CHAPTER 5 HPV infection and HPV-associated neoplasia in immunocompromised women

Human immunodeficiency virus (HIV)-positive women and women with transplant-associated immunocompromise are at increased risk for cervical intraepithelial neoplasia (CIN) and cervical cancer compared with healthy, immunocompetent women. HPV often manifests as a "field" effect in immunocompromised women who are also at increased risk for vaginal, vulval, and anal intraepithelial neoplasia. Immunocompromised women require careful follow-up with regular cy-tologic screening, and there should be a low threshold for performing colposcopic evaluation in these women. Once detected, CIN should be treated aggressively and the patient followed up closely for recurrence. Although treatment regimens are similar for immunocompromised and healthy women, the former may need multiple treatment modalities. Data on the ability of highly active antiretroviral therapy (HAART) to reduce the incidence of high-grade CIN and on the regression of existing CIN are mixed, some studies showing no benefit and others a modest benefit from HAART. However, the incidence of cervical cancer has not declined since the introduction of HAART, and the use of HAART among HIV-positive women has not changed the suggested approach to cervical cancer screening and treatment. Finally, prophylactic HPV vaccination offers the possibility of reducing the burden of disease among immunocompromised women, particularly if they are vaccinated before the onset of both sexual activity and immunocompromise. However, studies are needed to document safety and immunogenicity, and -given their high rate of prior HPV exposure -the effectiveness of the vaccine in these women.