Project 2 In 2008,'cervical cancer was responsible for 275,000 deaths, of which about 88% occurred in low- and middle-income countries (LMIC) (1,2). Cervical cancer is the third most common cancer in women worldwide and the most common cancer in many LMIC. In most cases, there is a slow progression from atypical cells to cervical intraepithelial neoplasia (CIN) to invasive carcinoma. Precancerous lesions can be treated and invasive cervical cancer be prevented. The screening methods currently available include cytological smears (Pap smear), visual inspection with acetic acid (VIA), and human papillomavirus (HPV) testing. A diagnosis of CIN can be confirmed by histology (biopsy), with or without colposcopy. There are also many treatment methods that are available, including cryotherapy, LEEP/ large loop excision of the transformation zone(LLETZ), cold knife conization (CKC), laser vaporization, cold coagulation, and hysterectomy. Many resource-limited countries have adopted a "single visit" or "screen-and-treat" approach using cryotherapy following a positive screening test. Cryotherapy has become the initial mode of treatment because of its feasibility and the limited availability of colposcopy/biopsy/LEEP. HIV has been shown to increase the risk of the development, progression and recurrence of CIN (3-5). Several studies have consistently shown that HIV-infected women present higher risk of CIN persistence or recurrence after standard therapy (6-14). In settings where LEEP is available and accessible, treatment with LEEP over cryotherapy is recommended by the WHO. This recommendation applies to women regardless of HIV status. However, there is a paucity of studies assessing the efficacy of cryotherapy or LEEP and the factors associated with successful treatment outcomes among HIV-infected women in LMIC. Moreover, there is no consensus in the treatment specifically for HIV-infected women in LMIC. The core objective of this application is to increase our knowledge about the efficacy of different treatment modalities for precancerous lesions which can help inform the implementation of the best treatment algorithms particularly for HIV-infected women with cervical neoplasia in LMIC.
HIV infection increases the risk for cervical cancer. Because of cost and feasibility related issues, the screening and treatment of cervical pre-cancer differs in LMIC from that of resource rich countries. Cryotherapy is the initial mode of treatment and LEEP is limited for those with more advanced lesions. It is not known if this is the best approach for HIV-infected women. As HIV-infected women live longer with treatment, we need to find the best way to prevent cervical cancer in this population.