More Cervical Problems for Girls HIV-Infected at Birth

BOSTON, April 26 -- Girls perinatally infected with HIV early in the AIDS epidemic have reached adolescence and a mixed picture is emerging on their reproductive health, researchers here reported.

In the first large-scale cohort study of this population, girls who acquired HIV at birth were at a higher risk of cervical abnormalities than HIV-free peers but less likely to become pregnant, found Susan B. Brogly, Ph.D., of Harvard, and colleagues.

The girls were no more likely to pass HIV on to their children than are women infected via sex or drug abuse, the researchers reported in the June issue of the American Journal of Public Health.

"These findings underscore the importance of Papanicolaou tests and promotion of safer sexual practices in this population," they wrote.

The study included 638 perinatally infected girls ages 13 through 21 followed for six years in the larger Pediatric AIDS Clinical Trials Group study. They were treated primarily at university-affiliated pediatric infectious disease clinics across the U.S. with follow-up visits every three months and periodic pelvic examinations and Pap smears.

Among the 27.3% of participants sexually active during follow-up, as learned by disclosure, pregnancy or genital infection, 94.8% (165) had had a pelvic examination. However, only 58.1% (101) had had a documented Pap test. (The American College of Obstetricians and Gynecologists recommends a first visit to an ob-gyn between the ages of 13 and 16.)

The rate of abnormal cervical cytology was 29.7% at first examination and was 47.5% overall among the 101 participants who'd had Pap smears. This rate was more than double the 11.5% found in a previous study among HIV-free university students.

The majority of abnormalities were low-grade squamous intraepithelial lesions (27), followed by atypical cells of undetermined significance (18), and high-grade lesions (3) at the first examination.

"The high proportion of abnormal cervical cytology?could be because of increased susceptibility to and persistence of human papillomavirus and other genital infections in these girls, as has been demonstrated in HIV-infected women," the researchers wrote.

Although the study did not include data on human papillomavirus infection, many cervical abnormalities persisted despite intervention (nine of 21 cleared after intervention, six of 14 untreated lesions cleared).

The incidence of pregnancy among participants ages 15 to 19 was (33.5 per 1,000 person-years, 95% CI 22.8 to 47.6), lower than the 86.7 per 1,000 incidence among their predominantly uninfected peers reported in the National Vital Statistics Report in 2003.

Although all the 32 girls whose pregnancy resulted in a live birth took antiretroviral therapy during the pregnancy, one infant was confirmed to be HIV infected perinatally.

This 3.3% rate of mother-to-child HIV transmission (95% CI 0.1 to 18.6) is similar to the 1.2% to 3.8% rates observed in the Women and Infants Transmission Study among HIV-infected women.

However, none of the pregnant girls in the study had been exposed to antiretroviral therapy in utero.

"Further study is needed to ascertain the effectiveness of antiretroviral therapy in preventing second-generation perinatal HIV transmission given the potential for transmission of a virus resistant to one or more classes of antiretroviral therapy," they researchers said.

The six-year cumulative incidence of sexually transmitted diseases after age 13 was:

• 4.6% for genital warts--condylomata--overall (95% CI 1.7 to 7.4) and 8.2% among sexually active girls (95% CI 3.7 to 12.7).
• 4.8% for trichomoniasis overall (95% CI 1.4 to 8.3) and 6.9% among sexually active girls (95% CI 2.4 to 11.5).
• 2.7% for chlamydial infection overall (95% CI 0.9 to 4.6) and 5.5% for those who were sexually active (95% CI 2.0 to 9.1).
• 2.2% for gonorrhea overall (95% CI 0.3 to 4.1) and 3.9% for sexually active girls (95% CI 0.8 to 7.0).
• 1.1% for syphilis (95% CI 0.0 to 2.6) and 1.6% for those who were sexually active (95% CI 0.0 to 3.7).

As expected, the genital infection rates were lower than those in the Reaching for Excellence in Adolescent Care and Health study of girls infected with HIV during adolescence, presumably through sexual contact.

Screening for genital infections was not performed routinely. Cases symptomatic at pelvic examination were referred to primary care for assessment.

Thus, the finding that 23 of the 638 girls were infected with condylomata caused by the human papillomavirus (HPV) putting them at elevated risk of cervical cancer was "troubling," the researchers said.

"Adolescents perinatally infected with HIV are often cared for in pediatric infectious disease clinics, where reproductive health issues may not be routinely addressed," Dr. Brogly and colleagues wrote. "Education on safer sexual practices is needed in this population."

"A considerable proportion of adolescents in our cohort engaged in unprotected sex despite close and frequent contact with HIV clinics," they added. "Sexual activity in perinatally HIV-infected adolescent girls is probably more common than many pediatricians assume."