzgerald 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.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):2085-92 (abstract). June 18, 2011.
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Thank you
The women in care at NCThe staff in the NC WHSDr MagureProf LuethyTo you all for listening!
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