Reports on HIV/AIDS: 1990

NOVEMBER 30, 1990, MMWR, Vol. 39, No. 47, pp. 846-849
Reported by: M Maiman, MD, R Fruchter, PhD, State Univ of New York Health Science Center,
Brooklyn; R Klein, MD, Montefiore Medical Center/Albert Einstein Coil of Medicine; C Marte, MD,
Community Health Project, Bellevue Hospital; S Schultz, MD, MA Chiasson, DrPH, New York City
Dept of Health. Div of HIV/AIDS, Center for Infectious Diseases; Div of STD/HIV Prevention,
Center for Prevention Svcs; Div of Chronic Disease Control and Community Intervention, Center
for Chronic Disease Prevention and Health Promotion, CDC.
Editorial Note: The findings of the investigations in New York City are consistent
with previous reports suggesting an association between HIV infection and cervical
disease in women (1-5). However, methodologic concerns about these four studies
emphasize the need for additional assessment of an association between HIV
infection and cervical disease. For example, the increased prevalence of cervical
dysplasia in the HIV-positive women at the two ambulatory-care clinics (6) may have
been associated with other possible risk factors. In addition, the community controls
used in that study may not be directly comparable to the study group, since the
HIV-positive women may have been more likely to have had sexual contact with
multiple partners, thereby independently increasing their risk for cervical disease.
Other methodologic concerns related to these studies include limited sample sizes,
limitations of cytologic screening for diagnostic purposes, and potential selection
bias. Finally, the study of HIV-positive women who were evaluated by Pap smear and
cervical biopsy was not blinded and lacked a control group (10).
These reports and other investigations have not determined whether HIV-infected
women are at increased risk for cervical cancer. This risk may be assessed indirectly
by examination of trends of cervical cancer rates in areas with high prevalences of
HIV-infected women. For example, in New York City, where the prevalence of HIV
infection in childbearing women (12.5 per 1000 in 1987-88) is one of the highest
among U.S. cities, the incidence of cervical cancer in women aged 15-44 years did not
increase from 1981 through 1986 (12,13). In the United States, approximately 85% of
women with AIDS or HIV infection are of reproductive age (15-44 years). However, in
1987, cervical cancer rarely was listed among HIV-related deaths in women of
reproductive age (14). Because the number of HIV-infected women has continued to
increase since 1987, trends in cervical cancer rates will need to be examined for more
recent years.
Clarification of the relationship between HIV infection and cervical cancer and
dysplasia is also complicated by complexities related to interpretation of cervical
cytologic abnormalities. Squamous cell carcinoma of the cervix and its precursors
form a spectrum of disease, ranging from mild dysplasia (CIN 1) to invasive
carcinoma. In addition, although dysplasia is the precursor of cervical cancer, not all
dysplastic tissue progresses to invasive disease. Without therapy, cervical dysplasia
can regress to normal tissue, persist without change, or progress to invasive disease.
Whether HIV-induced immune suppression substantially alters the course and severity of cervical dysplasia is unknown, but the findings summarized in this report
indicate a need for further investigation.
The etiology of cervical cancer may be multifactorial (15 ), including factors such as
number of sex partners, age at first intercourse, infectious agents (particularly HPV),
cigarette smoking, certain dietary deficiencies, and immunosuppression. The number
of sex partners, both of women with cervical cancer and their sexual contacts,
contributes independently to the risk, suggesting that cervical cancer is a sexually
transmitted disease. Thus, the behavior that places women at risk for HIV infection

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