title: The burden of cervical pre-cancer and cancer in HIV positive women in Zambia: a modeling study.
abstract: BACKGROUND
  HIV infection is associated with a higher incidence of precancerous cervical lesions and their progression to invasive cervical cancer (ICC). Zambia is a global epicenter of HIV and ICC, yet the overall burden of cervical pre-cancer [cervical intraepithelial neoplasia 3 (CIN3)] and ICC among its HIV positive adult female population is unknown. The objective of this study was to determine the burden of cervical disease among HIV positive women in Zambia by estimating the number with CIN3 and ICC.
  
  
  METHODS
  We conducted a cross-sectional study among 309 HIV positive women attending screening in Lusaka (Zambia's most populated province) to measure the cervical disease burden by visual inspection with acetic acid enhanced by digital cervicography (DC), cytology, and histology. We then used estimates of the prevalence of CIN3 and ICC from the cross-sectional study and Spectrum model-based estimates for HIV infection among Zambian women to estimate the burden of CIN3 and ICC among HIV positive women nationally.
  
  
  RESULTS
  Over half (52 %) of the study participants screened positive by DC, while 45 % had cytologic evidence of high grade squamous intraepithelial lesions (SIL) or worse. Histopathologic evaluation revealed that 20 % of women had evidence of CIN2 or worse, 11 % had CIN3 or worse, and 2 % had ICC. Using the Spectrum model, we therefore estimate that 34,051 HIV positive women in Zambia have CIN3 and 7,297 have ICC.
  
  
  CONCLUSIONS
  The DC, cytology, and histology results revealed a large cervical disease burden in this previously unscreened HIV positive population. This very large burden indicates that continued scale-up of cervical cancer screening and treatment is urgently needed.
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. bateman.allen@gmail.com.|University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. bateman.allen@gmail.com.
authors.forename: Allen C
authors.initials: AC
authors.lastname: Bateman
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Katundu.Katundu@cidrz.org.
authors.forename: Katundu
authors.initials: K
authors.lastname: Katundu
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. mulindim@gmail.com.|University of Zambia, Lusaka, Zambia. mulindim@gmail.com.
authors.forename: Mulindi H
authors.initials: MH
authors.lastname: Mwanahamuntu
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. sharon.kapambwe@cidrz.org.
authors.forename: Sharon
authors.initials: S
authors.lastname: Kapambwe
authors.affiliation: Vanderbilt University, Nashville, Tennessee, USA. vikrant.sahasrabuddhe@vanderbilt.edu.
authors.forename: Vikrant V
authors.initials: VV
authors.lastname: Sahasrabuddhe
authors.affiliation: Michigan Cancer Institute, Pontiac, MI, USA. mrhicks2@comcast.net.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Hicks
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Benjamin.Chi@cidrz.org.|University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Benjamin.Chi@cidrz.org.
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Jeffrey_Stringer@med.unc.edu.
authors.forename: Jeffrey S A
authors.initials: JS
authors.lastname: Stringer
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. professorparham@gmail.com.|University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. professorparham@gmail.com.|University of Zambia, Lusaka, Zambia. professorparham@gmail.com.
authors.forename: Groesbeck P
authors.initials: GP
authors.lastname: Parham
authors.affiliation: Centre for Infectious Disease Research in Zambia, Lusaka, Zambia. Carla.Chibwesha@cidrz.org.
authors.forename: Carla J
authors.initials: CJ
authors.lastname: Chibwesha
mesh_terms: D000328:Adult; D003430:Cross-Sectional Studies; D005260:Female; D015658:HIV Infections / Q000150:complications* / Q000821:virology; D006801:Humans; D015994:Incidence; D008403:Mass Screening; D008875:Middle Aged; D008962:Models, Theoretical; D015995:Prevalence; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis* / Q000453:epidemiology* / Q000821:virology; D055815:Young Adult; D015024:Zambia / Q000453:epidemiology; D002578:Uterine Cervical Dysplasia / Q000175:diagnosis* / Q000453:epidemiology* / Q000821:virology