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Figure.  Survival Curve of Time to High-risk Human Papillomavirus (hrHPV) Clearancea Between Cryotherapy and Loop Electrosurgical Excision Procedure (LEEP)
Survival Curve of Time to High-risk Human Papillomavirus (hrHPV) Clearancea Between Cryotherapy and Loop Electrosurgical Excision Procedure (LEEP)

Interval-censored data were used to generate the survival curves; in this method, an individual’s event occurs within the interval between visits, and the number of individuals at each interval is not available.

aClearance is defined as testing negative for all 12 hrHPV types among the 326 participants with at least 1 hrHPV type present at enrollment.

Table 1.  Baseline Characteristics Among Participants With High-risk Human Papillomavirus Results by Treatment Arm
Baseline Characteristics Among Participants With High-risk Human Papillomavirus Results by Treatment Arm
Table 2.  Hazard Ratios From Interval-Censored Survival Analyses for Risk Factors Associated With Recurrent Cervical Disease (CIN2+) (N = 326)a
Hazard Ratios From Interval-Censored Survival Analyses for Risk Factors Associated With Recurrent Cervical Disease (CIN2+) (N = 326)a
Table 3.  Sensitivity, Specificity, PPV, NPV, and AUC of hrHPV Testing at 12 Months to Detect CIN2+
Sensitivity, Specificity, PPV, NPV, and AUC of hrHPV Testing at 12 Months to Detect CIN2+
1.
Bray  F, Ferlay  J, Soerjomataram  I, Siegel  RL, Torre  LA, Jemal  A.  Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.   CA Cancer J Clin. 2018;68(6):394-424. doi:10.3322/caac.21492PubMedGoogle ScholarCrossref
2.
UNAIDS. Global HIV & AIDS statistics—fact sheet. Accessed June 30, 2021. https://www.unaids.org/en/resources/fact-sheet
3.
Walboomers  JM, Jacobs  MV, Manos  MM,  et al.  Human papillomavirus is a necessary cause of invasive cervical cancer worldwide.   J Pathol. 1999;189(1):12-19. doi:10.1002/(SICI)1096-9896(199909)189:1<12::AID-PATH431>3.0.CO;2-FPubMedGoogle ScholarCrossref
4.
Ahdieh  L, Klein  RS, Burk  R,  et al.  Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women.   J Infect Dis. 2001;184(6):682-690. doi:10.1086/323081PubMedGoogle ScholarCrossref
5.
Denslow  SA, Rositch  AF, Firnhaber  C, Ting  J, Smith  JS.  Incidence and progression of cervical lesions in women with HIV: a systematic global review.   Int J STD AIDS. 2014;25(3):163-177. doi:10.1177/0956462413491735PubMedGoogle ScholarCrossref
6.
McDonald  AC, Tergas  AI, Kuhn  L, Denny  L, Wright  TC  Jr.  Distribution of human papillomavirus genotypes among HIV-positive and HIV-negative women in Cape Town, South Africa.   Front Oncol. 2014;4:48. doi:10.3389/fonc.2014.00048PubMedGoogle ScholarCrossref
7.
Moscicki  AB, Ellenberg  JH, Farhat  S, Xu  J.  Persistence of human papillomavirus infection in HIV-infected and -uninfected adolescent girls: risk factors and differences, by phylogenetic type.   J Infect Dis. 2004;190(1):37-45. doi:10.1086/421467PubMedGoogle ScholarCrossref
8.
Fontham  ETH, Wolf  AMD, Church  TR,  et al.  Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society.   CA Cancer J Clin. 2020;70(5):321-346. doi:10.3322/caac.21628PubMedGoogle ScholarCrossref
9.
Chrysostomou  AC, Stylianou  DC, Constantinidou  A, Kostrikis  LG.  Cervical cancer screening programs in Europe: the transition towards HPV vaccination and population-based HPV testing.   Viruses. 2018;10(12):E729. doi:10.3390/v10120729PubMedGoogle Scholar
10.
Basu  P, Meheus  F, Chami  Y, Hariprasad  R, Zhao  F, Sankaranarayanan  R.  Management algorithms for cervical cancer screening and precancer treatment for resource-limited settings.   Int J Gynaecol Obstet. 2017;138(suppl 1):26-32. doi:10.1002/ijgo.12183PubMedGoogle ScholarCrossref
11.
Gaffikin  L, Blumenthal  PD, Emerson  M, Limpaphayom  K; Royal Thai College of Obstetricians and Gynaecologists (RTCOG)/JHPIEGO Corporation Cervical Cancer Prevention Group [corrected].  Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project.   Lancet. 2003;361(9360):814-820. doi:10.1016/S0140-6736(03)12707-9PubMedGoogle Scholar
12.
Khan  MJ, Smith-McCune  KK.  Treatment of cervical precancers: back to basics.   Obstet Gynecol. 2014;123(6):1339-1343. doi:10.1097/AOG.0000000000000287PubMedGoogle ScholarCrossref
13.
Venturoli  S, Ambretti  S, Cricca  M,  et al.  Correlation of high-risk human papillomavirus genotypes persistence and risk of residual or recurrent cervical disease after surgical treatment.   J Med Virol. 2008;80(8):1434-1440. doi:10.1002/jmv.21198PubMedGoogle ScholarCrossref
14.
Costa  S, De Simone  P, Venturoli  S,  et al.  Factors predicting human papillomavirus clearance in cervical intraepithelial neoplasia lesions treated by conization.   Gynecol Oncol. 2003;90(2):358-365. doi:10.1016/S0090-8258(03)00268-3PubMedGoogle ScholarCrossref
15.
Houfflin Debarge  V, Collinet  P, Vinatier  D,  et al.  Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions.   Gynecol Oncol. 2003;90(3):587-592. doi:10.1016/S0090-8258(03)00372-XPubMedGoogle ScholarCrossref
16.
Bodner  K, Bodner-Adler  B, Wierrani  F, Kimberger  O, Denk  C, Grünberger  W.  Is therapeutic conization sufficient to eliminate a high-risk HPV infection of the uterine cervix? a clinicopathological analysis.   Anticancer Res. 2002;22(6B):3733-3736.PubMedGoogle Scholar
17.
Mariategui  J, Santos  C, Taxa  L, Jeronimo  J, Castle  PE.  Comparison of depth of necrosis achieved by CO2- and N2O-cryotherapy.   Int J Gynaecol Obstet. 2008;100(1):24-26. doi:10.1016/j.ijgo.2007.07.009PubMedGoogle ScholarCrossref
18.
De Vuyst  H, Mugo  NR, Franceschi  S,  et al.  Residual disease and HPV persistence after cryotherapy for cervical intraepithelial neoplasia grade 2/3 in HIV-positive women in Kenya.   PLoS One. 2014;9(10):e111037. doi:10.1371/journal.pone.0111037PubMedGoogle Scholar
19.
Greene  SA, De Vuyst  H, John-Stewart  GC,  et al.  Effect of cryotherapy vs loop electrosurgical excision procedure on cervical disease recurrence among women with HIV and high-grade cervical lesions in Kenya: a randomized clinical trial.   JAMA. 2019;322(16):1570-1579. doi:10.1001/jama.2019.14969PubMedGoogle ScholarCrossref
20.
Chung  MH, Drake  AL, Richardson  BA,  et al.  Impact of prior HAART use on clinical outcomes in a large Kenyan HIV treatment program.   Curr HIV Res. 2009;7(4):441-446. doi:10.2174/157016209788680552PubMedGoogle ScholarCrossref
21.
Onyekwuluje  JM, Steinau  M, Swan  DC, Unger  ER.  A real-time PCR assay for HPV52 detection and viral load quantification.   Clin Lab. 2012;58(1-2):61-66.PubMedGoogle Scholar
22.
Bouvard  V, Baan  R, Straif  K,  et al; WHO International Agency for Research on Cancer Monograph Working Group.  A review of human carcinogens—part B: biological agents.   Lancet Oncol. 2009;10(4):321-322. doi:10.1016/S1470-2045(09)70096-8PubMedGoogle ScholarCrossref
23.
Nobbenhuis  MA, Meijer  CJ, van den Brule  AJ,  et al.  Addition of high-risk HPV testing improves the current guidelines on follow-up after treatment for cervical intraepithelial neoplasia.   Br J Cancer. 2001;84(6):796-801. doi:10.1054/bjoc.2000.1689PubMedGoogle ScholarCrossref
24.
Aerssens  A, Claeys  P, Garcia  A,  et al.  Natural history and clearance of HPV after treatment of precancerous cervical lesions.   Histopathology. 2008;52(3):381-386. doi:10.1111/j.1365-2559.2007.02956.xPubMedGoogle ScholarCrossref
25.
Kreimer  AR, Guido  RS, Solomon  D,  et al.  Human papillomavirus testing following loop electrosurgical excision procedure identifies women at risk for posttreatment cervical intraepithelial neoplasia grade 2 or 3 disease.   Cancer Epidemiol Biomarkers Prev. 2006;15(5):908-914. doi:10.1158/1055-9965.EPI-05-0845PubMedGoogle ScholarCrossref
26.
Zielinski  GD, Bais  AG, Helmerhorst  TJ,  et al.  HPV testing and monitoring of women after treatment of CIN 3: review of the literature and meta-analysis.   Obstet Gynecol Surv. 2004;59(7):543-553. doi:10.1097/00006254-200407000-00024PubMedGoogle ScholarCrossref
27.
World Health Organization.  WHO Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention. World Health Organization; 2013.
28.
Katundu  K, Bateman  AC, Pfaendler  KS,  et al.  The effect of cryotherapy on human papillomavirus clearance among HIV-positive women in Lusaka, Zambia.   J Low Genit Tract Dis. 2015;19(4):301-306. doi:10.1097/LGT.0000000000000131PubMedGoogle ScholarCrossref
29.
Kelly  H, Weiss  HA, Benavente  Y, de Sanjose  S, Mayaud  P; ART and HPV Review Group.  Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis.   Lancet HIV. 2018;5(1):e45-e58. doi:10.1016/S2352-3018(17)30149-2PubMedGoogle ScholarCrossref
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    Original Investigation
    August 5, 2021

    Human Papillomavirus Persistence and Association With Recurrent Cervical Intraepithelial Neoplasia After Cryotherapy vs Loop Electrosurgical Excision Procedure Among HIV-Positive Women: A Secondary Analysis of a Randomized Clinical Trial

    Author Affiliations
    • 1Department of Medicine, Emory University, Atlanta, Georgia
    • 2Department of Global Health, University of Washington, Seattle
    • 3Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
    • 4Early Detection, Prevention, and Infections Branch, International Agency for Research on Cancer/World Health Organization, Lyon, France
    • 5Kenya Medical Research Institute, Nairobi, Kenya
    • 6Chronic Viral Diseases Branch, Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
    • 7Coptic Hospital, Nairobi, Kenya
    • 8Department of Population Health, Aga Khan University, Nairobi, Kenya
    • 9Department of Obstetrics and Gynecology, Aga Khan University, Nairobi, Kenya
    JAMA Oncol. 2021;7(10):1514-1520. doi:10.1001/jamaoncol.2021.2683
    Key Points

    Question  Among HIV-positive women, is cryotherapy or loop electrosurgical excision procedure (LEEP) more effective at clearing cervical high-risk human papillomavirus (hrHPV) infection, and is persistent hrHPV detection associated with recurrent cervical intraepithelial neoplasia (CIN)?

    Findings  In this secondary analysis of a randomized clinical trial that included 354 HIV-positive women in Kenya, LEEP was 40% more likely to clear hrHPV infection compared with cryotherapy, and persistent hrHPV detection was 5 times more likely to be associated with recurrent CIN than no HPV.

    Meaning  LEEP may be more likely to clear hrHPV infection than cryotherapy, and persistent detection of hrHPV was associated with recurrent CIN among HIV-positive women.

    Abstract

    Importance  Persistence of cervical high-risk human papillomavirus (hrHPV) after treatment for cervical intraepithelial neoplasia grade 2 or higher (CIN2+) has not been compared between cryotherapy and loop electrosurgical excision procedure (LEEP) among HIV-positive women.

    Objective  To evaluate whether cryotherapy or LEEP is more effective at clearing hrHPV and whether persistent hrHPV is associated with CIN2+ recurrence among HIV-positive women.

    Design, Setting, and Participants  This is a secondary analysis of a randomized clinical trial conducted among women with HIV, hrHPV, and CIN2+ in Nairobi, Kenya. From June 2011 to September 2016, 354 HIV-positive women with CIN2+ disease had hrHPV cervical samples collected before and after treatment with cryotherapy or LEEP. Data were analyzed from September 2018 to January 2021.

    Interventions  Women were randomized 1:1 to receive cryotherapy or LEEP and were followed up every 6 months for 24 months with hrHPV cervical swab and Papanicolaou test with confirmatory biopsy.

    Main Outcomes and Measures  The main outcomes of this analysis were hrHPV positivity defined as having 1 of 12 hrHPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59) and disease recurrence defined as CIN grade 2 or higher as determined with cervical biopsy.

    Results  A total of 354 HIV-positive women with CIN2+ were included in the study; mean (SD) age was 37 (8) years in the cryotherapy arm and 38 (9) years in the LEEP arm. Baseline hrHPV prevalence was 90% (160 of 177) in the cryotherapy arm and 94% (166 of 177) in the LEEP arm (P = .24), and the most common hrHPV types detected were 16 (87 of 326 [27%]), 58 (87 of 326 [27%]), 35 (86 of 326 [26%]), 52 (66 of 326 [20%]), and 18 (56 of 325 [17%]). Over 24 months, clearance of hrHPV was significantly higher among those who underwent LEEP compared with cryotherapy (hazard ratio, 1.40; 95% CI, 1.03-1.90; P = .03). In multivariable analysis, hrHPV type-specific persistence at 12-month follow-up was significantly associated with CIN2+ recurrence from 12 months to 24 months (adjusted hazard ratio, 4.70; 95% CI, 2.47-8.95; P < .001). Performance of hrHPV testing at 12 months for recurrent CIN2+ was 93% sensitivity, 46% specificity, 38% positive predictive value, and 95% negative predictive value.

    Conclusions and Relevance  In this secondary analysis of a randomized clinical trial, HIV-positive women who received LEEP were more likely to clear hrHPV infection compared with those undergoing cryotherapy, reinforcing the efficacy of LEEP in this population. Persistent hrHPV was significantly associated with recurrent CIN2+, suggesting that LEEP’s benefits may be related in part to its ability to clear hrHPV infection. Screening for hrHPV infection after treatment among HIV-positive women may be used to rule out recurrent CIN disease given its high sensitivity and negative predictive value.

    Trial Registration  ClinicalTrials.gov Identifier: NCT01298596

    Introduction

    Infection with oncogenic high-risk human papillomavirus (hrHPV) is a necessary precursor to the development of cervical cancer, which is the fourth most frequently diagnosed cancer among women worldwide and the most common cause of cancer death among women in sub-Saharan Africa.1 Women living with HIV are often coinfected with hrHPV.2,3 They have a higher prevalence of hrHPV infection than the general population and are more likely to have persistent hrHPV infection leading to cervical intraepithelial neoplasia (CIN) and progression to cervical cancer, which is recognized as an AIDS-defining illness.4-7 Understanding hrHPV and HIV coinfection is helpful in determining the utility of hrHPV testing to prevent cervical cancer among women living with HIV.

    Testing for hrHPV is widely used to screen for cervical cancer and has replaced, or is used alongside, Papanicolaou (Pap) testing in many countries. Many national guidelines and the World Health Organization (WHO) have recommended hrHPV testing as a primary cervical cancer screening tool in both high-income countries and low- and middle-income countries.8-10 Testing for hrHPV is also used to screen for recurrent disease after treatment for precancerous cervical lesions and to help define the frequency and duration of follow-up. Data regarding its efficacy after cervical treatment among women living with HIV are less robust and may depend on the type of intervention used.

    In high-income countries, women with CIN grade 2 and higher (CIN2+) are often treated with loop electrosurgical excision procedure (LEEP), which excises the transformation zone and histologic abnormalities. In low- and middle-income countries, cryotherapy, which freezes the transformation zone, is recommended by WHO as an inexpensive and technically less complex method to treat CIN.11,12 However, neither modality is completely successful at treating CIN or clearing hrHPV infection,13-17 and their efficacy appears to be further reduced in the setting of HIV.18 Comparing outcomes between LEEP and cryotherapy is important for many low- and middle-income countries in sub-Saharan Africa, where HIV and hrHPV coinfection is highly prevalent and cryotherapy is commonly used.

    In a primary outcome analysis of a randomized clinical trial (RCT) comparing cryotherapy and LEEP, women living with HIV who received cryotherapy were 31% more likely to have recurrent CIN2+ than those who received LEEP.18,19 Results of hrHPV clearance and persistence after cryotherapy and LEEP from this RCT were not published, and they are presented here. In this secondary subgroup analysis, we compared clearance of hrHPV between the 2 interventions among women living with HIV in Kenya and evaluated its association with recurrent CIN2+ over 2-year follow-up.

    Methods
    Study Population

    This analysis is one of the aims of an RCT that compared LEEP and cryotherapy among women living with HIV in Kenya.19 Ethical approval was obtained from the Kenyatta National Hospital Ethics Research Committee, the University of Washington Institutional Review Board, and the Centers for Disease Control and Prevention. All participants provided written informed consent to participate in the study. The enrollment, randomization, and follow-up procedures of the RCT have been published previously19 and are detailed in the trial protocol (Supplement 1). In short, participants were recruited from the Coptic Hope Center for Infectious Diseases in Nairobi, Kenya, which provides free antiretroviral treatment (ART) to men, women, and children living with HIV and is funded by the US President’s Emergency Plan for AIDS Relief.20 Women living with HIV receiving care at the Hope Center were invited to participate and were screened with Pap testing and colposcopy-directed biopsy if indicated. Participants were eligible for the study if they were HIV positive, 18 years or older, sexually active, not pregnant, and had an intact cervix. They were excluded if they had a history of treatment for cervical lesions or a lesion that was not eligible for cryotherapy. Lesions ineligible for cryotherapy included those that involved greater than 75% of the cervix surface, extended more than 2 mm into the endocervical canal, had CIN2+ using endocervical curettage, or had a squamocolumnar junction that could not be fully visualized using colposcopy.

    Study Procedures

    Cervical cell specimens for conventional cytologic testing and hrHPV analysis were collected using a Cervex-Brush (Rovers Medical Devices), which was inserted and rotated in the cervical os, smeared on a glass slide for cytologic testing, and then stored in Thin-Prep solution (Hologic Inc). Cervical specimens for HPV testing were collected from participants at baseline before treatment and at 6-month visits. Sociodemographic information including medical, sexual, and reproductive histories was also obtained at baseline, and ART use and duration were abstracted from Hope Center health records. Participants underwent a biopsy if Pap test results showed a high-grade squamous intraepithelial lesion, and those with CIN2+ as determined by biopsy were randomized in a 1:1 ratio to treatment with LEEP or cryotherapy.

    Prior to intervention, the study physician visualized the cervix with a colposcope and applied Lugol solution to outline the lesion and transformation zone. Women receiving LEEP had their cervices injected with 3 to 5 mL of anesthetic and Lugol solution, after which a high-frequency electrosurgical generator, Finesse II (Utah Medical Products Inc), was inserted at a depth of 4 to 5 mm and drawn laterally across the cervix. Hemostasis was achieved with electrocoagulation or application of Monsel paste, or both.

    Women receiving cryotherapy underwent a 3-minute freeze, 5-minute thaw, and 3-minute freeze cycle using nitrous oxide. Depending on the location and size of the transformation zone with the lesion, the study physician used a 25-mm or 19-mm probe with either a flat surface or a shallow nipple. Following cryotherapy, Monsel paste was applied if bleeding was observed.

    Laboratory Testing

    Specimens were stored at −80 °C until thawed at room temperature for processing. Specimen DNA was extracted with the Chemagic Viral NA/gDNA Kit (catalog number CMG-1077; Perkin Elmer) on a Chemagic Magnetic Separation Module 1 (Perkin Elmer). Testing for HPV was performed with the Linear Array HPV Genotyping Test (LA; catalog numbers 04472209 and 03378012; Roche Diagnostics), which detects 37 HPV types and human β-globin as an endogenous control. The manufacturer’s protocol was modified to use 10 μL of DNA extract in the 100-μL polymerase chain reaction, and hybridization was automated on BeeBlot instruments (Bee Robotics Ltd). The LA probe for HPV-52 cross-reacts with HPV types 33, 35, and 58. For specimens positive for the HPV-52 probe and any of the 3 cross-reacting types, a real-time polymerase chain reaction assay was done to determine HPV-52 status.21 Specimens negative by LA for both HPV DNA and β-globin control were considered inadequate for evaluation.

    Statistical Analysis

    Twelve HPV types were considered high risk based on WHO International Agency for Research on Cancer categorization: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59.22 Participants with no cervical swab collected at baseline were excluded from the analysis. Analysis of hrHPV persistence at the 12-month follow-up visit included only those women with at least 1 hrHPV type detected at baseline. Participants with no hrHPV result (no cervical swab obtained) at 12 months were excluded from the 12-month analysis, unless the participant had recurrent cervical disease at the 6-month follow-up visit, in which case the 6-month hrHPV result and 6-month recurrent cervical disease were carried forward to the 12-month visit.

    Persistence of “any type-specific hrHPV” was defined as having at least 1 of the same hrHPV types present at baseline and at the 12-month follow-up visit. Persistence of “single type-specific hrHPV” was defined as having the same single hrHPV type present at baseline and at 12 months. Persistence of “multiple type-specific hrHPV types” was defined as 2 or more hrHPV types at baseline and 1 or more of the same hrHPV type present at 12 months. Recurrence of cervical disease was defined as the first CIN2+ result on colposcopy-directed biopsy conducted at 6, 12, 18, or 24 months. Women with recurrent CIN2+ detected at the 6-month follow-up had this result carried forward to the 12-month visit.

    Clearance of hrHPV infection was defined as testing negative for all hrHPV types among those women with at least 1 hrHPV type present at baseline. Interval-censored data were used to estimate the time of hrHPV clearance. For participants who cleared hrHPV infection between study visits, time to event was within the interval between the visit with the last positive hrHPV result and the visit with first negative hrHPV result. Cox proportional hazards regression for interval-censored data was used to estimate the hazard ratio (HR) and 95% CI for the association between hrHPV clearance (“event”) between LEEP and cryotherapy, and survival curves were plotted. Participants who did not clear hrHPV infection during follow-up were censored at their last known study visit.

    To compare associations between demographic or clinical characteristics at baseline, treatment for CIN2+, and persistence of individual or grouped hrHPV types, χ2 tests and t tests were used. Cox proportional hazards regression models for interval-censored data were used to determine unadjusted hazard ratios (HRs) and adjusted HRs (aHRs) and 95% CIs for the association between persistent type-specific hrHPV, treatment arm, viral load, CD4 count, and ART use and the outcome of recurrent cervical disease (CIN2+) (“event”). As the exact time of CIN2+ recurrence was not known, the time to event (first CIN2+ recurrence) falls within the interval between study visits. Women who did not experience recurrent CIN2+ were censored at the last known follow-up visit. Covariates associated with recurrent CIN2+ at the P < .05 level in univariate analysis were included in the final model. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) for detecting recurrent CIN2+ over 24 months was calculated for any hrHPV infection at 6 and 12 months. Data were analyzed from September 2018 to January 2021. All analyses were performed using Stata software, version 17.0 (StataCorp LLC).

    Results
    Study Population

    Results of the main RCT are described elsewhere.19 In brief, between June 2011 and September 2016, 5330 HIV-positive women were screened using Pap testing, 738 (13.8%) were found to have a high-grade squamous intraepithelial lesion, and 512 (9.6%) had CIN 2+ on subsequent colposcopy-directed biopsy. Of the 354 women with confirmed CIN2+ on colposcopy-directed biopsy and an hrHPV result at baseline, 177 (50%) received cryotherapy and 177 (50%) received LEEP treatment (eFigure in Supplement 2). Sociodemographic and HIV characteristics were similar between the cryotherapy and LEEP treatment groups (Table 1). Most women in the cryotherapy and LEEP arms had a monthly household income of less than $150/mo (62% vs 64%; P = .79), both were similarly immunocompromised (CD4 count < 250 cells/mm3; 29% vs 27%; P = .75), and a comparable proportion had been undergoing ART for at least 2 years at the time of enrollment (51% vs 57%; P = .20).

    hrHPV Prevalence and Types at Enrollment

    Prevalence of any hrHPV at baseline was 92% (326 of 354) overall, 90% (160 of 177) in the cryotherapy arm, and 94% (166 of 177) in the LEEP arm (eTable 1 in Supplement 2). Among women with hrHPV, 140 of 326 (43%) had a single type and 186 of 326 (57%) were positive for multiple hrHPV types. There was no difference in the prevalence of multiple hrHPV types by treatment arm (56% cryotherapy vs 58% LEEP; P = .61). The most common hrHPV types detected at baseline were 16 (87 of 326 [27%]), 58 (87 of 326 [27%]), 35 (86 of 326 [26%]), 52 (66 of 326 [20%]), and 18 (56 of 325 [17%]) and were similarly distributed between arms (eTable 1 in Supplement 2).

    hrHPV Clearance and Type-Specific Persistence

    Over 2-year follow-up, women who underwent LEEP were significantly more likely to clear all hrHPV compared with those treated with cryotherapy (HR, 1.40; 95% CI, 1.03-1.90; P = .03) (Figure). At 12 months after treatment, type-specific persistence of baseline hrHPV was significantly higher after cryotherapy compared with LEEP for any hrHPV (97 of 160 [61%] vs 82 of 166 [49%]; P = .04), hrHPV type 16 (29 of 42 [69%] vs 20 of 42 [48%]; P = .046), and hrHPV type 51 (7 of 16 [44%] vs 2 of 17 [12%]; P = .04) (eTable 1 in Supplement 2).

    Type-Specific hrHPV Persistence and CIN2+ Recurrence

    A significant proportion of women with type-specific hrHPV persistence at 12 months had recurrent CIN2+ during the 2-year follow-up period. The proportion of women with hrHPV persistence and recurrent CIN2+ varied: 39 of 64 (61%) with single type-specific hrHPV detection at enrollment, 21 of 41 (48%) with hrHPV types 16 and/or 18, 76 of 179 (42%) with any type-specific hrHPV, and 37 of 115 (32%) with multiple type-specific hrHPV (eTable 1 in Supplement 2). The proportion of women with hrHPV persistence at 6 months and recurrent CIN2+ during follow-up was 51% with single type-specific hrHPV, 46% with hrHPV types 16 and/or 18, 37% with any type-specific hrHPV, and 29% with multiple type-specific hrHPV (eTable 2 in Supplement 2). Women with type-specific persistent hrHPV detected at 12 months were 5 times more likely to have recurrent CIN2+ at 12 months or later compared with those who did not have hrHPV (HR, 5.28; 95% CI, 2.78-10.04; P < .001) (Table 2).

    In univariate analysis, CIN2+ recurrence during 12- to 24-month follow-up was associated with cryotherapy (HR, 1.71; 95% CI, 1.12-2.62; P = .01), CD4 count less than 250 cells/mm3 (HR, 1.89; 95% CI, 1.24-2.88; P = .003), and detectable HIV viral load (HR, 1.52; 95% CI, 1.00-2.31; P = .05) (Table 2). In multivariable analysis including treatment intervention and CD4 count, the association between type-specific hrHPV persistence and CIN2+ recurrence remained high and statistically significant (aHR, 4.70; 95% CI, 2.47-8.95; P < .001), while the association between treatment method and CIN2+ recurrence was not significant (aHR, 1.38; 95% CI, 0.90-2.14; P = .14) (Table 2).

    hrHPV Testing and CIN2+ Recurrence

    The sensitivity and NPV of hrHPV testing at the 12-month follow-up visit after treatment in detecting recurrent CIN2+ were high. Detecting any hrHPV at 12 months after treatment had 93% sensitivity (95% CI, 86%-98%), 46% specificity (95% CI, 39%-52%), 38% PPV (95% CI, 32%-45%), and 95% NPV (95% CI, 89%-98%) (Table 3). Limiting the detection of hrHPV to types 16 and/or 18 slightly increased specificity (62%) and PPV (43%) but substantially decreased sensitivity (48%) and NPV (66%) compared with detecting any hrHPV (AUC, 0.55 vs 0.69). Detecting type-specific persistence of hrHPV from baseline to 12 months was similar to hrHPV testing alone at 12 months (sensitivity, 86%; specificity, 57%) and had the best overall test result (AUC, 0.71) (Table 3). Testing for hrHPV at 6 months after treatment was similar to testing at 12 months with sensitivity of 89% (95% CI, 80%-95%), specificity of 41% (95% CI, 35%-47%), PPV of 35% (95% CI, 29%-41%), NPV of 91% (95% CI, 84%-96%), and AUC of 0.65 (eTable 3 in Supplement 2).

    Discussion

    In this study of women living with HIV who were treated for CIN2+ and had hrHPV at baseline, LEEP was more effective at clearing hrHPV infection over 2-year follow-up than cryotherapy. Persistent hrHPV detection was associated with a substantially greater risk of recurrent CIN2+ disease even after controlling for immune status, HIV viral suppression, and type of cervical intervention. Consistent with this, hrHPV testing after treatment had high test sensitivity and NPV for detecting recurrent cervical disease among women living with HIV.

    Cryotherapy is not as effective at clearing hrHPV because it may not achieve therapeutic depth compared with LEEP.17 Unlike LEEP, cryotherapy does not excise tissue but causes necrosis through freezing up to a depth of 5 to 7 mm.12,17 Cervical dysplasia may be present in deeper tissue than cryotherapy can reach and may be infected with subclinical or latent hrHPV. These results correlate with the primary outcome analysis of the RCT,19 which demonstrated that LEEP was also better than cryotherapy in preventing recurrent CIN2+. Taken together, they demonstrate the superior treatment efficacy of LEEP over cryotherapy among women living with HIV.

    In multivariable analysis, persistent hrHPV was associated with recurrent disease while the type of treatment intervention was not associated with recurrent disease. These findings suggest that part of the effectiveness of treatment by cryotherapy or LEEP may be not only by removing CIN but adjacent cells containing hrHPV that could develop into new lesions.23 The association between persistent hrHPV infection and CIN recurrence remained regardless of CD4 count or HIV viral load and indicates the key role of hrHPV in preventing, treating, and testing for cervical cancer among women living with HIV.

    While hrHPV clearance after LEEP was higher than cryotherapy among HIV-positive women, it was still lower than clearance reported among HIV-negative women. In our study, only 62% of women who received LEEP cleared hrHPV infection at 2 years, which was significantly higher than the 50% of women who cleared hrHPV infection after receiving cryotherapy. In contrast, clearance of hrHPV infection at 2-year follow-up among HIV-negative women has been found to be as high as 91.9% after receiving LEEP and 82.7% after receiving cryotherapy.24 Further analysis is needed to determine how the majority of HIV-positive women who test hrHPV positive after treatment should be evaluated and whether outcomes would change if hrHPV positivity were defined differently. The failure of cryotherapy and LEEP to clear hrHPV infection is comparable to their reduced ability to prevent recurrent CIN2+ relative to HIV-negative women and reflects the challenges of preventing cervical cancer among women living with HIV.

    Among HIV-negative women, the detection of persistent hrHPV infection after LEEP has been associated with a greater risk of CIN over long-term follow-up and is used to screen women with or without cytologic cotesting at 6 months after treatment.13,25,26 In a meta-analysis of studies performed among HIV-negative women, the NPV of hrHPV testing after treatment to detect recurrent CIN was 98%.26 Similarly, the NPV among HIV-positive women in this study was 95% at 12 months. Although the WHO recommends posttreatment follow-up for women living with HIV at 1 year,27 the sensitivity and NPV of hrHPV testing were high (89% and 91%, respectively) at 6 months after treatment, suggesting that earlier hrHPV testing could be performed and may be indicated because dysplastic lesions progress more rapidly to cervical cancer in this population.18,28

    Limitations

    This study has several limitations. This was a secondary subgroup analysis that was conducted at a single site in Kenya with 1 study clinician conducting both cryotherapy and LEEP procedures. Therefore, the generalizability of these results may be limited and is not necessarily representative of hrHPV prevalence and clearance in the country, let alone sub-Saharan Africa or the world. The study follow-up period was 2 years, which is too short to determine whether hrHPV detection and CIN led to cervical cancer or mortality, especially because many were receiving ART, which may attenuate these outcomes.29

    Conclusions

    This secondary analysis of an RCT supports the clinical benefits of LEEP over cryotherapy if this method is available and accessible in low- and middle-income countries. Testing for hrHPV after cervical treatment is useful in ruling out recurrent cervical disease among women living with HIV and could be administered as early as 6 months after treatment. Further study is needed to determine the cost-effectiveness of LEEP and the long-term implications of hrHPV persistence after treatment on cervical cancer and mortality among women living with HIV.

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    Article Information

    Accepted for Publication: May 12, 2021.

    Published Online: August 5, 2021. doi:10.1001/jamaoncol.2021.2683

    Corresponding Author: Michael H. Chung, MD, MPH, Division of Infectious Diseases, Department of Medicine, Emory University, 49 Jesse Hill Jr Dr, Atlanta, GA 30303 (michael.h.chung@emory.edu).

    Author Contributions: Dr Chung had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Chung, De Vuyst, Mugo, Sakr, McGrath.

    Acquisition, analysis, or interpretation of data: Chung, De Vuyst, Greene, Mugo, Querec, Nyongesa-Malava, Cagle, Luchters, Temmerman, Unger, McGrath.

    Drafting of the manuscript: Chung, Greene, Mugo, Querec, Sakr, McGrath.

    Critical revision of the manuscript for important intellectual content: Chung, De Vuyst, Greene, Mugo, Querec, Nyongesa-Malava, Cagle, Luchters, Temmerman, Unger, McGrath.

    Statistical analysis: Greene, Nyongesa-Malava, McGrath.

    Obtained funding: Chung.

    Administrative, technical, or material support: Chung, Greene, Mugo, Cagle, Sakr, Temmerman, Unger.

    Supervision: Chung, De Vuyst, Greene, Mugo, Querec, Sakr, Luchters.

    Conflict of Interest Disclosures: Dr Chung reported receiving grants from the Centers for Disease Control and Prevention during the conduct of the study and grants from the National Institutes of Health outside the submitted work. No other disclosures were reported.

    Funding/Support: This research was supported by the President’s Emergency Plan for AIDS Relief through the Centers for Disease Control and Prevention under the terms of cooperative agreements GH002036 and GH002001.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: Where authors are identified as personnel of the International Agency for Research on Cancer/World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy, or views of the International Agency for Research on Cancer/World Health Organization. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

    Data Sharing Statement: See Supplement 3.

    References
    1.
    Bray  F, Ferlay  J, Soerjomataram  I, Siegel  RL, Torre  LA, Jemal  A.  Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.   CA Cancer J Clin. 2018;68(6):394-424. doi:10.3322/caac.21492PubMedGoogle ScholarCrossref
    2.
    UNAIDS. Global HIV & AIDS statistics—fact sheet. Accessed June 30, 2021. https://www.unaids.org/en/resources/fact-sheet
    3.
    Walboomers  JM, Jacobs  MV, Manos  MM,  et al.  Human papillomavirus is a necessary cause of invasive cervical cancer worldwide.   J Pathol. 1999;189(1):12-19. doi:10.1002/(SICI)1096-9896(199909)189:1<12::AID-PATH431>3.0.CO;2-FPubMedGoogle ScholarCrossref
    4.
    Ahdieh  L, Klein  RS, Burk  R,  et al.  Prevalence, incidence, and type-specific persistence of human papillomavirus in human immunodeficiency virus (HIV)-positive and HIV-negative women.   J Infect Dis. 2001;184(6):682-690. doi:10.1086/323081PubMedGoogle ScholarCrossref
    5.
    Denslow  SA, Rositch  AF, Firnhaber  C, Ting  J, Smith  JS.  Incidence and progression of cervical lesions in women with HIV: a systematic global review.   Int J STD AIDS. 2014;25(3):163-177. doi:10.1177/0956462413491735PubMedGoogle ScholarCrossref
    6.
    McDonald  AC, Tergas  AI, Kuhn  L, Denny  L, Wright  TC  Jr.  Distribution of human papillomavirus genotypes among HIV-positive and HIV-negative women in Cape Town, South Africa.   Front Oncol. 2014;4:48. doi:10.3389/fonc.2014.00048PubMedGoogle ScholarCrossref
    7.
    Moscicki  AB, Ellenberg  JH, Farhat  S, Xu  J.  Persistence of human papillomavirus infection in HIV-infected and -uninfected adolescent girls: risk factors and differences, by phylogenetic type.   J Infect Dis. 2004;190(1):37-45. doi:10.1086/421467PubMedGoogle ScholarCrossref
    8.
    Fontham  ETH, Wolf  AMD, Church  TR,  et al.  Cervical cancer screening for individuals at average risk: 2020 guideline update from the American Cancer Society.   CA Cancer J Clin. 2020;70(5):321-346. doi:10.3322/caac.21628PubMedGoogle ScholarCrossref
    9.
    Chrysostomou  AC, Stylianou  DC, Constantinidou  A, Kostrikis  LG.  Cervical cancer screening programs in Europe: the transition towards HPV vaccination and population-based HPV testing.   Viruses. 2018;10(12):E729. doi:10.3390/v10120729PubMedGoogle Scholar
    10.
    Basu  P, Meheus  F, Chami  Y, Hariprasad  R, Zhao  F, Sankaranarayanan  R.  Management algorithms for cervical cancer screening and precancer treatment for resource-limited settings.   Int J Gynaecol Obstet. 2017;138(suppl 1):26-32. doi:10.1002/ijgo.12183PubMedGoogle ScholarCrossref
    11.
    Gaffikin  L, Blumenthal  PD, Emerson  M, Limpaphayom  K; Royal Thai College of Obstetricians and Gynaecologists (RTCOG)/JHPIEGO Corporation Cervical Cancer Prevention Group [corrected].  Safety, acceptability, and feasibility of a single-visit approach to cervical-cancer prevention in rural Thailand: a demonstration project.   Lancet. 2003;361(9360):814-820. doi:10.1016/S0140-6736(03)12707-9PubMedGoogle Scholar
    12.
    Khan  MJ, Smith-McCune  KK.  Treatment of cervical precancers: back to basics.   Obstet Gynecol. 2014;123(6):1339-1343. doi:10.1097/AOG.0000000000000287PubMedGoogle ScholarCrossref
    13.
    Venturoli  S, Ambretti  S, Cricca  M,  et al.  Correlation of high-risk human papillomavirus genotypes persistence and risk of residual or recurrent cervical disease after surgical treatment.   J Med Virol. 2008;80(8):1434-1440. doi:10.1002/jmv.21198PubMedGoogle ScholarCrossref
    14.
    Costa  S, De Simone  P, Venturoli  S,  et al.  Factors predicting human papillomavirus clearance in cervical intraepithelial neoplasia lesions treated by conization.   Gynecol Oncol. 2003;90(2):358-365. doi:10.1016/S0090-8258(03)00268-3PubMedGoogle ScholarCrossref
    15.
    Houfflin Debarge  V, Collinet  P, Vinatier  D,  et al.  Value of human papillomavirus testing after conization by loop electrosurgical excision for high-grade squamous intraepithelial lesions.   Gynecol Oncol. 2003;90(3):587-592. doi:10.1016/S0090-8258(03)00372-XPubMedGoogle ScholarCrossref
    16.
    Bodner  K, Bodner-Adler  B, Wierrani  F, Kimberger  O, Denk  C, Grünberger  W.  Is therapeutic conization sufficient to eliminate a high-risk HPV infection of the uterine cervix? a clinicopathological analysis.   Anticancer Res. 2002;22(6B):3733-3736.PubMedGoogle Scholar
    17.
    Mariategui  J, Santos  C, Taxa  L, Jeronimo  J, Castle  PE.  Comparison of depth of necrosis achieved by CO2- and N2O-cryotherapy.   Int J Gynaecol Obstet. 2008;100(1):24-26. doi:10.1016/j.ijgo.2007.07.009PubMedGoogle ScholarCrossref
    18.
    De Vuyst  H, Mugo  NR, Franceschi  S,  et al.  Residual disease and HPV persistence after cryotherapy for cervical intraepithelial neoplasia grade 2/3 in HIV-positive women in Kenya.   PLoS One. 2014;9(10):e111037. doi:10.1371/journal.pone.0111037PubMedGoogle Scholar
    19.
    Greene  SA, De Vuyst  H, John-Stewart  GC,  et al.  Effect of cryotherapy vs loop electrosurgical excision procedure on cervical disease recurrence among women with HIV and high-grade cervical lesions in Kenya: a randomized clinical trial.   JAMA. 2019;322(16):1570-1579. doi:10.1001/jama.2019.14969PubMedGoogle ScholarCrossref
    20.
    Chung  MH, Drake  AL, Richardson  BA,  et al.  Impact of prior HAART use on clinical outcomes in a large Kenyan HIV treatment program.   Curr HIV Res. 2009;7(4):441-446. doi:10.2174/157016209788680552PubMedGoogle ScholarCrossref
    21.
    Onyekwuluje  JM, Steinau  M, Swan  DC, Unger  ER.  A real-time PCR assay for HPV52 detection and viral load quantification.   Clin Lab. 2012;58(1-2):61-66.PubMedGoogle Scholar
    22.
    Bouvard  V, Baan  R, Straif  K,  et al; WHO International Agency for Research on Cancer Monograph Working Group.  A review of human carcinogens—part B: biological agents.   Lancet Oncol. 2009;10(4):321-322. doi:10.1016/S1470-2045(09)70096-8PubMedGoogle ScholarCrossref
    23.
    Nobbenhuis  MA, Meijer  CJ, van den Brule  AJ,  et al.  Addition of high-risk HPV testing improves the current guidelines on follow-up after treatment for cervical intraepithelial neoplasia.   Br J Cancer. 2001;84(6):796-801. doi:10.1054/bjoc.2000.1689PubMedGoogle ScholarCrossref
    24.
    Aerssens  A, Claeys  P, Garcia  A,  et al.  Natural history and clearance of HPV after treatment of precancerous cervical lesions.   Histopathology. 2008;52(3):381-386. doi:10.1111/j.1365-2559.2007.02956.xPubMedGoogle ScholarCrossref
    25.
    Kreimer  AR, Guido  RS, Solomon  D,  et al.  Human papillomavirus testing following loop electrosurgical excision procedure identifies women at risk for posttreatment cervical intraepithelial neoplasia grade 2 or 3 disease.   Cancer Epidemiol Biomarkers Prev. 2006;15(5):908-914. doi:10.1158/1055-9965.EPI-05-0845PubMedGoogle ScholarCrossref
    26.
    Zielinski  GD, Bais  AG, Helmerhorst  TJ,  et al.  HPV testing and monitoring of women after treatment of CIN 3: review of the literature and meta-analysis.   Obstet Gynecol Surv. 2004;59(7):543-553. doi:10.1097/00006254-200407000-00024PubMedGoogle ScholarCrossref
    27.
    World Health Organization.  WHO Guidelines for Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention. World Health Organization; 2013.
    28.
    Katundu  K, Bateman  AC, Pfaendler  KS,  et al.  The effect of cryotherapy on human papillomavirus clearance among HIV-positive women in Lusaka, Zambia.   J Low Genit Tract Dis. 2015;19(4):301-306. doi:10.1097/LGT.0000000000000131PubMedGoogle ScholarCrossref
    29.
    Kelly  H, Weiss  HA, Benavente  Y, de Sanjose  S, Mayaud  P; ART and HPV Review Group.  Association of antiretroviral therapy with high-risk human papillomavirus, cervical intraepithelial neoplasia, and invasive cervical cancer in women living with HIV: a systematic review and meta-analysis.   Lancet HIV. 2018;5(1):e45-e58. doi:10.1016/S2352-3018(17)30149-2PubMedGoogle ScholarCrossref
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