HIV Infection and Survival Among Women With Cervical Cancer

Abstract

Purpose Cervical cancer is the leading cause of cancer death among the 20 million women with HIV worldwide. We sought to determine whether HIV infection affected survival in women with invasive cervical cancer. Patients and Methods We enrolled sequential patients with cervical cancer in Botswana from 2010 to 2015. Standard treatment included external beam radiation and brachytherapy with concurrent cisplatin chemotherapy. The effect of HIV on survival was estimated by using an inverse probability weighted marginal Cox model. Results A total of 348 women with cervical cancer were enrolled, including 231 (66.4%) with HIV and 96 (27.6%) without HIV. The majority (189 [81.8%]) of women with HIV received antiretroviral therapy before cancer diagnosis. The median CD4 cell count for women with HIV was 397 (interquartile range, 264 to 555). After a median follow-up of 19.7 months, 117 (50.7%) women with HIV and 40 (41.7%) without HIV died. One death was attributed to HIV and the remaining to cancer. Three-year survival for the women with HIV was 35% (95% CI, 27% to 44%) and 48% (95% CI, 35% to 60%) for those without HIV. In an adjusted analysis, HIV infection significantly increased the risk for death among all women (hazard ratio, 1.95; 95% CI, 1.20 to 3.17) and in the subset that received guideline-concordant curative treatment (hazard ratio, 2.63; 95% CI, 1.05 to 6.55). The adverse effect of HIV on survival was greater for women with a more-limited stage cancer ( P = .035), those treated with curative intent ( P = .003), and those with a lower CD4 cell count ( P = .036). Advanced stage and poor treatment completion contributed to high mortality overall. Conclusion In the context of good access to and use of antiretroviral treatment in Botswana, HIV infection significantly decreases cervical cancer survival.

Fig 1.

Enrollment and retention. (*)Enrollment registers of the Botswana Prospective Cancer Cohort include all cancers and do not differentiate by cancer site. The number of eligible women with cervical cancer and number excluded were estimated from percentages of the full cohort.

Fig 2.

Kaplan-Meier estimated survival by HIV status (A) overall, (B) among participants who received guideline-concordant curative treatment, (C) by treatment intent, and (D) by stage. Number at risk is shown under the curves, and shaded areas indicate 95% confidence bands. Survival significantly differed by HIV status in these univariable analyses among all participants (P = .022), among those treated with radical intent (P = .019), and among those with limited-stage cancer (stage IA to IIB; P = .036). HIV+, with HIV infection; HIV–, without HIV infection.

Fig 3.

Effect of HIV on overall survival within subgroups. The P value is from the statistic for testing the interaction between HIV status and the subgroup variable. Only participants treated with curative intent are included in the comparison of effect of HIV by radiation dose received. ART, antiretroviral therapy; HR, hazard ratio.