Awareness and knowledge of human papillomavirus (HPV) infection among high-risk men of Hispanic origin attending a sexually transmitted infection (STI) clinic

Background

Genital Human papilloma virus (HPV) is one of the most commonly diagnosed Sexually Transmitted Infection (STIs) in men and women. Knowledge about HPV infection among men is limited. This study aims to determine correlates of adequate knowledge of HPV infection among men who attend an STI clinic in Puerto Rico.

Methods

A cross-sectional study of 206 men was conducted at an STI clinic in San Juan, PR. Adequate knowledge was defined as a score of at least 70% of correct responses among those men who reported having ever heard of HPV. Variables that achieved statistical significance in the bivariate analysis (p<0.05) were included in the multivariate logistic regression model.

Results

Although 52.5% of men reported having heard of HPV infection before the survey, only 29.3% of this sub-group had an adequate knowledge of HPV. Most men did not know that HPV is a risk factor for anal (38.7%), penile (50.0%) and oral (72.6%) cancer. Factors associated with adequate knowledge of HPV in age-adjusted models were being men who have sex with men (MSM) (OR=2.6;95%CI=1.1-6.1), self-report of genital warts (OR=3.2;95%CI=1.3-7.9) and herpes (OR=7.4;95% CI=2.2-25.1). MSM was marginally associated with adequate knowledge (OR=2.3;95% CI=0.9-5.9) and self-report of herpes remained significantly associated (OR=5.0;95%CI=1.3-18.4) in multivariate logistic regression analysis.

Conclusions

Awareness and knowledge of HPV was very low in this group of men. Interventions to increase knowledge and awareness in this group are necessary to promote preventive practices for HPV-related cancers in high-risk groups.

Updating the natural history of human papillomavirus and anogenital cancers

This chapter addresses the natural history of anogenital human papillomavirus (HPV) infection. Cervical infections are the best understood HPV infection. Cervical HPV persistence is the known necessary event for the development of cervical cancer. New infections appearing at any age are benign unless they persist. Several long-term natural history studies have now shed light on the very low risk of cervical intraepithelial neoplasia (CIN) 3+ in women past the peak of HPV acquisition (e.g., 30 or older) who are HPV-negative or clear their HPV. Although data on transmission of HPV are finally emerging, rates of transmission between heterosexual couples vary widely among studies. Factors that affect the calculations of these rates include a) intervals between testing points, b) rates of concordance or discordance at baseline, and c) difficulty in defining established infections versus contamination. Both cervix to anus and anus to cervix autoinoculation in the same woman appears to be quite common. Whether either site serves as a long-term reservoir is unknown. Studies show that anal infections in women and in men who have sex with men are quite common with cumulative rates up to 70-90%. Similarly, clearance of anal HPV is also common, with few individuals showing persistence unless they are human immunodeficiency virus (HIV)-infected. HIV strongly influences the development of anal intraepithelial neoplasia (AIN). The few studies on the natural history of AIN in HIV-infected men suggest that high-grade AIN is a precursor to invasive anal cancer. Although no natural history studies of AIN are available in women, women with other HPV-associated lesions, including CIN3+ and vulvar cancer, have higher rates of anal cancer. Data on the natural history of HPV of the male genitalia are also emerging, although penile intraepithelial neoplasia is poorly understood. Cumulative rates of HPV are extremely high in men and risks are associated with sexual behavior. Unlike women, prevalence rates are steady across all ages, suggesting that men do not develop protection against reinfection. This article forms part of a special supplement entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.

EUROGIN 2011 roadmap on prevention and treatment of HPV-related disease

The EUROGIN 2011 roadmap reviews the current burden of human papillomavirus (HPV)-related morbidity, as well as the evidence and potential practice recommendations regarding primary and secondary prevention and treatment of cancers and other disease associated with HPV infection. HPV infection causes ~600,000 cases of cancer of the cervix, vulva, vagina, anus and oropharynx annually, as well as benign diseases such as genital warts and recurrent respiratory papillomatosis. Whereas the incidence of cervical cancer has been decreasing over recent decades, the incidence of anal and oropharyngeal carcinoma, for which there are no effective screening programs, has been rising over the last couple of decades. Randomized trials have demonstrated improved efficacy of HPV-based compared to cytology-based cervical cancer screening. Defining the best algorithms to triage HPV-positive women, age ranges and screening intervals are priorities for pooled analyses and further research, whereas feasibility questions can be addressed through screening programs. HPV vaccination will reduce the burden of cervical precancer and probably also of invasive cervical and other HPV-related disease in women. Recent trials demonstrated that prophylactic vaccination also protects against anogenital HPV infection, anogenital intraepithelial lesions and warts associated with vaccine types, in males; and anal HPV infection and anal intraepithelial neoplasia in MSM. HPV-related oropharyngeal cancer could be treated less aggressively because of better survival compared to cancers of the oropharynx unrelated to HPV. Key findings in the field of cervical cancer prevention should now be translated in cost-effective strategies, following an organized approach integrating primary and secondary prevention, according to scientific evidence but adapted to the local situation with particular attention to regions with the highest burden of disease.

EUROGIN 2011 roadmap on prevention and treatment of HPV-related disease

The EUROGIN 2011 roadmap reviews the current burden of human papillomavirus (HPV)-related morbidity, as well as the evidence and potential practice recommendations regarding primary and secondary prevention and treatment of cancers and other disease associated with HPV infection. HPV infection causes ~600,000 cases of cancer of the cervix, vulva, vagina, anus and oropharynx annually, as well as benign diseases such as genital warts and recurrent respiratory papillomatosis. Whereas the incidence of cervical cancer has been decreasing over recent decades, the incidence of anal and oropharyngeal carcinoma, for which there are no effective screening programs, has been rising over the last couple of decades. Randomized trials have demonstrated improved efficacy of HPV-based compared to cytology-based cervical cancer screening. Defining the best algorithms to triage HPV-positive women, age ranges and screening intervals are priorities for pooled analyses and further research, whereas feasibility questions can be addressed through screening programs. HPV vaccination will reduce the burden of cervical precancer and probably also of invasive cervical and other HPV-related disease in women. Recent trials demonstrated that prophylactic vaccination also protects against anogenital HPV infection, anogenital intraepithelial lesions and warts associated with vaccine types, in males; and anal HPV infection and anal intraepithelial neoplasia in MSM. HPV-related oropharyngeal cancer could be treated less aggressively because of better survival compared to cancers of the oropharynx unrelated to HPV. Key findings in the field of cervical cancer prevention should now be translated in cost-effective strategies, following an organized approach integrating primary and secondary prevention, according to scientific evidence but adapted to the local situation with particular attention to regions with the highest burden of disease.

Anal human papillomavirus infection in a street-based sample of drug using HIV-positive men

HIV facilitates an increase in human papillomavirus (HPV)-associated conditions. HIV-positive men living in a substance use context in Los Angeles, USA, were recruited using respondent-driven sampling, completed a questionnaire and had biological samples including an anal HPV swab taken. A total of 316 evaluable men were enrolled in the study. The prevalence of any HPV, high-risk (HR) infection and multiple-type infection was highest for men who have sex with men (MSM) (93.9%, 64.6% and 29.7%, respectively). When any HPV and HR-HPV prevalence in all men was stratified by age, the youngest group had 100% and 68.2% prevalence, respectively, with similarly high rates maintained up to age 49 years. The individual's use of alcohol, marijuana, cocaine, methamphetamine or heroin was not significantly associated with anal HPV detection. In this marginalized population, high prevalence rates of anal HPV and HR-HPV occurring over a wide age range may increase the individual's risk for anal dysplasia and anal cancer.

Cervical human papillomavirus infection among young women engaged in sex work in Phnom Penh, Cambodia: prevalence, genotypes, risk factors and association with HIV infection

Background

Although cervical cancer is the leading cancer in Cambodia, most women receive no routine screening for cervical cancer and few treatment options exist. Moreover, nothing is known regarding the prevalence of cervical HPV or the genotypes present among women in the country. Young sexually active women, especially those with multiple sex partners are at highest risk of HPV infection. We examine the prevalence and genotypes of cervical HPV, as well as the associated risk factors among young women engaged in sex work in Phnom Penh, Cambodia.

Methods

We conducted a cross-sectional study among 220 young women (15–29 years) engaged in sex work in different venues including brothels or entertainment establishments, and on a freelance basis in streets, parks and private apartments. Cervical specimens were collected using standard cytobrush technique. HPV DNA was tested for by polymerase chain reaction (PCR) and genotyping using type-specific probes for 29 individual HPV types, as well as for a mixture of 10 less common HPV types. All participants were also screened for HIV status using blood samples. Multivariate logistic regression analyses were conducted to assess risk factors for any or multiple HPV infection.

Results

The prevalence of cervical HPV 41.1%. HPV 51 and 70 were the most common (5.0%), followed by 16 (4.6%), 71 (4.1%) and 81 (3.7%). Thirty-six women (16.4%) were infected with multiple genotypes and 23.3% were infected with at least one oncogenic HPV type. In multivariate analyses, having HIV infection and a higher number of sexual partners were associated with cervical HPV infection. Risk factors for infection with multiple genotypes included working as freelance female sex workers (FSW) or in brothels, recent binge use of drugs, high number of sexual partners, and HIV infection.

Conclusions

This is the first Cambodian study on cervical HPV prevalence and genotypes. We found that HPV infection was common among young FSW, especially among women infected with HIV. These results underscore the urgent need for accessible cervical cancer screening and treatment, as well as for a prophylactic vaccine that covers the HPV subtypes present in Cambodia.

Phase II trials of cetuximab (CX) plus cisplatin (CDDP), 5-fluorouracil (5-FU) and radiation (RT) in immunocompetent (ECOG 3205) and HIV-positive (AMC045) patients with squamous cell carcinoma of the anal canal (SCAC): Safety and preliminary efficacy results

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Background: Epidermal growth factor receptor (EGFR) expression and HPV infection are common in SCAC. We therefore initiated 2 phase II studies to evaluate the safety and efficacy of the EGFR inhibitor CX given concurrently with CDDP/5-FU/RT in HIV-positive (AMC045) and immunocompetent (E3205) patients with SCAC. Methods: All patients received CX (400 mg/m2 loading, then 250 mg/m2/wk IV x 6-8 wks) plus CDDP (75 mg/m2 IV q28 days x 2) and 5-FU (1000 mg/m2/day IV infusion days 1-4 q 28 days x 2) concurrently with RT (45-54 Gy) beginning with CX dose 2. Patients in E3205 also received 2 cycles of CDDP/5-FU alone prior to CX/CDDP/5-FU/RT; this was discontinued on recommendation of the NCI Anorectal Task Force after 28 patients. Both trials were powered to detect a reduction in 3-year local-regional failure (LRF) rate from 35% to 17.5% (alpha=0.10, beta=0.10), the primary end point. Other endpoints included progression free survival (PFS) and overall survival (OS). The results below include complete toxicity and preliminary efficacy data (including only the first 28 patients from E3205). Results: Expedited reporting was required for type I (any grade 5, grade 4 cardiac) or II (grade 4 RT skin, diarrhea) adverse events, with prespecified rates of >5% or >20%, respectively defined as unacceptable. Early stopping rules were not invoked for either trial. LRF rates data will be presented after more detailed case review is completed. Conclusions: CX plus CDDP/5-FU/RT is feasible in patients with SCAC, including patients with HIV infection. Preliminary safety and efficacy data appear encouraging, but accrual without neoadjuvant CDDP/5-FU continues in E3205, and additional followup of both study cohorts is required in order to determine whether pre-specified efficacy endpoints were met. [Table: see text]

Abstract A77: Impact of cancer status on survival of persons living with AIDS in Puerto Rico

Background: HPV is associated to cancer of the cervix, anus, vulva, vagina, penis, oral cavity and oro-pharynx. Studies in Puerto Rico (PR) and in the United States (US) have documented that HPV infection and HPV-related cancers are higher in persons living with HIV/AIDS (PLHA) than in the general population. After 30 years of the HIV/AIDS epidemic, cancer research in the HIV/AIDS population is highly warranted. However, in PR, a minority population with a disproportionate burden of HIV/AIDS as compared to the US, data on the burden of HPV-related cancers among HIV/AIDS patients is still limited. Primary aim: This study estimated the hazard ratio of death among PLHA in PR, by sex, age at AIDS diagnosis and cancer status.

Methods: A total of 29,535 (96%) of all the AIDS cases reported to the PR AIDS Surveillance system between 1985 and 2005, aged ≥15 years, were eligible for analysis. The PR AIDS Surveillance and PR Central Cancer Registry databases were linked using Link Plus v.2.0 software. Invasive cancers were coded according to the ICD-O3 and analyzed using the SEER programs. Only invasive cancer cases that was developed &gt; 3 months after AIDS diagnosis were considered. Survival by age at AIDS diagnosis, sex and cancer status (no cancer, HPV-related cancer, non-HPV related cancer) was estimated using Kaplan-Meier method, and survival curves were compared using the Long-Rank test. A Cox-proportional hazards model was used to estimate the hazard ratio of death with 95% CI. Confounding and interaction assessment was performed in this model. In addition, the proportional hazards assumption was tested. The STATA System release 11.0 (STATA Corp, College Station, TX, USA) was used for the statistical analysis.

Results: Women (median: 39 months, 95% CI: 35–42) had a longer observed survival than men (median: 21 months, 95% CI: 20–22) (p&lt;0.001). Median survival time differed by cancer status, being high among persons who did not developed cancer (median: 25 months, 95% CI: 24–26), than among those with HPV-related (median: 16 months, 95% CI: 11–26) and non-HPV related cancers (median: 7 months, 95% CI: 6–9) (p&lt;0.001). Among males, the hazard ratio of death was higher among those with non-HPV related cancers (HR: 1.62, 95% CI: 1.46–1.79) and those with HPV-related cancers (HR: 1.22, 95% CI: 0.85–1.76), after adjusting for age at AIDS diagnosis. Among women, a higher risk of death was only observed for those with non-HPV related cancers (HR: 1.97, 95% CI: 1.53–2.54) as compared to those without cancer.

Conclusions: As expected, our study provides evidence of decreased survival of PLHA patients who develop cancer, as compared to those who do not develop any malignancies. This supports the important of strengthening cancer screening as well as behavioral and clinical interventions in this population, in order to have an impact on disease survival, and potentially in the quality of life of PLHA populations in PR.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A77.

Abstract SY32-01: Human papillomavirus vaccines in females and males

Like cervical cancer, a high proportion of anal cancers are associated with human papillomavirus (HPV) infection, particularly HPV 16. Anal cancer is more common in women than men in the general population. While it is an uncommon cancer, the incidence of anal cancer in the general population is increasing by 2% per year among both men and women. Certain risk groups, such as men who have sex with men (MSM) and individuals immunocompromised by HIV infection or other causes, are at substantially higher risk of anal cancer than the general population, with reported incidences exceeding 100/100,000 in some studies.

The incidence of cervical cancer in the developed world has declined substantially in the last few decades with the advent of routine cervical cytology screening to identify women with the cervical cancer precursor lesion, high-grade cervical intraepithelial neoplasia (CIN), followed by removal of the CIN lesions prior to progression to cancer. The natural history of anal cancer appears to be similar to that of cervical cancer, with high-grade anal intraepithelial neoplasia (HGAIN) being the precursor lesion to anal cancer. Unlike screening and treatment of high-grade CIN, however, there is no routine screening for and treatment of HGAIN in high-risk populations to prevent anal cancer. Consequently, there are few options currently available to prevent anal cancer.

In addition to screening for and treatment of HGAIN, one such option would be to prevent anal HPV infection and HPV-associated anal diseases through prophylactic HPV vaccination. Since 2006, two highly effective HPV vaccines (bivalent, protecting against HPV 16 and 18) and quadrivalent (protecting against HPV 6, 11, 16 and 18) have been available to women to prevent infection with vaccine types and CIN/cervical cancer due to these types. To determine the safety and efficacy of HPV vaccination in males, and to determine its efficacy to prevent anogenital infection and HPV-associated disease of the anus and external genital region (penis, scrotum, perianal region), a randomized, placebo-controlled, double-blind trial of the quadrivalent vaccine (the Merck 020 protocol) was performed. The protocol included 3,463 heterosexual men and 602 MSM aged 16-26 years enrolled from 18 countries. Participants were eligible if they had at least one but no more than 5 lifetime sexual partners. MSM were excluded from participation if they were HIV-positive at baseline, but continued to participate in the study if they acquired HIV after vaccination.

Efficacy against HPV 6/11/16/18-associated external genital lesions (EGL) in the in the per protocol efficacy (PPE) population was 90.4% [95% CI: 69.2, 98.1]. Efficacy against HPV 6/11/16/18-related EGL in the intent to treat (ITT) population was 65.5% (95% CI: 45.8, 78.6). Almost all of the EGL were condyloma acuminatum. Efficacy against HPV 6/11/16/18-related persistent infection was 85.6% (97.5% CI: 73.4, 92.9) in the PPE population and 47.8% (95% CI: 36.0, 57.6) in the ITT population. Overall the vaccine was well tolerated, with no vaccine-related serious adverse events. Injection-site pain occurred significantly more frequently among those receiving the quadrivalent vaccine vs placebo (57% vs. 51%; p&lt;0.001).

To determine the efficacy of the quadrivalent vaccine against anal HPV infection and anal HPV-associated disease including HGAIN, the 602 MSM included in the study of EGL prevention were also studied for AIN prevention. In addition to the study procedures performed as part of the EGL study, the MSM underwent testing for anal HPV infection using anal swabs and AIN using high-resolution anoscopy-guided biopsies of lesions in the anal canal.

Among these MSM, the observed efficacy against HPV 6/11/16/18-related AIN (all grades combined including anal condyloma) in the PPE and ITT populations was 77.5% (95% CI: 39.6, 93.3) and 50.3% (95% CI: 25.7, 67.2), respectively. HGAIN specifically was reduced by 74.9% (95% CI: 8.8, 95.4) and 54.2% (95% CI: 18.0, 75.3) in the PPE and ITT populations. Persistent anal HPV 6/11/16/18 infection was reduced by 94.9% (95% CI: 80.4, 99.4) and 59.4% (95% CI: 43.0, 71.4) in the PPE and ITT populations, respectively.

Based on EGL data from the Merck 020 protocol, the quadrivalent vaccine was approved by the U.S. Food and Drug Administration (FDA) in 2009 for use in boys and men aged 9-26 years for prevention of genital warts. The Advisory Committee on Immunization Practices (ACIP) issued a permissive recommendation for the use of vaccine in males, with coverage under the Vaccines for Children program for eligible males up to the age of 18 years. The anal data were not available at the time of the FDA and ACIP review, but were reviewed by the FDA in December, 2010, which then approved the quadrivalent vaccine for prevention of AIN and anal cancer in both men and women.

Since HIV-seropositive individuals are at especially high risk of HPV-associated anogenital cancers, several studies have been done to determine safety and immunogenicity prior to studying vaccine efficacy. Currently HPV vaccination is not contraindicated in HIV-seropositive individuals, but efficacy may be limited among those with a high degree of prior exposure to vaccine HPV types due to extensive pre-vaccination sexual activity. A study of HIV-seropositive children (PACTG 1047) and older HIV-seropositive adult MSM (AIDS Malignancy Consortium) 052) both showed that the vaccine was safe and did not perturb CD4+ levels or HIV viral loads. Among individuals naïve to a given vaccine HPV type, almost all seroconverted. Efficacy studies are expected to being shortly among HIV-seropositive MSM.

In summary, anal cancer is a growing problem in the general population and especially among certain risk groups such as MSM and HIV-seropositive individuals, even among those who are well controlled on antiretroviral therapy. In the absence of routine screening programs to identify and treat HGAIN to reduce the risk of anal cancer, vaccination against HPV offers a promising long-term approach to reduction of anal cancer, as well as other male HPV-related lesions such as external genital and anal condyloma.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr SY32-01. doi:10.1158/1538-7445.AM2011-SY32-01

Burden of human papillomavirus infection and related comorbidities in men: implications for research, disease prevention and health promotion among Hispanic men

Genital human papillomavirus (HPV) infection is one of the most commonly diagnosed sexually transmitted infections world-wide. Over the last two decades, research has established a strong causal link between specific types of HPV infection and cancer, particularly cervical, anal, vulvar/vaginal, penile, and oropharyngeal cancer. Limited epidemiological studies of anogenital HPV infection have been conducted in Hispanic populations (including Puerto Rico), and population-based incidence and prevalence estimates of HPV infection among Hispanics are limited. Studies that evaluate knowledge and awareness of HPV among men are also scarce. With the world-wide introduction of two new prophylactic vaccines against high-risk HPVs causing cervical cancer, and the recent FDA approval of the quadrivalent vaccine in preventing genital warts in men, there is an urgency to determine the burden of HPV in Hispanic populations before vaccine programs are implemented on a widespread basis. Knowledge and acceptability of the vaccine prior to implementation of these programs are also necessary to allow a targeted assessment. This review article summarizes existing research on HPV infection and HPV-related morbidities in men, with a particular emphasis on Hispanic men in the United States and Puerto Rico. Three major areas are discussed: (1) genital warts, (2) HPV and related cancers and (3) biobehavioral and psychosocial factors related to HPV infection and vaccination. Specific recommendations for advancing HPV research and knowledge among Hispanic populations also are suggested.

Detection and quantitation of HPV in genital and oral tissues and fluids by real time PCR

BACKGROUND

Human papillomaviruses (HPVs) remain a serious world health problem due to their association with anogenital/oral cancers and warts. While over 100 HPV types have been identified, a subset is associated with malignancy. HPV16 and 18 are the most prevalent oncogenic types, while HPV6 and 11 are most commonly responsible for anogenital warts. While other quantitative PCR (qPCR) assays detect oncogenic HPV, there is no single tube assay distinguishing the most frequent oncogenic types and the most common types found in warts.

RESULTS

A Sybr Green-based qPCR assay was developed utilizing degenerate primers to the highly conserved HPV E1 theoretically detecting any HPV type. A single tube multiplex qPCR assay was also developed using type-specific primer pairs and TaqMan probes that allowed for detection and quantitation of HPV6,11,16,18. Each HPV type was detected over a range from 2 x 10(1) to 2 x 10(6)copies/reaction providing a reliable method of quantitating type-specific HPV in 140 anogenital/cutaneous/oral benign and malignant specimens. 35 oncogenic and low risk alpha genus HPV types were detected. Concordance was detected in previously typed specimens. Comparisons to the gold standard detected an overall sensitivity of 89% (95% CI: 77% - 96%) and specificity of 90% (95%CI: 52% - 98%).

CONCLUSION

There was good agreement between the ability of the qPCR assays described here to identify HPV types in malignancies previously typed using standard methods. These novel qPCR assays will allow rapid detection and quantitation of HPVs to assess their role in viral pathogenesis.

Prevalence, distribution and correlates of endocervical human papillomavirus types in Brazilian women

We determined the prevalence, distribution and correlates of human papillomavirus (HPV) types in 386 mixed-income, sexually active women in São Paulo, Brazil. Endocervical samples were tested for HPV DNA with L1 primers MY09 and MY11; negative and indeterminate samples were retested using GP 5+/6+ consensus primers. HPV was detected in 35% of all women; high-risk/probable high-risk types in 20%; low-risk types in 7%; and an indeterminate type in 10%. Twenty-five HPV types were found overall: 17 (probable) high-risk types and eight low-risk types. Approximately one-third (29%) of women with HPV infection were positive for type 16 or 18 and 36% were positive for types 6, 11, 16 or 18. The presence of (probable) high-risk HPV was associated with younger age, more lifetime sex partners and abnormal vaginal flora. Additional studies mapping the distribution of HPV types worldwide are necessary to prepare for vaccination programmes and direct future vaccine development.

Human papillomavirus-related disease in people with HIV

PURPOSE OF REVIEW

The incidence of human papillomavirus (HPV)-related cancers has increased among people with HIV infection compared with the general population. This review will describe recent findings in HPV-associated cancer incidence since the introduction of antiretroviral therapy, HPV/disease prevalence at sites other than cervix and anus, and recent data on screening and treatment of anal intraepithelial neoplasia.

RECENT FINDINGS

Consistent with high prevalence of anogenital HPV infection, new data on cervical intraepithelial neoplasia and anal intraepithelial neoplasia in HIV-positive men and women show that the incidence of cervical cancer has not declined since the introduction of antiretroviral therapy and that the incidence of anal cancer is rising. Several studies also highlight high rates of HPV infection and HPV-associated disease at sites other than the cervix and anus, including the penis and the mouth. Treatment methods for anal intraepithelial neoplasia have been described and show reasonable efficacy.

SUMMARY

New data imply that the problem of HPV-related cancers will not decline among HIV-positive men and women in the antiretroviral therapy era, highlighting the need to perform studies to determine if screening and treatment of anal intraepithelial neoplasia will prevent development of anal cancer. Recent data show progress in both these areas.

Factors associated with increased prevalence of human papillomavirus infection in a cohort of HIV-infected Brazilian women

OBJECTIVES

Human papillomavirus (HPV) infection is a major risk factor for cervical disease. Using baseline data from the HIV-infected cohort of Evandro Chagas Clinical Research Institute at Fiocruz, Rio de Janeiro, Brazil, factors associated with an increased prevalence of HPV were assessed.

METHODS

Samples from 634 HIV-infected women were tested for the presence of HPV infection using hybrid capture II and polymerase chain reaction. Prevalence ratios (PR) were estimated using Poisson regression analysis with robust variance.

RESULTS

The overall prevalence of HPV infection was 48%, of which 94% were infected with a high-risk HPV. In multivariate analysis, factors independently associated with infection with high-risk HPV type were: younger age (<30 years of age; PR 1.5, 95% confidence interval (CI) 1.1-2.1), current or prior drug use (PR 1.3, 95% CI 1.0-1.6), self-reported history of HPV infection (PR 1.2, 95% CI 0.96-1.6), condom use in the last sexual intercourse (PR 1.3, 95% CI 1.1-1.7), and nadir CD4+ T-cell count <100cells/mm(3) (PR 1.6, 95% CI 1.2-2.1).

CONCLUSIONS

The estimated prevalence of high-risk HPV-infection among HIV-infected women from Rio de Janeiro, Brazil, was high. Close monitoring of HPV-related effects is warranted in all HIV-infected women, in particular those of younger age and advanced immunosuppression.

Human papillomavirus infection in HIV-infected persons

Rates of cervical and anal human papillomavirus (HPV) infection and abnormal cytology are high in HIV-infected women, as are rates of anal HPV infection and abnormal cytology in HIV-infected men who have sex with men (MSM). Available evidence indicates that the incidence of anal cancer in HIV-infected MSM has increased in association with prolonged life expectancy achieved with antiretroviral therapy. Routine screening for cervical neoplasia is recommended for HIV-infected women. Routine screening is not yet universally recommended for anal neoplasia, although it should be considered for at-risk patients, particularly given recent improvements in local treatments. A preventive vaccine against cervical HPV infection is approved for use in young women before onset of sexual activity and acquisition of HPV infection. Its potential benefit in preventing anal infection in women and men has yet to be determined, and its potential utility in those with HIV infection remains unknown. This article summarizes a presentation on HPV infection in HIV-infected patients made by Joel Palefsky, MD, at an International AIDS Society-USA Continuing Medical Education course in Chicago in May 2007. The original presentation is available as a Webcast at www.iasusa.org.

Relationship of Pregnancy to Human Papillomavirus Among Human Immunodeficiency Virus–Infected Women

OBJECTIVE

Because parity is a reported risk factor for cervical cancer, we sought to estimate the effects of pregnancy on the prevalence, incident detection, and copy number of human papillomavirus (HPV) among human immunodeficiency virus (HIV)-infected women, patients at high risk for cervical cancer.

METHODS

Human immunodeficiency virus-infected women who had a pregnancy in the Women's Interagency HIV Study (n = 178) and the Women and Infants Transmission Study (n = 450) underwent serial type-specific HPV DNA testing using MY09/MY11 polymerase chain reaction. During pregnancy and during the prepregnancy and postpregnancy periods, we assessed HPV prevalence, incident detection, and HPV copy number (estimated using hybridization signal strength) of both oncogenic and nononcogenic HPV. All binary-regression analyses incorporated generalized estimating equations to address the repeated observations of the same women over time, and were further adjusted for parity, gestational age, smoking, antiretroviral use, number of lifetime sexual partners, and oral contraceptive use.

RESULTS

The prevalence and copy number of oncogenic and nononcogenic HPV did not significantly differ between pregnancy and either the prepregnancy or postpregnancy periods. Incident HPV detection was significantly lower for both oncogenic and nononcogenic HPV during pregnancy compared with the postpregnancy period (relative risk 0.534, 95% confidence interval 0.390-0.732, P < .001 and relative risk 0.577, 95% confidence interval 0.428-0.779, P < .001, respectively), but not compared with the prepregnancy period

CONCLUSION

Among HIV-infected women, the incident detection of HPV is lower during pregnancy compared with postpregnancy, while prevalence and copy number do no differ between pregnancy and either prepregnancy or postpregnancy.

LEVEL OF EVIDENCE

II-3.

Human papillomavirus-related tumors in HIV

PURPOSE OF REVIEW

Human papillomavirus-related anogenital cancers are theoretically preventable. Many HIV-infected women do not undergo routine cervical cytology screening, however, and there are currently no routine anal cytology screening programs. This review focuses on recent developments that may impact on the future incidence of these cancers: the effect of highly active antiretroviral therapy and the imminent approval of vaccines to prevent initial human papillomavirus infection.

RECENT FINDINGS

Highly active antiretroviral therapy has limited benefit to reduce the incidence of cervical intraepithelial neoplasia 3 and no benefit to reduce the incidence of anal intraepithelial neoplasia 3. Consistent with these findings, there has been no reduction in the incidence of cervical and anal cancer since the introduction of highly active antiretroviral therapy. More encouraging is the development of highly effective preventive human papillomavirus vaccines that are projected to reduce the incidence of cervical cancer by up to 70% among vaccinated women.

SUMMARY

HIV-positive men and women remain at risk for human papillomavirus-associated cancers, even in the highly active antiretroviral therapy era. Conversely, the incidence of anogenital cancers may decline in the future among HIV-positive individuals if they received the human papillomavirus vaccine before they acquired HIV infection, and studies should be done to assess the safety and efficacy of the vaccines in individuals already infected with HIV.

Serological detection of human papillomavirus type 16 infection in human immunodeficiency virus (HIV)-positive and high-risk HIV-negative women

Serial measurement of antibodies has not been used to provide evidence of active viral replication of human papillomavirus (HPV). Serum specimens from sequential study visits contributed by 642 human immunodeficiency virus (HIV)-positive and 116 HIV-negative participants enrolled in the Women's Interagency HIV Study were used to detect significant rises in HPV type 16 (HPV-16) antibody levels. Factors associated with a significant rise were identified using multivariable logistic regression models with generalized estimating equations. Among HIV-positive women, 8.3% of 1,997 pairs showed antibody rises, compared to 6.1% of 361 pairs among HIV-negative women (P = 0.191). For HIV-positive women, rises were associated with current (odds ratio [OR], 23.4; P < 0.001) or past (OR, 8.9; P < 0.001) HPV-16 infection relative to never being HPV-16 infected and with CD4+ cell counts (OR per 100-cell increase, 0.8; P < 0.001) but not with sexual behavior. For HIV-negative women, rises were associated with past (OR, 10.9; P = 0.033) HPV-16 infection relative to no HPV-16, current cigarette smoking (OR, 5.0; P = 0.029) relative to no smoking history, and having 6 to 10 lifetime sexual partners compared to 0 to 5 partners (OR, 9.9; P = 0.036). Serial measurement of HPV-16 serum antibodies is a useful tool for identifying active HPV-16 viral replication. Rises among HIV-positive women may more often result from reactivation of a latent HPV infection in the context of HIV-induced immunosuppression, while rises among HIV-negative women may more often result from reinfection with HPV.

Biology of HPV in HIV infection

HIV-positive men and women are at increased risk of anogenital and oral HPV infection. The risks for HPV-associated high-grade intra-epithelial neoplasia (IN) and cancer are also increased. The prevalence of oral, anal, and cervical HPV infection in HIV-positive individuals compared with HIV-negative individuals increases with progressively lower CD4+ levels, as does incident high-grade IN. In contrast to IN, development of cancer is not related to lower CD4+ level. With increasing grades of IN and cancer, the proportion of tissues with copy-number abnormalities (CNA) increases, with one of the most common genetic changes being amplification of chromosome 3q. The presence of CNA is associated with the integration of HPV DNA into the host genome, with loss of HPV E2 and/or E2 rearrangement. This suggests a link between CNA and increased HPV-induced chromosomal instability mediated through de-repressed E6 and E7 expression consequent to loss of functional E2 protein. In addition, epigenetic changes occur with increasing frequency in high-grade IN and cancer, such as hypermethylation leading to down-regulation of potential tumor suppressor genes. Analysis of these data together suggests that immune suppression plays a more prominent role in the earlier stages of HPV-associated disease, up to and including incident high-grade IN. Persistent high-grade IN and development of cancer may be more strongly related to the cumulative effect of HPV-associated genetic instability and the resulting host genetic changes. There are few data to suggest a direct role for HIV in the pathogenesis of HPV-associated neoplasia, but HIV-associated attenuation of HPV-specific immune responses may allow for persistence of high-grade IN and sufficient time for accumulation of genetic changes that are important in progression to cancer.