Impact of Cryotherapy vs Loop Electrosurgical Excision Procedure (LEEP) on Recurrence of Cervical Intraepithelial Neoplasia and HIV Cervical Shedding among HIV-positive Women

The Challenge
HIV-infected women are disproportionately affected by human papillomavirus (HPV) related diseases including cervical cancer. Cervical cancer prevention depends on early diagnosis, treatment, and continued clinical follow-up. However, there are no standardized guidelines on the optimal methods to treat cervical pre-cancerous disease among HIV-infected women.

Project Goals
Together with the Coptic Hope Center for Infectious Diseases, the TREE team had the unique opportunity to implement a cervical cancer screening and treatment program to help address the gap in treatment guidelines for HIV-infected women with cervical cancer. Globally, common treatment modalities for cervical intraepithelial neoplasia (CIN) include loop electrosurgical excision procedure (LEEP) and cryotherapy. LEEP is the standard of care for treatment of CIN in the United States and Europe, and cryotherapy is commonly used in resource-limited settings with a single-visit see-and-treat approach. These treatments have been tested in HIV-uninfected women, but the treatment complications and efficacy have not been rigorously compared to each other in an HIV-infected cohort.

Our Approach
TREE implemented a randomized controlled trial at the Coptic Hope Center to compare cryotherapy vs. loop electrosurgical excision procedure (LEEP) on the recurrence of pre-cancerous lesions among 400 HIV-infected women with histologically confirmed high grade cervical lesions. We also examined the effect of cervical treatment on HIV shedding from the cervix. Cryotherapy and LEEP remove pre-cancerous lesions but they also damage the cervix in the process, which may lead to increased HIV shedding. To examine the level of HIV after cervical treatment, the TREE team collected and analyzed cervical HIV-1 RNA and DNA.

This study was led by Dr. Michael Chung and conducted in collaboration with Dr. Nelly Mugo of the Kenya Medical Research Institute (KEMRI), Dr. Hugo DeVuyst of the International Agency of Research on Cancer (IARC), Drs. Grace John-Stewart, Barbra Richardson, and Christine McGrath, of the UW Department of Global Health, and Dr. Sharon Greene of the Centers for Disease Control and Prevention.


1. Greene SA, De Vuyst H, John-Stewart GC, McGrath CJ, Marson KG, Trinh TT, Yatich N, Kiptinness C, Cagle A, Nyongesa Malava E, Sakr SR, Mugo NR, Chung MH. Effectiveness of Cryotherapy versus Loop Electrosurgical Excision Procedure Among HIV-Infected Women: A Randomized Controlled Trial. 2019. JAMA. Oct 22;322(16):1570-1579. doi: 10.1001/jama.2019.14969. [original work]

2. Perez-Guzman PN, Chung MH, Vuyst H, Dalaer S, Mutai KK, Muthoni K, Kigen B, Kilonzo N, Hallett TB, Smit M. The Impact of Scaling Up Cervical Cancer Screening and Treatment Services Among Women Living with HIV in Kenya: A Modelling Study. 2020. BMJ Global Health. In Press. [original work]

3. Vodicka E, Zimmerman MR, Kosgei RJ, Lee F, Mugo NR, Okech TC, Sakr SR, Stergachis A, Chung MH, Garrison LP, Babigumira JB. Estimating the Costs of HIV Clinic Integrated versus Non-integrated Treatment of Pre-Cancerous Cervical Lesions and Costs of Cervical Cancer Treatment in Kenya. 2019. PLoS One. Jun 6;14(6):e0217331. doi: 10.1371/journal.pone.0217331. [original work]


Research Title: 
Cervical Cancer Screening and Treatment Among HIV-infected Women