A report by George Beatty, MD, MPH, associate clinical professor of medicine, UCSF Positive Health Program at San Francisco General Hospital and Trauma Center:
HPV infection in HIV+ women causes more dysplasia and progresses more rapidly to cervical cancer. HIV+ women also get infected with many more HPV subtypes than HIV – women.
Though there is a nonavalent (that means 9 subtypes) vaccine in development, which may ultimately be more appropriate for use in HIV, what we have now is a quadrivalent vaccine. The quadrivalent HPV vaccine works well in HIV negative women, but we have less information about its effectiveness in HIV+ women.
Kahn, et al, evaluated the immunogenicity of this vaccine in HIV+ women ages 16-23, who were HPV DNA negative at baseline and Cespedes presented results of ACTG 5240, reporting on vaccination in HIV+ women ages 13-45 both with and without current HPV infection, whose CD4 was > 200.
Both studies found robust rates of immune responses (>90%) at 4 weeks post-vaccination. In the former study, response was slightly lower in women who weren’t on ART vs those who were, and slightly lower for HPV subtype 18 vs 6, 11, and 16, but all responses were well in the range expected to achieve immunity.
Notably, for subtype 18, the response fell significantly at 48 weeks post-immunization, from 90% to 74% in women not on ART, and from 100% to 87% in women on ART. In the ACTG study, women who already had the HPV subtypes still got a significant boost in immune response. While more clinical endpoint data is needed, this vaccine still looks like it performs better than many in routine use today, and the ACTG data suggests that we not exclude women on the basis of age.
We know from earlier work (Parham, et al. 2010) in Zambia, that one only needs to vaccinate between 28 and 68 women to prevent 1 cervical cancer death. That isn’t a bad deal, and poster WEPE258 describes a meta-analysis concluding that HPV infection doubles the risk of acquiring HIV.
Though lots of questions remain (What is the clinical impact in HIV+’s ? Can we use a simpler dosing strategy? What is the durability and will we need booster vaccination? How the heck do we roll this out and pay for it in Africa?), vaccination is clearly a cost-effective way to save lives, and we shouldn’t wait on further data to implement HPV vaccination programs in these women at extremely high risk of cancer.
Kahn, et al. Immunogenicity of the HPV-6, -11, -16, -18 vaccine in HIV-positive young women.
Kojic, et al. Safety and immunogenicity of the quadrivalent human papillomavirus vaccine in HIV-positive women.
Houlihan, et al. HPV infection and increased risk of HIV acquisition: a systemativc review and meta-analysis.