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Priya Batra 1 , Louise Kuhn 2 and Lynette Denny 3 1 College of Physicians and Surgeons, Columbia University

Excisional therapy outcomes for cervical intraepithelial neoplasia (CIN) in a South African population with high HIV prevalence Priya Batra 1 , Louise Kuhn 2 and Lynette Denny 3 1 College of Physicians and Surgeons, Columbia University

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Priya Batra 1 , Louise Kuhn 2 and Lynette Denny 3 1 College of Physicians and Surgeons, Columbia University

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  1. Excisional therapy outcomes for cervical intraepithelial neoplasia (CIN) in a South African population with high HIV prevalence Priya Batra1, Louise Kuhn2 and Lynette Denny3 1College of Physicians and Surgeons, Columbia University 2Mailman School of Public Health, Columbia University 3Faculty of Health Sciences - Department of Obstetrics and Gynaecology, University of Cape Town

  2. HIV/cervical cancer in South Africa • Most common cancer in South African women; relatively high mortality • Compounded by HIV (2008 adult prevalence 18.1%) • Annual incidence of CIN is four to five times greater in HIV-positive women WHO/ICO HPV Information Centre, 2007

  3. Excisional therapy for CIN Normal cervical epithelium Cellular atypia with HPV infection – non-invasive CIN HPV-induced nuclear changes – invasive carcinoma Large Loop Excision of the Transformation Zone (LLETZ) William J. Mann, Jr., MD, for UTDOL

  4. Objectives • Describing women undergoing LLETZ in Cape Town’s public health system • Evaluating the impact of HIV status on LLETZ outcomes

  5. Methods • Design/setting • Retrospective chart review • Groote Schuur Hospital, Cape Town (primary referral center, Western Cape) • Sample • All new patients>16 years of age undergoing LLETZ between 01/01/06 and 12/31/08 (n=778) • Data time points Index visit LLETZ visit 4-month post-LLETZ visit

  6. Results

  7. Demographics - women undergoing LLETZ (N=778)

  8. No difference in LLETZ histology by HIV status

  9. Excision margins positive for residual CIN • 55.1% of specimens had >1 excision margins positive for CIN • Women with >1 positive margins more likely to be HIV-positive (p<0.0001)

  10. Post-LLETZ treatment outcomes *Incomplete treatment: LSIL or more severe lesion by Pap smear at 4 months post-LLETZ

  11. HIV-positive women significantly more likely to have abnormal Pap at 4 months • p<0.0001for effect of HIV status on post-LLETZ Pap smear result • No protective effect of ART use

  12. Findings: summary • Post-LLETZ loss to follow-up rate of over 20% • HIV-positive women significantly more likely to default • HIV-positive women significantly more likely to: • Have cervical disease by Pap smear after LLETZ • Have excision margins positive for residual CIN • No protective effect of ART therapy • ART use self-reported; data on duration of therapy/CD4 count unavailable

  13. Interpretation and conclusions • Suboptimal LLETZ treatment outcomes in HIV-positive women (Adam et al. 2008, Lima et al. 2009, Massad et al. 2007) • Poor follow-up in HIV-positive women • Unclear cervix-specific treatment benefit of ART (Ahdieh-Grant et al. 2004, Heard et al. 2005, Soncini et al. 2007)

  14. Interpretation and conclusions • Suboptimal LLETZ treatment outcomes in HIV-positive women(Adam et al. 2008, Lima et al. 2009, Massad et al. 2007) • Poor follow-up in HIV-positive women • Unclear cervix-specific treatment benefit of ART(Ahdieh-Grant et al. 2004, Heard et al. 2005, Soncini et al. 2007) Cervical surveillance should be emphasized for HIV-positive women in South Africa

  15. Acknowledgements University of Cape Town Dr. R. Soeters Dr. N. Mbatani Dr. P. Van Greunen Dr. R. Boa Colposcopy clinic staff Columbia University Dr. M. Sobieszczyk Dr. J. Rubin Western Cape Department of Health The Doris Duke Charitable Foundation

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