HIV+ Status and Cervical Cancer: Cytological Aspects of Cervical Smear in Cameroon Setting

Introduction: The early detection of precancerous lesions being very important for the preventive management of cervical cancer, we felt it was important to identify these lesions on potential backgrounds including HIV-positive (HIV+) women to suggest control strategies of cervical cancer in Cameroon. Objective: To determine the prevalence of precancerous lesions in women infected with the human immunodeficiency virus (HIV), to investigate the determinants of the HIV and cervical cancer association, and to make recom-mendations regarding cervical cancer screening in these patients of the city of Douala. Methodology: Our study was a case-control cross-sectional study from July 2017 to December 2017 (6 months) including 108 women among which 34 HIV+ matched with 74 HIV−. HIV serology was done using the complete HIV enzygnost test. Cervical smears for cytological lesions were fixed to the cyto-fixator and then stained by the Papanicolaou technique and read under an optical microscope. The cervical smear slides for viral excretion were fixed with a methanol-acetone mixture of equal volume; HPV test-ing was done by the indirect immune-peroxidase technique using P16 protein. The excretion of HSV type 1 & 2 was investigated by the indirect immunofluorescence technique using the Simplex Virus type 1 & 2 Rabbit an-ti-Herpes from DAKO (France). Results: The two groups of women were compared with the chi square test with a significance threshold of P < 0.05. The average age was 40.07 with extremes of 21 and 71 years and a standard deviation of 9.99. Of the 34 HIV+ patients, 23 had an abnormal cervix compared to 36 cases of abnormal cervix among HIV− with a statistically significant difference (P = 0.006649). 12 cases of dysplasia were observed in the 34 HIV+ women and distributed as follows: 0% of mild dysplasia, 18.92% of moderate dysplasia and 13.51% of severe dysplasia. In HIV− women we de-tected 6 cases of dysplasia including 1.35% of mild dysplasia, 4.05% of moderate dysplasia and 2.70% of severe dysplasia. Regarding HPV infection, we observed 21 cases of HPV among 34 HIV+ women (61.76%) against 23 cases in HIV− women (31.08%); we did not detect any cases of HSV. Conclusion: The prevalence of precancerous lesions remains high in HIV+ women, hence the need to include routine screening for precancerous lesions in all HIV+ women at all ages, as well as the routine search for HPV excretion in all those with cellular dysplasia.


Introduction
Invasive cervical cancer is a pathology of viral aetiology, which generally takes more than 25 years to develop, from primary infection with an oncogenic papillomavirus of genital tropism to the different grades of histological pre-cancerous lesions, reflecting the persistence of infection to invasive cancer. For each grade of precancerous cervical lesion (CIN1, CIN2 or CIN3), there is a probability of regression to a normal epithelium, and a probability of persistence or progression to a more advanced stage [1]. Once mild dysplasia is identified, it usually takes between 10 and 20 years before invasive cervical cancer develops. 60% or more of mild dysplasia regress spontaneously and only 10% progress to moderate or severe dysplasia within 2 to 4 years.
In some cases, moderate or severe dysplasia may occur without going through the detectable stage of mild dysplasia.
Severe dysplasia is more likely to progress to invasive cancer, but less than 50% of cases progress to invasive cancer. This percentage is even lower among young women. In the early 1990s, it appeared that precancerous lesions and invasive cervical cancer were more common and more rapid in HIV infection [2].
It is estimated that the incidence of invasive cervical cancer is about 5 to 15 times higher in HIV− infected women than in the general population [3].
A prospective study conducted in 15 European countries between 1993 and 1999 among women aged 20 to 49 years shows that invasive cancer of the cervix is the AIDS classifying event in 2.5% of cases [4].
The incidence of cervical cancer remains high in women with HIV infection.
In the US, the standardized incidence rate of cervical cancer in HIV− infected women is 2.9 (95% CI 1.9 -4.2), significantly higher compared to HIV− women.
However, the incidence is similar in HIV− infected women who are regularly E. Henri et al. Open Journal of Obstetrics and Gynecology screened for smear and treated for precancerous lesions and in HIV− women, which favors a positive impact of screening on the occurrence of cervical cancer [6].
In contrast, the effect of antiviral treatment on the incidence of this cancer remains controversial. Indeed, the stability of the cervical cancer rate in the US between 1992 and 2003 suggests a weak effect of anti-retroviral treatment, whereas, on the other hand, French data shows a risk of cancer twice as low in women under treatment for more than 6 months [6] [7].
The proportion of women infected with HIV is currently increasing and their survival is prolonged due to anti-retroviral drugs as well as efforts to prevent opportunistic infections by anti-infectious therapies [8]. However, we observe the emergence of cervical intraepithelial pathology that can lead to invasive carcinoma.
In Cameroon, a descriptive and retrospective study carried out between October 1992 and June 1995 in the city of Yaoundé among 65 HIV+ women and 50 HIV− women revealed 95% inflammatory smear, 1.5% low-grade squamous intraepithelial lesions in HIV+ women and 70% of inflammatory smears, 4% of low-grade squamous intraepithelial lesions in HIV− women with a difference not statistically significant [8].
However, HIV+ women appear to have pre-cancerous cervical lesions more frequently than HIV−, thus predisposing them to cervical cancer in the longer term [8]. The absence of a publication in Cameroon on the immune-histochemical contribution in the detection of precancerous lesions on cervical smears justifies the present study whose objective was to evaluate cervical smear abnormalities in HIV + women as well as their prevalence, as well as the prevalence of cervical HPV16 and HSV1 & 2 infection in both HIV+ women and HIV− women.

Methodology
Type of study: This was a cross-sectional analytical case-control study from Both groups of women were compared with the chi square test with a significance level of P < 0.05.
The natural history of cervical cancer takes shape with the precocity of unprotected sex in an environment of social precariousness exposing to a multi sexual partnership and therefore to sexually transmitted infections including HPV.
These variables commonly associated with HPV infection have not been studied in our series; however, the age and occupation variables were invariably distributed in both groups.
The mean age was 40.07 with extremes of 21 and 71 years and a standard deviation of 9.99 with a peak in the 31 -40 age group in both groups [ Table 1]; housewives were in majority [ Table 2].
The data analysis revealed that abnormal cervical coloration, contact hemorrhage, and condyloma were the most common lesions in HIV+ women with a statistically significant difference compared to the control group (HIV−); concerning the coloration of the cervix (33.82% against 42.68% P = 0.006549) the contact hemorrhage (33.82% against 24.39% P = 0.00666) and the condylomas (8.82% against 2.44% P = 0.00588) [ Table 4].    Table 5 and Table 6].

Microscopic Lesions of the Cervix
Research of Viral Markers by Immuno-Histochimics E. Henri et al.   In our series of 108 women, we found many more HPV markers in HIV+ women than in HIV− women; 21 out of 34 HIV+ (61.76%) versus 23 out of 74 HIV− (31.08%) (P = 0.0025775) [ Table 7].
In this study, we did not have a positive result for the search for Herpes Simplex Virus type 1 and 2 excretions by indirect immunofluorescence.

Discussion
The aim of this study was to contribute to research and documentation on cervical cancer in Cameroonian women infected with HIV.
The results obtained were discussed based on clinical, cytological and immunohistochemical variables.  On the other hand, the excretion of HSV 1 & 2 is not found in this study and does not seem to correlate with the HIV serological profile.
But our study reveals a strong correlation between papilloma and the occurrence of cervical dysplasia as reported by other authors [9] [10] [11] [12] [13].

The limits of our study
This study, however, has limitations because of the choice of the site (Laquintinie hospital), whose users mainly come from poor social strata and the pay-Open Journal of Obstetrics and Gynecology ment nature of the basic analyzes like the cervical smear which limited the sample (108). All of which does not allow absolute conclusions. The same is true for the technique used for viral excretion (immunofluorescence).

Conclusions
The results of our study confirm the data of the literature making HIV+ status the determining factor in the emergence of cervical dysplasia.
As such we suggest the following: -To include systematic screening for cervical lesions in all HIV+ women regardless of age; -To systematically search for HPV excretion in all HIV+ women with cellular dysplasia; -To intensify educational activities on HIV/AIDS and cervical cancer in Cameroon; -To systematically put HIV+ women with cellular dysplasia under anti-retroviral therapy even if the CD4 count is normal and the viral load undetectable.