Mauck, Christine K. MD*; Weiner, Debra H. MPH†; Lai, Jaim Jou MPH†; Schwartz, Jill L. MD*
Background: Colposcopy is used to evaluate vaginal microbicides, but its link to risk of HIV is unknown. This reanalysis of 9 safety studies determined the impact of omitting colposcopy on the number of findings detected and assessed whether colposcopy was useful in identifying nonoxynol-9 (N-9) as an unsafe product in one study.
Methods: Product-related findings seen with naked eye and colposcopy or by colposcopy alone were evaluated. Using data from one study, the ratio of findings in N-9 users to those in hydroxyethylcellulose (HEC) users was compared for findings seen by naked eye and colposcopy versus findings detected only by colposcopy.
Results: Of the 403 finding observations in the 9 studies, 173 (43%) would have been missed without colposcopy. Data from the N-9/HEC study showed that without colposcopy, there would have been 7 times as many observations in the N-9 group as in the HEC group (63 vs. 9). With colposcopy, the N-9/HEC ratio was 13:9 or 1.4. Considering epithelial integrity, finding type, and size showed similar patterns, except that among the smallest findings (<5 mm), the N-9/HEC ratio was 1.2 by naked eye and nearly the same at 1.4 by colposcopy.
Conclusion: Colposcopy was not helpful in identifying an unsafe product: the conclusions reached using naked eye examination alone were more alarming regarding the safety of N-9 than reached by including colposcopy. Recommendations include: (1) naked eye examinations should be continued in microbicide studies; (2) colposcopy may be considered for early studies, such as first-in-human studies, but has no place in large studies; and (3) colposcopy should be replaced as soon as possible with a more objective validated biomarker of HIV risk.
Colposcopy has long been used in the evaluation of cervical neoplasia. Since the early 1990s, a modified colposcopy procedure has also been used for the evaluation of the cervicovaginal epithelium during assessment of new vaginal products, particularly those intended to prevent HIV. In 1995, the World Health Organization convened a meeting of colposcopy experts to standardize the procedure and nomenclature used to capture changes in the cervicovaginal epithelium that could, at least in theory, indicate possible damage from new vaginal products. An outcome of the meeting was the Manual for the Standardization of Colposcopy for the Evaluation of Vaginally Administered Products. This manual has been updated twice: once in 2000 and again in 2004, each time after a meeting of experts convened by CONRAD/World Health Organization to discuss and refine the procedure. The current version, Manual for the Standardization of Colposcopy for the Evaluation of Vaginally Administered Products, Update 2004,1 includes a detailed description of the procedure, terminology for findings, photographs to help ensure consistency in terminology, and a sample data collection form.
The rationale for this effort is that epithelial disruption, even if small, could represent a portal of entry for HIV or other sexually transmitted infection pathogens, and that inflammation (erythema/edema) or disruption of blood vessels (petechiae/ecchymoses), even if small, could represent recruitment of HIV target cells. It seems logical that if the epithelium could be studied under magnification rather than just with the naked eye, more findings would be detected, irrespective of their clinical significance.
This use of colposcopy has not been without controversy. The procedure is costly, requires specialized equipment and training, and adds time to the examination, data collection, and analysis. The evaluation is somewhat subjective and dependent on level of examiner's effort. Reproducibility among examinations and among examiners has been questioned. Most importantly, a link between colposcopic findings and an increased risk of HIV/sexually transmitted infection acquisition has not been demonstrated, making it difficult to meaningfully interpret results.
A study by Ballagh et al published in 2004 attempted to address some of these criticisms.2 The investigators conducted 5 paired observations on each of 14 women who did not have any gynecological conditions or colposcopic findings at screening that required follow-up or treatment. The study did not require use of any vaginal product, and there were no restrictions on vaginal activity. The investigators found that colposcopy, in and of itself, did not induce changes in the epithelium (it had been suspected that the procedure could induce findings through, for example, drying or stretching of the vagina). On average, colposcopy added about 7 minutes to the examination time. Without colposcopy, that is, using naked eye examination alone, 34 of 77 (44%) findings would have been missed. This would have included 4 of 7 (57%) deep epithelial disruptions, the type of finding of greatest concern for HIV transmission.3 Using naked eye examination as a screening tool for colposcopy—that is, performing colposcopy only on participants with findings on naked eye examination, which has been proposed as a way to reduce the time and cost of colposcopy—would have resulted in only 11% fewer colposcopy examinations because almost all participants had at least 1 finding on naked eye examination.
The utility of colposcopy for evaluating candidate vaginal products was questioned again in December 2009 at a meeting convened by the National Institute of Allergy and Infectious Diseases/Division of AIDS, entitled Best Practices for Phase I Assessment of Microbicide Safety. As a result, we undertook a secondary analysis of 9 studies for which we had data indicating whether a given finding was seen by both colposcopy and naked eye examination or only by colposcopy.4
MATERIALS AND METHODS
Table 1 shows the 9 studies. Each enrolled between 12 and 120 women who used investigational vaginal gels with or without cervical barriers. Most subjects in these studies used their product daily for about 2 weeks, but in one crossover study, each product was used only once (study A) and in another study the product was used for 6 months (study E). Colposcopy was performed at between 2 and 6 scheduled visits in each study. Eight clinical sites conducted these studies, with the understanding and consent of the participants and after approval of the responsible ethical committees.
Data for the present analysis consisted of all product-related findings from the 9 studies. Because our interest is the conclusions one would draw from each examination, each visit was treated as a “snapshot” of an independent event, meaning that a given finding was counted more than once if it was observed at more than one visit. They are thus referred to as “finding observations.”
Study I was particularly useful in evaluating the significance of colposcopic findings.13 Subjects had been randomized to 1 of 3 products comprising a range of anticipated vaginal effects: (1) nonoxynol-9 (N-9), a product that has been shown in a phase III trial to be associated with an increased risk of HIV if used frequently3 and therefore more likely to show damage; (2) the hydroxyethylcellulose (HEC) placebo,7 which has been shown to be safe in phase III trials,14,15 and therefore not expected to show damage; and (3) cellulose sulfate, which was expected to show results in between these 2. Women not at risk for HIV were randomly assigned (20 per group) to use one of these products twice daily for 13½ days, for a total of 27 doses. The women were examined by naked eye examination and colposcopy at baseline, midway through dosing, 8 to 18 hours after the last dose, and again 58 to 66 hours after the last dose.
Number of Findings That May Have Been Missed Without Colposcopy
Of the 403 finding observations seen in the 9 studies, 173 (43%) would have been missed if colposcopy had not been performed, a figure very similar to the 44% as reported by Ballagh et al. Of the 12 deep epithelial disruptions, 2 (17%) would have been missed. As expected, small findings (<5 mm) were most likely to be missed without colposcopy (65%), compared with only 36% of findings 5 to 10 mm and 18% of findings >10 mm.
Implications of Findings Missed Without Colposcopy
Although knowing how many findings would have been missed without colposcopy is important, it is also relevant to know the significance of these findings and whether naked eye examination might be sufficient. To investigate this, we focused on study I, specifically the data from the N-9 and HEC arms. Ten women in the N-9 group and 11 women in the HEC group provided a total of 94 product-related finding observations to the analysis. Of these, 76 (83%) were in the N-9 group and 18 (17%) were in the HEC group (Table 2). (Very similar results were obtained in a separate analysis that included baseline findings, iatrogenic findings, and findings not felt to be product-related for other reasons [5, 3, and 7 in the N-9 group, respectively and 6, 3, and 1 in the HEC group, respectively]). Of the 76 N-9 finding observations, 63 were seen with the naked eye and colposcope and 13 were seen only with the colposcope. Of the 18 HEC finding observations, 9 were seen with the naked eye and colposcope and 9 only with the colposcope. Had the examination been done by naked eye alone, that is, without colposcopy, it would have appeared that there were 7 times as many finding observations in the N-9 group as in the HEC group (63 vs. 9). By colposcopy, the ratio of finding observations in the N-9 and HEC groups was 13:9 or 1.4.
Given our analysis method—each finding being counted each time it was observed—colposcopy findings that persist are counted more than once. If a product, such as N-9, induced a type of finding that was both (a) more likely to be observed by naked eye and (b) more likely to persist, there could have been some inflation of results in that group. We evaluated this by looking only at the first day on which each finding was observed and found very little difference in results compared with those using all days of observation: the N-9:HEC ratio for naked eye findings was 43:7 or 6.1 and for colposcopy only was 10:8 or 1.2.
Breaking the 94 finding observations down by epithelial integrity and type of finding (Table 2) shows similar patterns: a higher ratio of N-9 to HEC via naked eye examination compared with colposcopy alone. The only exception to this is petechiae/ecchymoses for which the ratios are 1.3 and 2.7, respectively, probably because by definition petechiae are small, <3 mm, and therefore more likely to be seen only by colposcopy.
Table 2 shows finding observations broken down by size. All of the largest findings (defined as those >10 mm) were observable without the colposcope. All but one of these large findings was in the N-9 group. The medium-sized findings (5–10 mm) showed an N-9:HEC ratio of 4.2 and 1.5 for naked eye examination and colposcopy alone, respectively. The smallest findings, those <5 mm and most likely to be detected by colposcopy were, in fact, more often seen by colposcopy: 10 of 15 in the N-9 group required a colposcope to be seen as did 7 of 11 in the HEC group. However, the ratio of N-9 to HEC was 1.2 by naked eye and nearly the same at 1.4 by colposcopy.
It is clear that omitting colposcopy from the evaluation of new vaginal products will result in fewer findings being observed. However, for colposcopy to provide added value in distinguishing potentially unsafe candidate vaginal products from safer ones, it needs to reveal “red flags” about products that would otherwise appear safe by naked eye examination alone.
In the reanalysis of study I presented here, the conclusions reached using naked eye examination alone would have been much more alarming with regard to the relative safety of N-9 versus HEC than the conclusions reached by including colposcopy. This was true when all findings were taken together, when findings were broken down by type (with the exception of petechiae/ecchymoses) and even when findings were broken down by size: colposcopy did not provide any clear warning about N-9 above that provided by the naked eye.
In conclusion, colposcopy is expensive, its clinical significance and predictive value are not known, and in one small study of N-9 versus HEC placebo, it did not help distinguish the products. The naked eye examination clearly distinguished the unsafe product from the safe one, whereas colposcopy did not, and, in fact, colposcopy made the products look more similar than naked eye examination.
Recommendations include the following: (1) naked eye examinations should be continued in all microbicide studies; (2) colposcopy may be considered for early studies, such as first-in-human studies but has no place in large studies; and (3) colposcopy should be replaced as soon as possible with a more objective, validated biomarker of HIV risk that can be used to help triage products.
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