Transcript Research opportunities and challenges in the Dominican Republic

Research opportunities and challenges in
the Dominican Republic
Carolina Abuelo MD MSc, HIV Medical
Association Clinical Fellow
Providence, RI
Abnormal Pap smears in Santiago
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Location, location, location!
Cervical cancer
HIV
Pap smears
Methods
Ethics
Santiago
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Hospital Regional Universitario José Maria
Cabral y Báez
Cervical cancer
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leading cause of cancer deaths in women in
developing countries is cervical CA.
83% of cervical CA occur in locations without
access to Pap smears
most common cause of years of life lost in Latin
America and the Caribbean
DR 54% of eligible women screened in 2002
1032 incident cases, about 562 die annually
Estimated age standardized incidence rates of
cervical CA in Latin America and Caribbean, 2002
Worldwide prevalence of HPV infection is estimated
to be between 9% and 13% (all ages) WHO data
Estimated prevalence of HPV infection in selected
geographic areas (30-45 years old)
13.3%2
Ontario, Canada
15.3%5
Reims, France
18%*,7
Shanxi Province, China
14.5%3
Morelos State, Mexico
16.6%4
40.2%–41.6%6
Harare, Zimbabwe
Concordia, Argentina
Georgios Papanikolaou
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Γεώργιος Παπανικολάου
05/13/1883-02/19/1962
presented his results in 1928 in Battle Creek,
Michigan
1941: test to detect cancer
Pap Smear
HPV and HIV
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Cervical high risk neoplasia is correlated with
HPV
cervical CA is a criterion for the diagnosis of
AIDS as stage C disease
In a large US multicenter study of the natural
history of HIV infection and related diseases to
women, cervical cytology was found to be
abnormal in 38.3% of HIV+ women.
Risk factors for abnormal Pap
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CD4 count, HIV RNA level, detection of HPV,
and number of male sex partners within 6 months
of enrollment
Terminology for Cervical Cytology
(Bethesta)
ASCUS
Normal
LSIL
HSIL
 Two types of atypical squamous cells (ASC)4
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Atypical squamous cells of undetermined significance (ASCUS)
Atypical squamous cells, cannot exclude high-grade squamous
intraepithelial lesions (ASC-H)
 Squamous intraepithelial lesions (SIL)4
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Low-grade SIL (LSIL): Mild dysplasia, cervical intraepithelial
neoplasia 1 (CIN 1)
High-grade SIL (HSIL): Moderate and severe dysplasia, CIN 2/3,
carcinoma in situ (CIS)
Follow up for abnormal Pap smear . . .
HIV in the DR
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DR is one of the countries where the HIV
epidemic is generalized
unpublished data from 2007 reveals HIV positivity
at Cabral y Baez of 2.76% from a total of 7,782
men and women tested
Primary Aims:
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To assess the prevalence of abnormal Pap
smear among HIV + women in Santiago.
To assess the persistence of abnormal Pap
smear among HIV + women in Santiago.
Secondary Aim:
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To collect information on risk factors (low CD4
count, high plasma viral load, antiviral therapy,
number of sexual partners, use of condoms,
smoking) associated with cervical HPV
infection.
Methods
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retrospective chart review of 100 HIV + since
2003
Pap smears reported according to the 2001
Bethesda System
The prevalence of abnormal pap smear = total
number of abnormal pap smears/total number of
charts reviewed.
Incidence versus Persistence
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Because fewer than 50 women have had more than
1 Pap, it is not possible to determine incidence,
defined as a normal Pap is followed by an
abnormal Pap.
persistence of abnormal Pap: women with
abnormal Pap followed with colposcopy for low
grade squamous intraepithelial lesions (LGSIL) or
higher.
For this study, persistence is defined as two
consecutive abnormal Pap smears.
Nitty Gritty
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226 women with Pap smears.
100 randomly selected
unsatisfactory pap smears or vaginal cytology will
be excluded.
demographic data abstracted
risk factors will be collected: CD4, plasma viral
load, HAART, number of sexual partners, use of
condoms, history of STI, gravidity, and smoking.
Information about the cytology and follow up will
be recorded.
Analysis:
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univariate analysis will be used to determine
which variables are associated with abnormal
cytology.
association between abnormal follow-up smears
and demographic and clinical predictors will be
examined using logistic regression.
SAS 9.1
Challenges, Part I
Challenges, Part II
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Mal olor en el hospital Jose Maria Cabral y Baez
viernes 9 de enero de 2009
Pacientes del Hospital regional Y universitario
Jose Maria Cabral Y Baez presentaron este viernes
quejas por el mal olor que sale de la morgue.
Se dice que el olor a descomposicion es tan fuerte
que sube hasta el 4to piso. se dice que la razon
de aquel mal olor es por que los frezers que
mantienen los cuerpos de los cadaveres estan
descompuestos.
Fly in the ointment: IRB challenges
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Permission from multiple places
Language issues
For interventions need consent forms
Additional Resources
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Micah Johnson, Brown Medical Student
([email protected])
Pequeños Pasitos, James Craig Pickard and Rita
Josefina Rizek ([email protected] )
Thank you
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Susan Cu Uvin, MD
Tim Flanigan MD
Claudia Rodriguez MD
Mike Stein MD
Brown University Global Health Scholarship
References
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[i] Solomon D, Davey D, Kurman R, Moriarty A, O'Connor D, Prey M, Raab S, Sherman M, Wilbur D,
Wright TJ, Young N. The 2001 Bethesda System.Terminology for reporting results of cervical cytology.
JAMA. 2002;287:2114–2119.
[i] Schiffman M, Castle PE. The promise of global cervical-cancer prevention. N Engl J Med.
2005;353:2101-2104.
[ii] Yang BH, Bray FI, Parkin DM, Sellors JW, Zhang ZF. Cervical cancer as a priority
for prevention in different world regions: an evaluation using years of life lost. Int J Cancer 2004;109(3
(April)):418–24.
[iii] Murillo R, Almonte M, Pereira A, et al. Cervical Cancer Screening Programs in Latin America and
the Caribbean. Vaccine 26S (2008) L37–L48.
[iv] http://www.who.int/healthinfo/survey/whsdom-dominicanrepublic.pdf
[v] WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Summary
report on HPV and cervical cancer statistics in Dominican Republic. 2007. [12/02/08].
Available at www. who. int/ hpvcentre
[vi] P Schuman, SE Ohmit, RS Klein, et al. Longitudinal Study of Cervical Squamous Intraepithelial
Lesions in Human Immunodeficiency Virus (HIV)–Seropositive and At-Risk HIV-Seronegative Women.
Journal of Infectious Diseases, 2003; 188: 128-36.
[vii] From the Centers for Disease Control and Prevention. 1993 revised classification system for HIV
infection and expanded surveillance case definition for AIDS among adolescents and adults. JAMA.
1993 Feb 10;269(6):729-30
[viii] Massad, L, Riester, K, Anastos, K et al. Prevalence and predictors of squamous cell abnormalities
in papanicolau smears from women infected with HIV-1. Journal of Acquired Immune Deficiency
Syndromes. 1999; 21 (1) 33-41.
[ix] Veras, B. Prevalencia de Casos positivos de VIH en pruebas realizadas en el Hospital Jose Ma.
Cabral y Baez, Santiago, Rep. Dom., 2007. Boletin Notas de Epidemiologia Vol No.5. Octubre 2008