                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                        September 9, 1994

               Women and HIV Infection (Part VIII)

                     AIDS Definition Revised

     A doctor diagnoses AIDS when an HIV-infected person develops
one of several infections or diseases specified by CDC in its "AIDS
surveillance case definition." These illnesses include PCP,
Kaposi's sarcoma (a type of cancer), toxoplasmosis, and others. As
knowledge about HIV and AIDS has grown over the years, CDC has
expanded its definition to include additional AIDS-defining
illnesses. In January 1993, CDC added cervical cancer, along with
pulmonary tuberculosis and recurrent pneumonia, to the list of
AIDS-indicator illnesses in HIV-infected people.
     The revised AIDS definition also includes all HIV-infected
people with severe CD4 cell depletion (less than 200 CD4 cells per
cubic millimeter). CD4 cells are critical immune system cells that
number from about 800 to 1,000 in a healthy person.
     "According to the old definition," says Arrowsmith-Lowe, "if
you had a very low CD4 count but no AIDS-defining illness,
technically you didn't have AIDS and therefore couldn't qualify
for assistance, even if you felt sick. This CD4 cutoff should help
those patients get assistance and reliable medical care." (Marian
Segal. FDA Consumer, October 1993.)

                    Invasive Cervical Cancer

(Excerpt from:  Centers for Disease Control and Prevention. 1993
Revised Classification system for HIV infection and expanded
surveillance case definition for AIDS among adolescents and adults. 
MMWR 1992;41(No.RR-17):[Inclusive page numbers].)

     Several studies have found an increased prevalence of cervical
dysplasia, a precursor lesion for cervical cancer, among HIV-
infected women (60, 61). In a study of 310 HIV-infected women
attending methadone maintenance and sexually transmitted disease
clinics in New York City and Newark, New Jersey, cervical dysplasia
was confirmed by biopsy and/or colposcopy in approximately 22%, a
prevalence rate 10 times greater than that found among women
attending family planning clinics in the United States (Wright TC,
personal communication; 62). Several studies have documented that
a higher prevalence of cervical dysplasia among HIV-infected women
is associated with greater immunosuppression (Wright TC, personal
communication; 61,63).  In addition, HIV infection may adversely
affect the clinical course and treatment of cervical dysplasia and
cancer (64-69).
     Invasive cervical cancer is a more appropriate AIDS-indicator
disease than is either cervical dysplasia or carcinoma in situ
because these latter cervical lesions are common and frequently do
not progress to invasive disease (70). Also, cervical dysplasia or
carcinoma in situ among women with severe cervicovaginal
infections, which are common in HIV-infected women, can be
difficult to diagnose. In contrast, the diagnosis of invasive
cervical cancer is generally unequivocal.
     Invasive cervical cancer is preventable by the proper
recognition and treatment of cervical dysplasia. Thus, the
occurrence of invasive cervical cancer among all women--including
those who are HIV-infected--represents missed opportunities for
disease prevention.  The addition of invasive cervical cancer to
the list of AIDS-indicator diseases emphasizes the importance of
integrating gynecologic care into medical services for HIV-infected
women.

References

60.  Laga M, Icenogle JP, Marsella R, et al. Genital papillomavirus
     infection and cervical dysplasia--opportunistic complications
     of HIV infection. Int J Cancer 1992;50:45-8.

61.  Schafer A, Friedmann W, Mielke M, Schwartlander B, Koch MA.
     The increased frequency of cervical dysplasia-neoplasia in
     women infected with the human immunodeficiency virus is
     related to the degree of immunosuppression. Am J Obstet
     Gynecol 1991;164:593-9.

62.  Sadeghi SB, Sadeghi A, Robboy SJ. Prevalence of dysplasia and
     cancer of the cervix in a nationwide Planned Parenthood
     population.  Cancer 1988;61:2359-61.

63.  Feingold AR, Vermund SH, Burk RD, et al. Cervical cytologic
     abnormalities and papillomavirus in women infected with human
     immunodeficiency virus. J Acquir Immune Defic Syndr
     1990;3:896-903.

64.  Maiman M, Fruchter RG, Serur E, Remy JC, Feuer G, Boyce J.
     man immunodeficiency virus infection and cervical neoplasia.
     Gynecol Oncol 1990;38:377-82.

65.  Klein RS, Adachi A, Fleming I, Ho GYF, Burk R. A prospective
     study of genital neoplasia and human papillomavirus (HPV) in
     HIV-infected women (abstract). Vol.1. Presented at the VIII
     International Conference on AIDS/III STD World Congress,
     Amsterdam, The Netherlands, July 19-24, 1992.

66.  Fruchter R, Maiman M, Serur E, Cuthill S. Cervical
     intraepithelial neoplasia in HIV infected women (abstract). 
     Vol.1.  Presented at the VIII International Conference on
     AIDS/III STD World Congress, Amsterdam, The Netherlands, July
     19-24, 1992.

67.  Richart RM, Wright TC. Controversies and the management of
     low-grade cervical intraepithelial neoplasia. Cancer (in
     press).

68.  Rellihan MA, Dooley DP, Burke TW, Berkland ME, Longfield RN. 
     Rapidly progressing cervical cancer in a patient with human
     immunodeficiency virus infection. Gynecol Oncol 1990;
     36:435-8.

69.  Schwartz LB, Carcangiu ML, Bradham L, Schwartz PE. Rapidly
     progressive squamous carcinoma of the cervix coexisting with
     human immunodeficiency virus infection: clinical opinion.
     Gynecol Oncol 1991;41:255-8.

70.  Richart RM. Cervical intraepithelial neoplasia: a review. 
     In: Sommers SC, ed. Pathology annual, 1973. New
     York:Appleton-Century- Crofts, 1973:301-28.

Cervical Disease -- Additional Reading

1.   Centers for Disease Control and Prevention. Risk for Cervical
     Disease in HIV-Infected Women - New York City. MMWR. 1990
     Nov;39(47):846-9.

2.   Mandelblatt JS. Fahs M. Garibaldi K. et al. Association
     Between HIV Infection and Cervical Neoplasia: Implications
     for Clinical Care of Women at Risk for Both Conditions. AIDS.
     1992;6(2):173-8.

3.   Schafer A. Friedmann W. Mielke M. et al. The Increased
     Frequency of Cervical Dysplasis-Neoplasia in Women Infected
     with the Human Immunodeficiency Virus is Related to the Degree
     of Immunosuppression. American Journal of Obstetrics and
     Gynecology. 1991 Feb;164(2):593-9.

4.   Vermund SH. Kelley KF. Klein RS. et al. High Risk of Human
     Papillomavirus Infection and Cervical Squamous Intraepithelial
     Lesions Among Women with Symptomatic Human Immunodeficiency
     Virus Infection. American Journal of Obstetrics and
     Gynecology. 1991 Aug;165(2):392-400.

                    Invasive Cervical Cancer
                  CDC Training Bulletin Excerpt

     Question:  Now that invasive cervical cancer has been added
to the list of indicator illnesses for AIDS, can CDC recommend how
often women who are HIV+ should have a pap smear?

     Answer:  Recommendations for the medical management of
HIV-infected women is not dependent on the addition of diseases,
such as invasive cervical cancer, to the CDC AIDS case surveillance
definition.  The 1993 expanded AIDS case definition did not result
in the reporting of many AIDS cases among women with a presenting
diagnosis of invasive cervical cancer.  PCP is still the leading
AIDS-defining diagnosis among women reported with AIDS through June
1993.  The November 30, 1990, edition of the MMWR contained a 1988
consensus recommendation from several organizations concerning how
frequently women with and at risk for HIV infection should have Pap
smears.  Although personal physicians must make this decision based
on risk factors for cervical cancer, the recommendation states that
HIV-infected women should have a Pap smear annually.  The American
College of Obstetrics and Gynecology reiterated this information
in their 1992 recommendations.

(Centers for Disease Control and Prevention.  Training Bulletin
#62.  August 23, 1993.)

                  Cervical Disease - References
                            1993-1994

Adachi A. Fleming I. Burk RD. et al. Women with human
immunodeficiency virus infection and abnormal Papanicolaou smears:
a prospective study of colposcopy and clinical outcome. Obstet
Gynecol. 1993 Mar;81(3):372-7.

Braun L. Role of human immunodeficiency virus infection in the
pathogenesis of human papillomavirus-associated cervical neoplasia.
Am J Pathol. 1994 Feb;144(2):209-14.

Conti M. Agarossi A. Parazzini F. et al. HPV, HIV infection, and
risk of cervical intraepithelial neoplasia in former intravenous
drug abusers. Gynecol Oncol. 1993 Jun;49(3):344-8.

Goodkin K. Antoni MH. Helder L. Sevin B. Psychoneuroimmunological
aspects of disease progression among women with human
papillomavirus-associated cervical dysplasia and human
immunodeficiency virus type 1 co-infection. Int J Psychiatry Med.
1993;23(2):119-48.

Hankins CA. Lamont JA. Handley MA. Cervicovaginal screening in
women with HIV infection: a need for increased vigilance? Can Med
Assoc J. 1994 Mar 1;150(5):681-6.

Henry-Stanley MJ. Simpson M. Stanley MW. Cervical cytology findings
in women infected with the human immunodeficiency virus. Diagn
Cytopathol. 1993 Oct;9(5):508-9.

Inman GJ. Cook ID. Lau RK. Human papillomaviruses, tumour
suppressor genes and cervical cancer [editorial] Int J STD AIDS.
1993 May-Jun;4(3):128-34.

Jenks S. AIDS-related cancers emerging as a second epidemic [news]
J Natl Cancer Inst. 1993 Sep 1;85(17):1369-70.

Joshi J. Mali B. Bhave G. Wagle U. Cervical neoplasia and
cytological manifestations of sexually transmitted diseases in
HIV-seropositive prostitutes [letter]. Cytopathology.
1993;4(1):63-4.

Levine AM. AIDS-related malignancies: the emerging epidemic. J Natl
Cancer Inst. 1993 Sep 1;85(17):1382-97.

McKenna MT. Buehler JW. Qualters JR. Chu SY. HIV and trends in
cervical cancer death rates among young women [letter; comment] Am
J Public Health. 1993 Dec;83(12):1792-3.

Maggwa BN. Hunter DJ. Mbugua S. et al. The relationship between
HIV infection and cervical intraepithelial neoplasia among women
attending two family planning clinics in Nairobi, Kenya. AIDS. 1993
May;7(5):733-8.

Maiman M. Fruchter RG. Guy L. Human immunodeficiency virus
infection and invasive cervical carcinoma. Cancer. 1993 Jan
15;71(2):402-6.

Maiman M. Fruchter RG. Serur E. et al. Recurrent cervical
intraepithelial neoplasia in human immunodeficiency virus-
seropositive women. Obstet Gynecol. 1993 Aug;82(2):170-4.

Mandelblatt J. Squamous cell cancer of the cervix, immune
senescence and HPV: is cervical cancer an age-related neoplasm?
Adv Exp Med Biol. 1993;330:13-26.

Markos AR. Wade AA. Walzman M. Management of cervical
intraepithelial neoplasia in departments of genitourinary
medicine--a national survey. Int J STD AIDS. 1993
Jan-Feb;4(1):41-2.

Northfelt DW. Cervical and anal neoplasia and HPV infection in
persons with HIV infection. Oncology (Huntingt). 1994
Jan;8(1):33-7; discussion 38-40.

Rabkin CS. Biggar RJ. Baptiste MS. et al. Cancer incidence trends
in women at high risk of human immunodeficiency virus (HIV)
infection. Int J Cancer. 1993 Sep 9;55(2):208-12.

Rose PG. Fraire AE. Multiple primary gynecologic neoplasms in a
young HIV-positive patient. J Surg Oncol. 1993 Aug;53(4):269-72.

Smith JR. Kitchen VS. Botcherby M. et al. Is HIV infection
associated with an increase in the prevalence of cervical
neoplasia? Br J Obstet Gynaecol. 1993 Feb;100(2):149-53.

Spinillo A. Tenti P. Zappatore R. De Seta F. et al. Langerhans'
cell counts and cervical intraepithelial neoplasia in women with
human immunodeficiency virus infection. Gynecol Oncol. 1993
Feb;48(2):210-3.

Tannenbaum I. Women and HIV. RN. 1993 May;56(5):34-41.

                  Cervical Disease - References
          IXTH International Conference on AIDS - 1993

Agarossi A. Muggiasca ML. Ciminera N. et al. Follow up of
HIV1-positive women treated for cervical neoplasia. Int Conf AIDS.
1993 Jun 6-11;9(1):407 (abstract no. PO-B14-1634).

Altice FL. Selwyn PA. Tanguay S. Illicit drug use, STD's and
abnormal pap smears among HIV+ and HIV-female prisoners. Int Conf
AIDS. 1993 Jun 6-11;9(2):703 (abstract no. PO-C15-2919).

Bartlett JA. Zimmerman M. Cameron M. et al. Clinical
characteristics of HIV infected women in North Carolina. Int Conf
AIDS. 1993 Jun 6-11;9(1):512 (abstract no. PO-B32-2262).

Bensaid-Mrejen D. Barau G. Beder. Pigne A. Lebrette. Rozenbaum W.
A screening and treatment unit for HPV infections in HIV infected
women: advantages. Int Conf AIDS. 1993 Jun 6-11;9(1):410 (abstract
no. PO-B14-1649).

Cote T. Schiffman M. Biggar R. et al. Invasive cervical cancer
among women with AIDS: results of registry linkage (Meeting
abstract). Proc Annu Meet Am Assoc Cancer Res; 34:A1546 1993.

Cote T. Schiffman M. Biggar R. et al. Invasive cervical cancer
among women with AIDS: results of registry linkage. NACMR Study
Group. Int Conf AIDS. 1993 Jun 6-11;9(1):408 (abstract no.
PO-B14-1637).

Cu-Uvin S. Eastman-Abaya R. Nitta K. et al. Cervical dysplasia and
infections among incarcerated women: a comparison of HIV (+) and
HIV (-) inmates. Int Conf AIDS. 1993 Jun 6-11;9(1):409 (abstract
no. PO-B14-1644).

Ellerbrock T. Wright TC. Chiasson MA. Bush TJ. Strong independent
association between HIV infection and cervical intraepithelial
neoplasia (CIN). Cervical Disease Study Group. Int Conf AIDS. 1993
Jun 6-11;9(1):50 (abstract no. WS-B07-5).

Fink MJ. Fruchter R. Maiman M. et al. Cytology, colposcopy and
histology in HIV positive women. Int Conf AIDS. 1993 Jun
6-11;9(1):460 (abstract no. PO-B23-1947).

Johnstone FD. McGoogan E. Brettle RP. Smart GE. A population study
of cervical cytology in HIV infected women. Int Conf AIDS. 1993 Jun
6-11;9(1):408 (abstract no. PO-B14-1639).

Khalsa SK. Salmon LE. Sandler KR. Gynecological manifestations in
early HIV disease, and screening Pap smears versus colposcopy. Int
Conf AIDS. 1993 Jun 6-11;9(1):410 (abstract no. PO-B14-1647).

Naud P. Brum S. Hunsche A. et al. Human papillomavirus, cervical
displasya and viral type. Int Conf AIDS. 1993 Jun 6-11;9(1):409
(abstract no. PO-B14-1646).

Sankari SS. Rajini. Comparative study of incidence of HIV infection
in risk groups of women with CIN, STD clinic attending women and
antenatal women. Int Conf AIDS. 1993 Jun 6-11;9(1):60 (abstract no.
WS-B17-4).

Stephens PC. Zheng T. Holford T. et al. Incident AIDS and cervical
cancer in Connecticut women: an ecological examination of time
trends and age period cohort effects. Int Conf AIDS. 1993 Jun
6-11;9(1):60 (abstract no. WS-B17-1).

Vivas C. Ramirez JM. Ibarra E. Martin F. Prevalence of human
papilomavirus (HPV) infection and cervical intraepitelial neoplasia
(CIN) in women with and without HIV infection. Int Conf AIDS. 1993 
Jun 6-11;9(1):409 (abstract no. PO-B14-1643).

von Eckardstein S. Kuppers V. Havenith B. Somville T. First
experiences in the therapy of cervical intaepithelial neoplasia in
HIV-infected women by the use of the CO2- laser. Int Conf AIDS.
1993 Jun 6-11;9(1):408 (abstract no. PO-B14-1640).

Wiley E. Nightingale S. Lawrence J. Prevalence of human papilloma
virus/cervical dysplasia in HIV+ women patients at a midwestern US
public hospital. Int Conf AIDS. 1993 Jun 6-11;9(1):409 (abstract
no. PO-B14-1642).

Wright T. Sun X. Ellerbrock T. Chiasson M. Human papillomavirus
infections in HIV+ and HIV- women: prevalence, association with
cervical intraepithelial neoplasia, and impact of CD4+ count. Int
Conf AIDS. 1993 Jun 6-11;9(1):60 (abstract no. WS-B17-2).

