Anal condyloma is a sexually-transmitted disease caused by the HPV. Even though it can be transmitted to any susceptible individual, it is more prevalent in HIV-positive patients. An anal condyloma is the most commonly reported anal disease in HIV-positive patients, and the occurrence of an anal condyloma is closely related to the HIV-positive patients' immune deficiency, sexual intercourse patterns, and number of sexual partners. This research addressed the commonly-involved immune deficiencies in HIV-positive patients. The study population was all male patients who had mostly contracted HIV infection through sexual contact. Among those, 60 out of the 85 patients (70.6%) indicated that they were homosexuals, and a considerable number of nonrespondents were assumed to be homosexuals. Although a direct investigation was not conducted, HPV infection was thought to have been transmitted through anal sexual intercourse. According to Hwang et al. [11
], greater numbers of male patients were prone to anal diseases in HIV-infected patients than in those without HIV infection. Moreover, homosexual intercourse was reported to be significantly higher in terms of transmission routes.
An anal condyloma reportedly has a recurrence rate of 20 to 50%, and surgical treatment is generally known to have low recurrence rates. However, depending on the particular study, the values vary [1
]. The postoperative recurrence rate was about 30% in this study. About 20% of the 30% with recurrence were intractable anal condyloma patients showing repeated recurrences after surgical treatment. Factors involved in the recurrence are anticipated to be reinfection from repeated sexual contact, postoperatively-remaining lesions, and reappearance of lesions caused by latent viruses in the body.
An anal condyloma is a disease spread through direct sexual contact. Hence, the incidence and recurrence rates have been reported highly in individuals with frequent sexual contacts and multiple sexual partners [4
]. Thus, a considerable number of patients with recurrence have the possibility of reinfections. Although reinfections were thought to be included in this study, ll, the possibility of reinfections was not recorded in the interviews with recurrent patients. In terms of the technical aspects of surgery, a single specialized surgeon performed all operations, and no differences were shown in the recurrence rates over time. Thus, this was considered an insignificant factor.
Cell-mediated immunity is associated with the reappearance of asymptomatic and latent infections. Previous studies have already verified the fact that cellular immunity is involved in HPV-induced lesions and have reported that anal-condyloma prevalence is more common in HIV-positive patients and transplant recipients managed with immunosuppressants [9
HPV generates the transformation of Langerhans cells, which play an essential role in the local cutaneous immune response, and sustains infections by consuming CD4 cells, CD16 (macrophages/natural killer cells) cells, and CD1a (Langerhans cells) cells in infected sites. These local responses are profoundly related to a weakened immune system of the whole body [9
]. Le Poole et al. [6
] presented evidences of immunosuppression, including decreases in transporters associated with antibody expression and dendritic cells, increases in interleukin-10 production by analyzing immunological indicators in anal condyloma lesion patients without HIV infections or other immunosuppressive treatment.
In this study, we planned the research by taking into account the possibility that different factors affecting the immunity of HIV-infected patients might influence the recurrence of an anal condyloma. However, CD8 lymphocytes, HIV RNA copies, antiretroviral treatment, and other variables were not related with recurrence; however, the number of CD4 lymphocytes was found to be lower in the recurrent group than in the non-recurrent group. Because CD4 lymphocytes are excellent indicators reflecting the immunity condition of HIV-infected patients, the condition of the immune system of a patient should be associated with the recurrence of disease. However, statistically significant differences were shown only after the sixth postoperative month and did not completely coincide with the recurrent times of the patients.
A high prevalence of syphilis was exhibited in the nonrecurrent group. This was attributable to the inclusion of positive responders in qualitative test and did not reflect current infections. Critchlow et al. [16
] reported that compared to non-HIV-infected patients, HIV-infected patients rarely shifted from positive to negative responses after HPV infections. The outcome was thought to be attributable to diminished responses generated by concurrent infections with various HPV subtypes or usual treatments. Moreover, a domestic study [17
] reported that high-risk and multiple HPV infections were more frequently detected in HIV-infected patients than in patients without HIV infection. Thus, further study on the relationship between HPV subtypes and recurrence is thought to be essential. In addition, Mistrangelo et al. [7
] reported that recurrence rates declined in the group administered with plants known to enhance the postoperative immunity of patients who had undergone anal condyloma surgery. In this regard, further studies on the application of immune-regulating substances pre- and postoperatively are expected to produce favorable results.
In conclusion, a marked decrease in CD4 lymphocytes was observed in the recurrent group compared to the nonrecurrent group with respect to anal condylomata in HIV-positive patients. Thus, diminished immunity mediated by CD4-related cells is thought to affect the recurrence of an anal condyloma.