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The women who were HIV-positive were just as likely to report good to excellent health as those who were HIV negative (P = NS) (SF-36; Table 2). HIV-positive women also perceived their health to be just as good as those who were HIV negative. (SF-36; Table 3). No HIV-positive women expected her health to worsen. There was no association with education, socioeconomic status, religion, ethnicity, education, marital status. or co-wives. No woman in this study who relocated to Accra within the year was HIV-positive (P

Table 3 shows risk factors associated with cervical cancer in univariate and logistic regression analyses. In univariate analyses, women with cervical cancer were more likely to be either HIV-1-infected or HIV-2-infected than were control women; however, these differences were not statistically significant. In logistic regression analysis, when controlling for age, low socioeconomic status, and lifetime number of sex partners > 6, the variables that remained associated with cervical cancer were having high-risk HPV infection (OR 23.0; 95% CI 10.5-50.2), parity > 2 (OR 5.5; 95% CI 2.3-13.4), and low economic status (OR 2.4; 95% CI 1.2-4.9). However, when high-risk HPV infection was removed from the model, HIV-1 infection or dual HIV infection was associated with cervical cancer (OR 3.4; 95% CI 1.4-8.3). Although HIV-2 infection was also associated with having cervical cancer, the association did not achieve statistical significance, perhaps due to the small number of HIV-2-positive women (OR 3.9; 95% CI 0.4-35.6). The positive association of HIV infection and cervical cancer remained unchanged when the analysis was restricted to case and control participants with evidence of high-risk HPV DNA (OR 3.4; 95% CI 1.1-10.8).

Relatively unique to West Africa is the issue of HIV-2 infection. In this study, a higher prevalence of HIV-2 was observed among participants with cervical cancer than among controls; however, the small numbers of women with HIV-2 infection in the absence of HIV-1 infection limited the power of the study to achieve a statistically significant result. An association of cervical carcinoma and HIV-2 infection has been previously noted in studies conducted in West Africa [16,35]. Although HIV-2 infection is associated with an increased likelihood of cervical HPV clearance compared with that for HIV-1 infection, after accounting for CD4 cell count, women infected with HIV-2 do not appear to be appreciably more likely to clear cervical HPV infection than those infected with HIV-1 [36].

In interpreting the results of this study, a few limitations should be noted. First, controls who were recruited in the oncology and surgical outpatient clinics may not have been representative of the general population with respect to the probability of having HIV infection; however, if the pathology that resulted in their seeking care at the clinic had been related to HIV infection, the measure of effect would be biased towards the null hypothesis of no association between HIV infection and cervical cancer. Second, women who were recruited in university hospitals may not have been representative of women with cervical cancer in the general population in terms of probability of having HIV infection; to adjust for this potential bias (Berkson bias), control participants were selected from oncology and surgical outpatient clinics of the same institutions from which the case patients were selected. Third, control-participants were on average younger and had a higher socioeconomic status than did case-participants; however, these differences were addressed in multivariate analysis, and therefore were unlikely to affect validity of results. Fourth, the few cervical cancer specimens in which high-risk HPV DNA was not identified were probably false negatives, but their number was sufficiently small that their inclusion in the case group would not have appreciably altered the conclusions of this study. 041b061a72


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