HIV and Cervical Cancer: Behind the Very High Number of SAs

Recently published study Lancet According to medical journals, women living with HIV in South Africa in 2018 accounted for an estimated 63.4% of new cases of cervical cancer, which is dramatically higher than the world-class level of about 6%.

The study also found that women living with HIV were on average six times more likely to develop cervical cancer than women not living with HIV.

“Absolutely, most women with cervical cancer who live with HIV were from South Africa,” the author writes.

Of the estimated 33,000 new cases of cervical cancer in women living with HIV in 2018, about 8200 were in South Africa. It is estimated that there were approximately 570,000 new cases of cervical cancer worldwide in 2018, including women who are not living with HIV.

Cancer caused by a virus

“Cervical cancer is caused by an infection from the human papillomavirus (HPV). It is one of the most strongly associated viruses. It is a very common virus and very common. It’s a sexually transmitted disease, “explains Professor Sinead Delany-Moretlwe, researcher and director of the Witz Reproductive Health and HIV Institute (Witz RHI).

However, not all types of HPV cause cervical cancer. According to the World Health Organization, there are more than 100 types of HPV, and only two are associated with most cases of cervical cancer. These are types 16 and 18, and according to WHO, they cause about 70% of all cervical cancers.

Dr. Karin Richter, a pathologist in clinical virology at Lancet Laboratories, states that so far there are 12 to 15 types of HPV that cause some form of cancer.

These are known as high risk types. She says that all HPV types cause uncontrolled growth, but affect different areas such as the skin. A good example is plantar warts. It has a low risk and generally does not cause cancer.

High risk HPV

Delany-Moretlwe says that if a woman is infected with high-risk HPV type, that does not mean she will definitely develop cervical cancer. “Most people get infected, and over time, the infection goes away … but at a small rate, the infection persists,” she explains.

“The longer it lasts, the more it essentially inherits the cell’s mechanics, and it begins to replicate intracellularly in such a way that the cell begins to produce abnormally, becomes an abnormal cell, and eventually becomes a cancer cell. You can, “she adds. ..

Dr. Nomonde Mbatani, Senior Specialist and Head of the Gynecologic Oncology Unit at Groote Schuur Hospital, explains that prolonged high-risk HPV infections ultimately cause the skin to respond to viral stimuli.

This alters the cells at the microscopic level and picks them up when a Papanicolaou smear is performed. If left untreated, these abnormal cells can progress to cancer, but this does not happen in all patients.

Connection with HIV

by Lancet Studies show that women living with HIV are more likely to get HPV infections and are less likely to get rid of them than women who are not infected with HIV, both of which contribute to a sustained increase in HPV infection rates. It is a factor.

Mubatani states that not only smoking but also a weakened immune system are some of the risk factors associated with cervical cancer. According to Richter, women living with HIV are not receiving antiretroviral treatment and are at a particularly high risk of developing cervical cancer. The number of CD4 is small.

This is because their immune system may not be able to get rid of high-risk HPV infections. Delany-Moretlwe agrees that early women living with HIV begin treatment and the longer the treatment period, the less likely they are to develop persistent HPV infection. “The aggressive deployment of antiretroviral therapy is a very important strategy in cervical cancer prevention, in addition to the specific preventive strategies we have, screening and vaccination,” she says. I will.

Prevention is the key

According to Delany-Moretlwe, cervical cancer can be prevented by vaccination with the HPV vaccine before it becomes infected with the HPV, and if detected early, it is easy to treat, so screening is essential.

Mbatani explains that there are two methods of screening for cervical cancer used in the public health sector. The first is to use a cervical cytology that includes a Papanicolaou smear that can be mounted on a liquid base or glass slide.

She says liquid-based Papanicolaou stain specimens are more effective because it is easier to isolate abnormal cells for analysis.

She says that Papanicolaou smears, where the specimens are attached to glass slides, can cause problems such as broken slides and poor quality of the collected specimens. She adds that the difficulty of Papanicolaou stains is generally the time it takes to get results, as they must be interpreted by cytologists.

If abnormal cells are detected, the woman must return to the clinic or hospital, often leading to loss of follow-up. According to the Cervical Cancer Prevention and Management Policy issued by the National Ministry of Health in 2017, women over the age of 30 are allowed three free Papanicolaou stains in the public sector every 10 years.

Women at high risk, such as women living with HIV, should be screened more often, first at the time of HIV diagnosis and then every three years. Another ideal screening method, according to Mubatani, is the HP VDNA test.

Results are usually available within 2 hours and do not necessarily have to be interpreted by a professional cytologist. This means that women can wait for their results in a medical facility and receive treatment on the same day if treatment is needed. However, according to Mubatani, this test is expensive and not readily available in the public sector.

The effects of the Covid-19 pandemic have reduced screening rates, says Mubatani. Even today, she says, institutions such as Groote Schuur can only focus on the treatment of severe cases of HPV infection or cervical cancer.

Spotlight We asked the National Institute of Public Health about the effects of the pandemic on both Papanicolaou stains and HPV vaccination rates, but no response was received by the time of publication.

How is cervical cancer treated?

If abnormal cells are detected in the skin of the cervix, treatment includes removal of those cells. According to Mubatani, this can be done either by some form of excision, burning, laser irradiation, or freezing of the affected area.

This sounds painful, but she explains that the nerve supply to the cervix is ​​minimal and most of the time these treatments are given as outpatient treatments using local anesthetics.

Patients still need to go to regular Papanicolaou stains because abnormal cells can recur. When abnormal cells progress to cancer, the treatment used depends on the stage of the cancer.

If detected early, surgery is the preferred treatment and is usually effective, says Mubatani.

If the cancer is diagnosed only at an advanced stage, she states that radiation therapy is the preferred treatment because the combination of surgery and radiation therapy is usually not ideal because of serious side effects. The tumor may already be too large to be removed.

HPV vaccinated cervical cancer is one of the few cancers that can be prevented with a vaccine, Delany-Moretlwe said.

“The real intervention that changes whether or not to eradicate cervical cancer is how well the vaccination program can be scaled up,” she adds.

South Africa launched a school-based HPV vaccination campaign for 4th grade girls in 2014. Women can also be vaccinated later in life, but to be effective they must be done before they become infected with HPV. Wits RHI is currently working on a study to monitor the effectiveness of the HPV vaccination campaign in South Africa.

Study called Want This study monitors the effectiveness of double- and single-dose HPV vaccination schedules for community-level HPV prevalence in South African adolescent girls. Richter explains that two vaccines are available in South Africa, Cervarix and Gardasil.

She says that Cervarix used in vaccination campaigns protects against HPV types 16 and 18, and Gardasil protects against 16 and 18 as well as 6 and 11 that cause genital warts.

What Needs to Change in the Treatment of Cervical Cancer?

Ideally for Mubatani, all women over the age of 30 should be screened for cervical cancer. She generally says that more education is needed to warn women about the need for screening before symptoms of cervical cancer appear.

Richter outlines preventative measures such as HPV vaccination and the need to ensure that the immune system is so strong that there is no risk of HPV infection, with more emphasis on early detection and treatment of women living with HIV. ..

* This article was created by Spotlight – Health journalism for the public good.