This pilot study provides a new insight into the risk of HIV acquisition associated with mechanical injury to the cervix due to procedures related to cervical cancer screening. Our results show no relationship between cervical procedures and risk of HIV acquisition; however, they need to be interpreted cautiously for several reasons.
Of the 199 women who underwent cervical procedures, only 7 women acquired HIV, and, among women who had a recent cervical procedure (within the last 3 months), only 2 acquired HIV. This low number of outcomes can certainly explain our negative findings.
Our study was hypothetically subject to confounding given that all the women who underwent cervical procedures were counseled to abstain from sex for 4 weeks following cervical treatment; therefore, behavior modification could have resulted in decreased exposures to HIV during a potential period of susceptibility. However, any difference in sexual behavior between the two groups would have been limited to the first month following the cervical procedures.
There are limited data in the literature reporting the effect of cervical procedures on the risk of HIV acquisition. The effect of cervical procedures (cryosurgery, LEEP, and cone) on genital tract shedding and HIV transmission was investigated in a study by Wright et al. in 2001 [13
]. This study showed greater than 10,000-fold increased local viral replication and genital shedding which persists for up to 4 weeks following treatment. This increased genital shedding, thought to be due to cervical inflammation leading to local activation of CD4 lymphocytes, could translate into a significantly increased risk of HIV transmission for partners of HIV-infected women. In HIV-negative women, cervical inflammation due to cervical procedures could theoretically increase the number of HIV target cells and lead to increased susceptibility to HIV acquisition.
shows a protective, though not statistically significant, effect of endocervical curettage on HIV acquisition. It was our hypothesis that any cervical procedure leading to cervical inflammation may lead to increased risk of HIV acquisition. Therefore, it is unclear how to explain the protective trend shown between endocervical curettage and HIV acquisition, although the small numbers of outcomes of HIV acquisition must be considered.
There are several strengths to our analysis, including a large sample size, a low rate of loss to followup, and frequent followup. Limitations include a small number of HIV acquisition events, which affected the power and statistical precision of our findings. There were seven outcomes (HIV acquisition) in total among the 199 women who underwent procedures in this exploratory analysis. Larger studies need to be performed to confirm our findings such that we can be assured that procedures associated with cervical cancer screening and management are safe for women in areas with high endemic HIV rates.