Effect of HIV infection on the natural history of anal human papillomavirus infection

Natural history of human papillomavirus infections involving anal, penile, and oral sites among HIV-positive men

AIM

The aim of this study was to characterize the natural history of human papillomavirus (HPV) infection at anal canal, penile, and oral sites in HIV-positive men based on their sexual behavior.

METHODS

This is a single-center, prospective cohort study. The prevalence, clearance, and incidence of HPV infection at anal, penile, and oral sites were studied in HIV-positive men who have sex with men (MSM) and heterosexual individuals using multiplex polymerase chain reaction. Risk factors associated with HPV infection were analyzed.

RESULTS

In total, 733 patients (538 MSM, 195 heterosexual) were included in the study between 2005 and 2009. The prevalence, clearance, and incidence of HPV infection were 73%, 30%, and 36% at anal site; 26%, 56%, and 17% at penile site; and 16%, 44%, and 11% at oral site, respectively. At anal site, MSM had a higher HPV prevalence (84% vs. 42%; odds ratio,7.3; 95% confidence interval [CI], 5.2-10.6) mainly for multiple (≥3) HPV types, higher incidence rate (324 vs. 92 new HPV-infected person per 1000 person-years [hazard ratio, 8.1; 95% CI, 3.8-17.3]), and a lower clearance rate (125 vs. 184 cleared HPV-infected person per 1000 person-years [hazard ratio, 0.5; 95% CI, 0.3-0.9]) than did heterosexuals. Similar prevalence, clearance, and incidence rates of penile and oral HPV infection were found between groups. The most common high-risk HPV type for the 3 body sites studied was the HPV-16. Finally, a similar proportion of heterosexuals (7%) and MSM (6%) presented concurrent HPV infections (anal-penile-oral sites). History of anal warts was associated with higher HPV prevalence in the 3 body parts.

CONCLUSIONS

Although MSM presented the highest risk of anal HPV infection, heterosexual men also showed a remarkable prevalence of anal HPV infection and a comparable risk to MSM for penile and oral HPV infection. Taking into account all these results, the careful inspection of the anal canal, penile, and oral sites should at least be routine in each clinic visit of HIV-infected men independently of their sexual behavior.

Risk factors for anal human papillomavirus infection type 16 among HIV-positive men who have sex with men in San Francisco

BACKGROUND

HIV-positive men who have sex with men (MSM) are at high risk of anal cancer compared with the general population. Human papillomavirus (HPV) infection, particularly HPV 16, is causally associated with anal cancer. However, the risk factors for anal HPV 16 infection are poorly understood. We determined the prevalence and risk factors for anal HPV 16 infection in a population of HIV-positive MSM, most of whom were being treated with antiretroviral therapy.

DESIGN

Cross-sectional data from the baseline visit of a 4-year prospective cohort study.

METHODS

Three hundred forty-eight HIV-positive MSM were recruited in San Francisco, and they received a detailed sexual behavior risk factor questionnaire. An anal swab was used to collect specimens for HPV type-specific DNA testing using L1 HPV DNA polymerase chain reaction. We used log-binomial multivariable models to determine the risk factors for anal HPV 16 infection.

RESULTS

Ninety-two percent of HIV-positive MSM had at least 1 anal HPV type, 80% had at least 1 oncogenic HPV type, and 42% had HPV 16. Non-Hispanic white race and higher level of education were associated with a decreased risk of HPV 16 infection. A higher number of total male partners was associated with HPV 16 (relative risk: 1.6, 95% confidence interval 1.1 to 2.4, P = 0.01) for 201-1000 partners compared with 1-200. Injection drug use was independently associated with anal HPV 16 infection (relative risk: 1.5, 95% confidence interval 1.2 to 1.9, P = 0.003).

CONCLUSIONS

The prevalence of anal HPV infection, including HPV 16, is high in HIV-positive MSM. HIV-positive MSM should be counseled about the risk associated with increased partners and injection drug use.

High prevalence and incidence of high-grade anal intraepithelial neoplasia among young Thai men who have sex with men with and without HIV

BACKGROUND

Men who have sex with men (MSM) are at elevated risk of having anal cancer. However, the prevalence and incidence among MSM of high-grade anal intraepithelial neoplasia (HGAIN), the putative precursor of anal cancer, is understudied, particularly in Asians.

METHODS

A total of 123 HIV-positive and 123 HIV-negative MSM were enrolled at the Thai Red Cross AIDS Research Centre in Bangkok, Thailand, and followed for 12 months. Anal sample collection for human papillomavirus (HPV) genotyping and high-resolution anoscopy (HRA) with biopsies were performed at every visit.

RESULTS

Mean age at enrollment was 28.9 years. HIV-positive MSM were more commonly infected with high-risk HPV types in the anus than HIV-negative MSM (57.5 vs. 36.6%; P  =  0.001). The prevalence of HGAIN was 18.9% in HIV-positive and 11.4% in HIV-negative MSM (P  = 0.1). The incidence of HGAIN at 12 months was 29% in HIV-positive and 8% in HIV-negative MSM (P  =  0.001). The hazard ratios for incident HGAIN in multivariate models were 5.16 [95% confidence interval (CI) 1.89-14.08, P  < 0.001] in MSM with persistent HPV 16 and/or 18 infection and 2.62 (95% CI 1.04-6.61, P  =  0.042) in HIV-positive MSM.

CONCLUSIONS

Approximately one-third of HIV-positive MSM developed incident HGAIN within 12 months. Given the relative increased prevalence of HIV among MSM worldwide, local HGAIN data are needed to guide practitioners, policy makers, and communities in planning for strategies to screen for and treat HGAIN in this population.

Feasibility of incorporating self-collected rectal swabs into a community venue-based survey to measure the prevalence of HPV infection in men who have sex with men

BACKGROUND

Inclusion of self-collected rectal swabs (SCRS) into existing community venue-based HIV surveillance systems for men who have sex with men (MSM) may provide a feasible method for monitoring human papillomavirus (HPV) vaccine-related outcomes in this population. We measured the prevalence of HPV and anal dysplasia through incorporating SCRS into ManCount, the Vancouver site of the M-Track HIV surveillance system.

METHODS

Participating MSM were provided with a self-collection kit for collection on-site or at a follow-up venue. Swabs were subject to polymerase chain reaction amplification for HPV detection, and cytology slides were reviewed for anal dysplasia. Factors associated with participation were identified through multivariate logistic regression.

RESULTS

Of 766 men completing ManCount, 268 (35%) agreed to participate, self-collecting 252 specimens (247 on-site). Of 239 complete specimens, 33.5% did not have detectable β-globin; in the remainder (159 specimens) the prevalence of HPV infection was 62.3% (23.3% HPV type 16 or 18; 38.4% HPV type 6, 11, 16, or 18). In the 62.3% (149) of specimens adequate for cytology, the prevalence of anal dysplasia was 42.3% (HSIL 11.4%, LSIL 18.8%, ASC-US 6.7%, ASC-H 5.4%). Participation was associated with venue type, availability of on-site collection, and other characteristics.

CONCLUSIONS

SCRS can be feasibly integrated within existing community venue-based HIV surveillance systems for MSM, and may be a suitable method for monitoring the impact of HPV vaccination in this population. However, participation may be influenced by venue type and availability of on-site collection, and adequacy of SCRS specimens may be lower in community venues as compared with clinical settings.

Epidemiology, natural history and risk factors for anal intraepithelial neoplasia

Studies conducted in HIV-seropositive individuals have enhanced our understanding of the natural history of anal intraepithelial neoplasia (AIN) and of factors predictive of progression to high-grade AIN, the immediate precursor to anal cancer. AIN is frequently detected in HIV-seropositive individuals. Factors that increase the risk for AIN include HIV infection, low current or nadir blood CD4+ cell counts, receptive anal intercourse, oncogenic human papillomavirus (HPV) infection, persistent anal HPV infection, multiple HPV type infections and high anal HPV viral load. This review confirms the importance of high-grade AIN in HIV-seropositive individuals and HIV-seronegative men having sex with men.

High prevalence of anal human papillomavirus infection and associated risky behaviors in men infected with human immunodeficiency virus in Taiwan

A cross-sectional study was conducted to investigate the prevalence, types, and risk factors associated with anal HPV infection among HIV-infected men in outpatient clinics at an AIDS designated hospital in Taiwan. Anal swabs were collect and PCR (polymerase chain reaction) was used to analyze the types of anal HPV infection. HPV DNA was detected in 74.2% of the 198 participants, including high-risk types (40.4%), low-risk types (18.2%) and multiple-types (6%). The most common types were HPV 16 (13.1%), 6 (10.4%), 11 (7.1%) and 18 (6.1%). The significant risk factor for being infected with any type or a high-risk type of HPV was having sexual partners (>3) in the preceding 6 months. Low-risk type of anal HPV infection was associated with a history of anal lesions. Our findings support the need for regular follow-up of all HIV/HPV coinfected patients and their partners to allow early detection of anal intraepithelial neoplasia.

Lack of regression of anal squamous intraepithelial lesions despite immune restoration under cART

BACKGROUND

A high prevalence of anal squamous intraepithelial lesions (ASIL) and human papillomavirus (HPV) infections were observed in HIV-infected men who have sex with men (MSM) in the precART (combined antiretroviral therapy) era. The impact of cART on the natural history of HPV infection and ASIL is poorly documented.

METHODS

Ninety-four HIV-infected MSM naive of cART were enrolled in a longitudinal study before starting cART. Patients were evaluated for anal cytology, histology and anal HPV DNA at baseline, month 12 and month 24 of cART. HPV DNA genotyping was performed by Linear Array assay. Anal cytologic samples were processed by the Thin Prep method.

RESULTS

Analyses included 76 patients with at least two visits with available cytology. The median age was 39.4 years. The median (interquartile range) CD4 cell count was 301 cells/μl (242-339) at baseline and 545 cells/μl at month 24, when 93% of patients had plasma HIV-RNA 50 copies/ml or less. An abnormal result was observed in 45 of 76 patients at baseline (59%) with prevalent low-grade squamous intraepithelial lesion (LSIL) in 27 patients (36%) and high-grade squamous intraepithelial lesion (HSIL) in seven patients (9%) and in 36 of 69 patients assessed at month 24 (52%) with LSIL in 23 patients (33%) and HSIL in six patients (9%). At month 24, regression of the severity of lesions was observed in 44% of patients, whereas a lesion occurred in 37% of patients.

CONCLUSION

Our results show a high prevalence and incidence of ASIL in HIV-infected MSM despite immune restoration under cART. These data emphasize that HIV-positive MSM although receiving effective cART remain at high risk of anal squamous intra-epithelial lesions.

The role of human papillomavirus in nongenital cancers

Human papillomavirus (HPV), one of the most common sexually transmitted diseases worldwide, has an established role in the pathogenesis of genital malignancies such as cervical cancer. The virus has also been implicated in the oncogenesis of nongenital cancers including head and neck malignancies (specifically oropharyngeal cancers) as well as anal cancer. There is less clarity regarding its role in lung and esophageal cancers. Worldwide, the incidence and prevalence of HPV-associated oropharyngeal cancer has been increasing over time. These patients have improved outcomes compared with those with HPV-negative oropharyngeal cancers, and there is continued interest in designing treatments specifically for this HPV-positive subgroup. Clinicians continue to gain an understanding of HPV in anal cancers and the risk factors associated with infection and progression to malignancy. This has potential implications for the eventual screening of high-risk groups. While HPV vaccination is currently approved for the prevention of cervical cancer, it also has potential in the prevention of all HPV-associated malignancies. In this review, current understanding of the role of HPV in nongenital cancers is discussed, as well as future implications for treatment and prevention.

Association of immune status with recurrent anal condylomata in human immunodeficiency virus-positive patients

Purpose

An anal condyloma is a proliferative disease of the genital epithelium caused by the human papillomavirus. This condition is most commonly seen in male homosexuals and is frequently recurrent. Some reports have suggested that immunosuppression is a risk factor for recurrence of a condyloma. Thus, we investigated the risk factors for a recurrent anal condyloma in human immunodeficiency virus (HIV)-positive patients.

Methods

We retrospectively analyzed 85 consecutive patients who were diagnosed with and underwent surgery for an anal condyloma from January 2007 to December 2011. Outcomes were analyzed based clinical and immunologic data.

Results

Recurrent anal condylomata were found in 25 patients (29.4%). Ten cases (40.0%) were within postoperative 3 months. At postoperative 6 months, the CD4 lymphocyte count in the recurrent group was lower than it was in the nonrecurrent group (P = 0.023).

Conclusion

CD4-mediated immunosuppression is a risk factor for recurrent anal condylomata in HIV-positive patients.

The prevalence of anal human papillomavirus among young HIV negative men who have sex with men

Men who have sex with men (MSM) especially those who are HIV positive are at risk for HPV-associated anal cancer. We systematically reviewed studies with data on the prevalence of vaccine preventable anal HPV among men who have sex with men aged 25 or younger and identified 6 studies. None of these studies were specifically designed to determine the prevalence of HPV in this population. Available data, albeit limited, suggest many young MSM may not already be HPV infected. Further studies using representative sampling focused on teenage MSM are required to confirm this.

Anal human papillomavirus infection and associated neoplastic lesions in men who have sex with men: a systematic review and meta-analysis

BACKGROUND

Men who have sex with men (MSM) are at greatly increased risk of human papillomavirus (HPV)-associated anal cancer. Screening for the presumed cancer precursor, high-grade anal intraepithelial neoplasia (AIN), followed by treatment in a manner analogous to cervical screening, has been proposed. We aimed to assess available data for anal HPV disease that can inform pre-cancer screening programmes.

METHODS

We searched PubMed, OVID Medline, and Embase for all studies published before Nov 1, 2011, that reported prevalence and incidence of anal HPV detection, AIN, and anal cancer in MSM. We calculated summary estimates using random-effects meta-analysis.

FINDINGS

53 studies met the inclusion criteria, including 31 estimates of HPV prevalence, 19 estimates of cytological abnormalities, eight estimates of histological abnormalities, and nine estimates of anal cancer incidence. Data for incident HPV and high-grade AIN were scarce. In HIV-positive men, the pooled prevalence of anal HPV-16 was 35·4% (95% CI 32·9-37·9). In the only published estimate, incidence of anal HPV-16 was 13·0% (9·6-17·6), and clearance occurred in 14·6% (10·2-21·2) of men per year. The pooled prevalence of histological high-grade AIN was 29·1% (22·8-35·4) with incidences of 8·5% (6·9-10·4) and 15·4% (11·8-19·8) per year in two estimates. The pooled anal cancer incidence was 45·9 per 100,000 men (31·2-60·3). In HIV-negative men, the pooled prevalence of anal HPV-16 was 12·5% (9·8-15·4). Incidence of HPV-16 was 11·8% (9·2-14·9) and 5·8% (1·9-13·5) of men per year in two estimates. The pooled prevalence of histological high-grade AIN was 21·5% (13·7-29·3), with incidence of 3·3% (2·2-4·7) and 6·0% (4·2-8·1) per year in two estimates. Anal cancer incidence was 5·1 per 100,000 men (0-11·5; based on two estimates). There were no published estimates of high-grade AIN regression.

INTERPRETATION

Anal HPV and anal cancer precursors were very common in MSM. However, on the basis of restricted data, rates of progression to cancer seem to be substantially lower than they are for cervical pre-cancerous lesions. Large, good-quality prospective studies are needed to inform the development of anal cancer screening guidelines for MSM.

FUNDING

Australian Government Department of Health and Ageing.

The epidemiology and natural history of anal human papillomavirus infection in men who have sex with men

Studies on the epidemiology and natural history of anal human papillomavirus (HPV) infection are essential to understand the significance of this virus in the aetiology of anal cancer in men who have sex with men (MSM). This paper presents a review of studies on anal HPV in MSM. For this review, a Medline search was performed to identify English-language articles published in peer-reviewed journals on the epidemiology, natural history and risk factors for anal HPV infection in MSM. Anal HPV prevalence is high in MSM and infection with multiple HPV types is common. The available prospective data suggest detection of new anal HPV infections may also be common. However, with limited epidemiological data available on infection dynamics and associated behavioural risk factors, it is difficult to draw conclusions on how persistent anal HPV infection is in this population.

Six-month incidence, persistence, and factors associated with persistence of anal human papillomavirus in men: the HPV in men study

BACKGROUND

Although there are limited numbers of incidence and persistence estimates for anal human papillomavirus (HPV) in women and in men who have sex with men (MSM), there are no such reports for men who have sex with women (MSW).

METHODS

Genotyping was performed on anal samples from men, aged 18-70, from São Paulo, Brazil; Cuernavaca, Mexico; and Tampa, Florida, who provided specimens at enrollment and the 6-month visit of a 4-year prospective study. Eligibility included no history of genital warts or human immunodeficiency virus. A total of 954 MSW and 156 MSM provided evaluable specimens at both visits. Persistence was defined as type-specific infection at each visit.

RESULTS

Incident anal infection was common among both MSM and MSW but generally higher for MSM for HPV groups and specific genotypes. A total of 5.1% of MSM and 0.0% of MSW had a persistent HPV-16 infection at the 6-month visit. Cigarette smoking among MSM and age among MSW were associated with persistent infection with any HPV genotype.

CONCLUSIONS

Although anal HPV infection is commonly acquired by both MSW and MSM, incident events and persistence occurred more often among MSM. Cigarette smoking is a modifiable risk factor that may contribute to HPV persistence among MSM.

FoxP3 overexpression and CD1a+ and CD3+ depletion in anal tissue as possible mechanisms for increased risk of human papillomavirus-related anal carcinoma in HIV infection

AIM

We analysed local cellular and humoral immunity factors in the anal mucosa in an attempt to explain how HIV infection increases the risk of anal cancer in HPV-infected patients.

METHOD

HIV-positive cases and matched HIV-negative controls with more than one recurrence of condylomas were included in a prospective study following treatment of the initial lesions. Patients were followed every 3 to 6 months for the development of anal intraepithelial neoplasia (AIN3) and cancer for up to 60 months. Tissue CD1a(+), CD3(+), CD4(+), CD8(+) cells and mRNAs of selected cytokines and chemokines were quantified and compared in patients with or without AIN3 or cancer using morphometric or immunohistochemistry analysis and qRT-PCR.

RESULTS

Sixty-six individuals (22 patients and 44 controls) were included. In the case group, CD1a(+) and CD3(+) cell counts were significantly lower in biopsies from AIN3 and cancer specimens compared with those from AIN 1-2 or normal biopsies (P < 0.0001). A CD1a(+) count of < 10/mm was predictive of AIN3 and cancer (Odds ratio = 9.4, 95% CI: 5.4-18.3, P < 0.0001). IL-8 and IL23 levels were significantly higher in cancer than in non-cancer tissues regardless of HIV status (P = 0.02). FoxP3 expression was significantly higher in HIV-infected cases than in controls with AIN3/cancer (P < 0.04).

CONCLUSION

Depletion of CD1a(+) and CD3(+) cells and overexpression of FoxP3 in the anal mucosa appear likely to contribute to the risk of HPV-related anal cancer in HIV-infected patients. Furthermore, overexpression of IL-8 and IL-23 in the anal mucosa might be responsible for the development of this cancer regardless of HIV status.

Increases in human papillomavirus detection during early HIV infection among women in Zimbabwe

BACKGROUND

Individuals who acquire human immunodeficiency virus (HIV) may experience an immediate disruption of genital tract immunity, altering the ability to mount a local and effective immune response. This study examined the impact of early HIV infection on new detection of human papillomavirus (HPV).

METHODS

One hundred fifty-five Zimbabwean women with observation periods before and after HIV acquisition and 486 HIV-uninfected women were selected from a cohort study evaluating hormonal contraceptive use and risk of HIV acquisition. Study visits occurred at 3-month intervals. Cervical swab samples available from up to 6 months before, at, and up to 6 months after the visit when HIV was first detected were typed for 37 HPV genotypes or subtypes.

RESULTS

We observed ∼5-fold higher odds of multiple (≥2) new HPV detections only after HIV acquisition, relative to HIV-negative women after adjusting for sexual behavior and concurrent genital tract infections. We also observed ∼2.5-fold higher odds of single new HPV detections at visits before and after HIV acquisition, relative to HIV-uninfected women in multivariable models.

CONCLUSIONS

These findings suggest that HIV infection has an immediate impact on genital tract immunity, as evidenced by the high risk of multiple new HPV detections immediately after HIV acquisition.

Age-specific prevalence of human papillomavirus infection in males: a global review

PURPOSE

Global data on age-specific prevalence of human papillomavirus (HPV) infection in males, especially for oncogenic HPV types 16 and 18, are essential for future efforts to prevent HPV-related diseases, including expanded access to HPV prophylactic vaccines for boys and young men.

METHODS

A systematic review of peer-reviewed publications was conducted to summarize worldwide data on genital HPV-DNA prevalence in men. Studies using polymerase chain reaction or hybrid capture detection assays were included.

RESULTS

Approximately 6,600 abstracts were identified. Of them, 64 reported age-specific HPV prevalence and were included in the review. Of these, 38 were from populations at high risk of HPV infections, such as sexually transmitted infection clinic attendees, human immunodeficiency virus-positive males, and male partners of women with HPV infection or abnormal cytology. The largest proportions of studies were from Europe (38%) and North America (25%), with smaller proportions from Central and South America (19%), Asia (11%), and Africa (5%). Across all regions, data on HPV prevalence were generally limited to men >18 years of age. HPV prevalence was high among sexually active men in all regions but with considerable variation, from 1% to 84% among low-risk men and from 2% to 93% among high-risk men. Peak HPV prevalence spanned a wide range of ages and was generally not concentrated in the younger age groups. Age-specific prevalence curves were relatively flat or declined only slightly following peak prevalence.

CONCLUSIONS

Genital HPV infection in men varies widely, both between and within high- and low-risk groups and by geographic region. Compared with that in women, HPV prevalence in men seems to peak at slightly older ages and remains constant or decreases slightly with increasing age, suggesting persistent HPV infection or a higher rate of reinfection.

Anal and oral human papillomavirus (HPV) infection in HIV-infected subjects in northern Italy: a longitudinal cohort study among men who have sex with men

Background

A study including 166 subjects was performed to investigate the frequency and persistence over a 6-month interval of concurrent oral and anal Human Papillomavirus (HPV) infections in Human Immunodeficiency Virus (HIV)-infected men who have sex with men (MSM).

Methods

Patients with no previously documented HPV-related anogenital lesion/disease were recruited to participate in a longitudinal study. Polymerase chain reaction (PCR) was performed to detect HPV from oral and anal swabs and to detect Human Herpes Virus 8 (HHV-8) DNA in saliva on 2 separate specimen series, one collected at baseline and the other collected 6 months later. A multivariate logistic analysis was performed using anal HPV infection as the dependent variable versus a set of covariates: age, HIV plasma viral load, CD4+ count, hepatitis B virus (HBV) serology, hepatitis C virus (HCV) serology, syphilis serology and HHV-8 viral shedding. A stepwise elimination of covariates with a p-value > 0.1 was performed.

Results

The overall prevalence of HPV did not vary significantly between the baseline and the follow-up, either in the oral (20.1 and 21.3%, respectively) or the anal specimens (88.6 and 86.3%). The prevalence of high-risk (HR) genotypes among the HPV-positive specimens was similar in the oral and anal infections (mean values 24.3% and 20.9%). Among 68 patients with either a HR, low-risk (LR) or undetermined genotype at baseline, 75% had persistent HPV and the persistence rates were 71.4% in HR infections and 76.7% in LR infections. There was a lack of genotype concordance between oral and anal HPV samples. The prevalence of HR HPV in anus appeared to be higher in the younger patients, peaking (> 25%) in the 43-50 years age group. A decrease of the high level of anal prevalence of all genotypes of HPV in the patients > 50 years was evident. HHV-8 oral shedding was positively related to HPV anal infection (p = 0.0046). A significant correlation was found between the persistence of HHV-8 shedding and HIV viral load by logistic bivariate analysis (Odds Ratio of HHV-8 persistence for 1-log increase of HIV viral load = 1.725 ± 0.397, p = 0.018).

Conclusions

A high prevalence of HPV infection was found in our cohort of HIV-infected MSM, with a negative correlation between anal HPV infection and CD4 cell count.

Persistence and clearance of HPV from the penis of men infected and non-infected with HIV

Due to high rates of human papillomavirus (HPV) infection, the incidence of intraepithelial neoplasia and anal cancer, most studies concerning HPV in men seropositive for HIV have focused on the anal canal. Few studies have targeted the penile region in HIV-infected men. A total of 72 men seropositive for HIV and 72 men seronegative for HIV were followed-up for 6 months, and their penile exfoliated cells were tested for HPV DNA. There were no significant differences between the HIV-positive and HIV-negative men in persistence (respectively, 69.5% vs. 66.9%), clearance (respectively, 15.3% vs. 23.1%), and those men never infected with HPV during the four follow-up visits (15.2% for HIV-positive vs. 20% for HIV-negative). High-risk HPV types were detected more frequently in penile smears from men infected with HIV, while, in HIV-seronegative men, the low-risk HPV types were more abundant (P = 0.001). Multiple infections with both high- and low-risk HPV types were significantly more frequent in HIV-seropositive compared to those who were HIV-seronegative (P = 0.0004). The attendance rates at follow-up visits were 86%, 78%, and 58% in months 1, 2, and 6, respectively, for men infected with HIV and 93%, 72%, and 60% for the HIV-negative group. It is concluded that HIV infection can be considered a risk factor for clearance and persistence of HPV. Multiple infections with different types of HPV including high-risk HPVs are frequent in men who are infected with HIV.

HAART and progression to high-grade anal intraepithelial neoplasia in men who have sex with men and are infected with HIV

BACKGROUND

Human immunodeficiency virus (HIV)-seropositive men who have sex with men (MSM) are at risk for anal intraepithelial neoplasia (AIN) and cancer. The goal of this study was to identify risk factors associated with high-grade AIN (AIN-2,3) in HIV-positive MSM, including the receipt of highly active antiretroviral therapy (HAART).

METHODS

A cohort study involving 247 HIV-seropositive MSM receiving HAART or initiating HAART was followed up every 6 months for 3 years with human papillomavirus (HPV) testing and high-resolution anoscopy to identify predictors of AIN-2,3 by Cox regression analysis and period prevalence logistic regression.

RESULTS

AIN-2,3 was observed during the study in 132 (53%) of 247 participants. The progression rate to AIN-2,3 from a lesser abnormality at baseline was 12.8 cases per 1000 person-months (95% confidence interval [CI], 9.8-16.5 cases per 1000 person-months). The risk of AIN-2,3 increased with age (odds ratio [OR], 3.09 [95% CI, 1.12-8.52] for men 40-49 years of age and 4.78 [95% CI, 1.29-17.73] for men >50 years of age, compared with men <40 years of age) and for men whose CD4+ cell counts were <50 cells/mm(3) before starting HAART (OR, 14.40 [95% CI, 1.45-143.58]). Men who had been receiving their current HAART regimen for >4 years had a marginally significant lower risk of AIN-2,3 after adjustment for HPV (OR, 0.28 [95% CI, 0.07-1.06]) compared with those treated for <4 years. Anal HPV type 16 (HPV16) or type 18 (HPV18) infections (OR, 14.18; [95% CI, 3.51-57.32]) and HPV16 and HPV18 co-infection (OR, 31.03 [ 95% CI, 5.68-169.60]) were strongly associated with progression to AIN-2,3.

CONCLUSION

HPV16 and HPV18 infections and a low nadir CD4+ cell count increase the risk of AIN-2,3. Receiving the same HAART regimen for >4 years may contribute some benefit against AIN-2,3.

Anal HPV infection in HIV-positive men who have sex with men from China

Background

Anal HPV infection, which contributes to the development of anal warts and anal cancer, is well known to be common among men who have sex with men (MSM), especially among those HIV positives. However, HIV and anal HPV co-infection among MSM has not been addressed in China.

Methods

A cross-sectional study was conducted in Beijing and Tianjin, China. Study participants were recruited using multiple methods with the collaboration of local volunteer organizations. Blood and anal swabs were collected for HIV-1 serological test and HPV genotyping.

Results

A total of 602 MSM were recruited and laboratory data were available for 578 of them (96.0%). HIV and anal HPV prevalence were 8.5% and 62.1%, respectively. And 48 MSM (8.3%) were found to be co-infected. The HPV genotypes identified most frequently were HPV06 (19.6%), HPV16 (13.0%), HPV52 (8.5%) and HPV11 (7.6%). Different modes of HPV genotypes distribution were observed with respect to HIV status. A strong dose-response relationship was found between HIV seropositivity and multiplicity of HPV genotypes (p<0.001), which is consistent with the observation that anal HPV infection was an independent predictor for HIV infection.

Conclusions

A high prevalence of HIV and anal HPV co-infection was observed in the MSM community in Beijing and Tianjin, China. Anal HPV infection was found to be independently associated with increased HIV seropositivity, which suggests the application of HPV vaccine might be a potential strategy to reduce the acquisition of HIV infection though controlling the prevalence of HPV.

Anal HPV infection in Slovenian men who have sex with men

Anal human papillomavirus (HPV) infection commonly affects men who have sex with men (MSM) and is associated with the development of anal cancer, with the highest prevalence in MSM who are positive for human immunodeficiency virus (HIV). The purpose of this study was to determine the prevalence of anal HPV infection and genotype distribution in Slovenian MSM and its correlation with behavioral patterns in order to predict the possible impact of quadrivalent HPV vaccine in this population. To our knowledge, this is the first study of prevalence and genotype distribution of anal HPV infection in MSM from any of the Eastern European countries. The study included 136 MSM who visited two outpatient offices from January 2007 through December 2008. All participants were clinically examined and tested for HIV, and anal swabs were taken for HPV testing. The results showed a high prevalence of anal HPV infection in both HIV-negative (75%) and HIV-positive (95%) MSM. Promiscuity and use of “poppers” (alkyl nitrites taken for recreational purposes through direct inhalation) were clearly associated with a higher prevalence of anal HPV infection. The four most common HPV genotypes were 6, 11, 16, and 18. The prevalence of anal HPV infection in Slovenian MSM is higher in comparison with other studies. Quadrivalent HPV vaccine could have great potential in this population.

Smoking enhances risk for new external genital warts in men

Repeat episodes of HPV-related external genital warts reflect recurring or new infections. No study before has been sufficiently powered to delineate how tobacco use, prior history of EGWs and HIV infection affect the risk for new EGWs. Behavioral, laboratory and examination data for 2,835 Multicenter AIDS Cohort Study participants examined at 21,519 semi-annual visits were evaluated. Fourteen percent (391/2835) of men reported or were diagnosed with EGWs at 3% (675/21,519) of study visits. Multivariate analyses showed smoking, prior episodes of EGWs, HIV infection and CD4+ T-lymphocyte count among the infected, each differentially influenced the risk for new EGWs.

Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis

This meta-analysis investigated human papillomavirus (HPV) prevalence in vulvar, vaginal and anal intraepithelial neoplasia (VIN, VAIN, AIN) grades 1-3 and carcinoma from 93 studies conducted in 4 continents and using PCR assays. Overall HPV prevalence was 67.8%, 85.3% and 40.4% among 90 VIN1, 1,061 VIN2/3 and 1,873 vulvar carcinomas; 100%, 90.1% and 69.9% among 107 VAIN1, 191 VAIN2/3 and 136 vaginal carcinomas; and 91.5%, 93.9% and 84.3% among 671 AIN1, 609 AIN2/3 and 955 anal carcinomas, respectively. HPV16 was found more frequently (>75%) and HPV18 less frequently (<10%) in HPV-positive vulvar, vaginal and anal carcinomas than in cervical carcinoma. HPV6 and 11 were common in VIN1 and AIN1, but not in VAIN1. HPV prevalence in vulvar carcinoma varied most by histological type (69.4% in warty-basaloid and 13.2% in keratinized type) and was also higher in women 60 years or younger and in studies carried out in North America. HPV prevalence in anal carcinoma was higher among women (90.8%) than men (74.9%), but no difference by gender emerged in North America. The majority of AIN2/3 derived from studies of HIV-positive individuals and/or men who have sex with men. Among AIN2/3, HIV infection was associated with higher HPV prevalence, more multiple-type infections and a relative under-representation of HPV16. In conclusion, approximately 40% of vulvar, 60% of vaginal and 80% of anal carcinoma may be avoided by prophylactic vaccines against HPV16/18. This proportion would be similar for the corresponding high-grade lesions of the vagina and anus, but higher for VIN2/3 (75%) than for vulvar carcinoma.

Anal intraepithelial neoplasia in a multisite study of HIV-infected and high-risk HIV-uninfected women

OBJECTIVES

To study anal intraepithelial neoplasia and its associations with anal and cervical human papillomavirus (HPV), cervical neoplasia, host immune status, and demographic and behavioral risk factors in women with and at risk for HIV infection.

DESIGN

Point-prevalence analysis nested within a prospective study of women seen at three clinical centers of the Women's Interagency HIV Study.

METHODS

In 2001-2003 participants were interviewed, received a gynecological examination, anal and cervical cytology testing and, if abnormal, colposcopy-guided or anoscopy-guided biopsy of visible lesions. Exfoliated cervical and anal specimens were assessed for HPV using PCR and type-specific HPV probing. Logistic regression analyses were performed, and odds ratios (ORs) estimated risks for anal intraepithelial neoplasia.

RESULTS

Four hundred and seventy HIV-infected and 185 HIV-uninfected women were enrolled. Low-grade anal intraepithelial neoplasia was present in 12% of HIV-infected and 5% of HIV-uninfected women. High-grade anal intraepithelial neoplasia was present in 9% of HIV-infected and 1% of HIV-uninfected women. In adjusted analyses among HIV-infected women, the risk factors for low-grade anal intraepithelial neoplasia were younger age [OR = 0.59, 95% confidence interval (CI) = 0.36-0.97], history of receptive anal intercourse (OR = 3.2, 95% CI = 1.5-6.8), anal HPV (oncogenic types only OR = 11, 95% CI = 1.2-103; oncogenic and nononcogenic types OR = 11, 95% CI = 1.3-96), and cervical HPV (oncogenic and nononcogenic types OR = 3.5, 95% CI = 1.1-11). In multivariable analyses among HIV-infected women, the only significant risk factor for high-grade anal intraepithelial neoplasia was anal HPV infection (oncogenic and nononcogenic types OR = 7.6, 95% CI = 1.5-38).

CONCLUSION

Even in the era of highly active antiviral therapy, the prevalence of anal intraepithelial neoplasia was 16% in HIV-infected women. After controlling for potential confounders, several risk factors for low-grade anal intraepithelial neoplasia differed from risk factors for high-grade anal intraepithelial neoplasia.

HIV-Infected Patients With Anal Carcinoma Who Subsequently Developed Oral Squamous Cell Carcinoma: Report of 2 Cases

We describe 2 patients who had human immunodeficiency virus (HIV) infection and who first developed human papillomavirus (HPV)-related anal squamous cell carcinoma and later, oral squamous cell carcinoma. At the time each patient developed oral cancer, they were responding well to antiretroviral therapy with undetectable viral loads. Careful screening for oral cancers may be indicated in HIV-infected patients with HPV-associated anal cancer.

Type-specific human papillomavirus-DNA load in anal infection in HIV-positive men

OBJECTIVE

To characterize anal human papillomavirus (HPV) infections in terms of genotype prevalence and type-specific DNA load in HIV-positive men.

DESIGN

HIV-positive men attending the colo-proctological clinic of a University Hospital in Rome were recruited prospectively from November 2004 to July 2007. HIV-negative outpatients attending the same clinic over the same period were used as a control group.

METHODS

Anal brushings were tested for HPV-DNA using polymerase chain reactions and direct sequencing; type-specific HPV-DNA copies were measured in most positive samples. HPV data were correlated with patient HIV status and risk factors.

RESULTS

HPV-DNA infection was detected in 81% of HIV-positive men. Almost all homosexual men were HPV-infected. The infection rate in low-risk HPV types was higher than in high-risk types. The spectrum of HPV genotypes was comparable between HIV-positive and HIV-negative men. Numbers of HPV-DNA copies varied greatly between samples but did not differ significantly between HIV-positive and HIV-negative men. In many samples, low-risk (HPV 6, 61, 70, and 74) viral loads were comparable with those of high-risk HPVs.

CONCLUSION

Type-specific HPV-DNA copies at baseline appear to be independent of patient immune status and of HPV genotype. HPV genotype risk and viral load should be further evaluated for their potential predictive role in persistence and progression.

Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions

Human papillomavirus (HPV) infection is commonly found in the genital tract of men and women with or without any clinical lesion. The association of HPV DNA with several different ano-genital cancers other than cervical has been reported for the vulva, vagina, anus and penis. HPV DNA has also been identified in head and neck cancers in the oral cavity, the oropharynx and the larynx in both sexes. In men, 80-85% of anal cancers and close to 50% of penile cancers are associated with HPV infection. In women, HPV DNA is prevalent in 36-40% vulvar cancer cases and close to 90% of vaginal cancers. There is limited data available on the natural history and HPV-related diseases in the genital tract in men, although studies are ongoing. Efficacy of HPV vaccines in the prevention of HPV infection and disease among men also remains unknown. Among HPV DNA positive ano-genital cancer cases, HPV-16 is the most frequently found followed distantly by HPV-18. In benign HPV-related diseases such as genital warts or recurrent respiratory papillomatosis HPV-6 and 11, the two most frequent non-oncogenic types, are the predominant types detected. Oncogenic types are rarely detected. In this article we summarize and review studies describing the natural history of HPV infections among men and its impact on HPV related disease in women. We summarize the evidence linking HPV in the epidemiology and etiology of cancers of the vulva, vagina, anus and oropharynx and present recent estimates of the burden of and HPV type distribution in genital warts and in cases of HPV infection of the airways.

Anal intraepithelial neoplasia and other neoplastic precursor lesions of the anal canal and perianal region

Anal cancer is rare and this helps to explain why anal pre-neoplastic conditions are poorly understood, especially with regard to their natural history and management. Anal intraepithelial neoplasia is closely linked to human papillomavirus infection and is particularly common in homosexuals and in immunosuppressed patients, especially those with HIV/AIDS. The high regression rates of low-grade anal intraepithelial neoplasia may simply reflect inconsistent pathologic reporting. Higher grades of anal intraepithelial neoplasia may remain static for long periods of time in immunocompetent patients, but those with HIV/AIDS show early and rapid malignant transformation. In general, most anal pre-neoplastic conditions are best diagnosed by biopsy and treated by surgical excision, although local recurrence is a problem. In anal Paget's disease, it is important to ascertain, at the time of diagnosis, whether it is due to a primary in-situ apocrine-type of neoplasia of the anus or if the disease is secondary to an invasive primary carcinoma of the rectum.

[Impact of prophylactic HPV vaccines on dermatology and venereology]

Prophylactic HPV L1 VLP quadrivalent and bivalent vaccines are of great importance for patients seen by dermatologists and venereologists. Both vaccines protect against HPV16- and HPV18-associated anogenital cancers, as well as cancers of the mouth, the upper respiratory tract and skin, especially of the fingers and periungual region. The quadrivalent HPV6, 11, 16, 18 vaccine also prevents anogenital warts (condylomata acuminata) which are the most common benign tumors of this body region. HPV-vaccination (Gardasil) has been approved in Germany since October 2006 for young girls between 9-16 and young women between 16-26 years of age. Many experts feel that boys and young men should also be vaccinated. Men would profit from a vaccine that protects against HPV infections, especially anogenital warts, as well as penile and anal carcinomas. In immunosuppressed organ transplant recipients and HIV-positive individuals, HPV can be widespread, chronic and often rapidly progressive to malignant tumors; thus these groups would greatly benefit from HPV immunization.

Human papillomavirus infection and disease in the HIV+ individual

HPV infection of both the genital tract and oral cavity of HIV+ men and women is increased. HPV-related pathology is also increased in the HIV+ individuals, usually with further increases seen for those HIV+ individuals with lower CD4 cell counts. Fortunately, the rates of cervical cancer and anal cancer are relatively low and not related to CD4 cell count. Treatment of the HIV+ individual with HPV-related disease is challenging and requires close long-term follow-up to prevent recurrent disease. The mechanism of how HPV and HIV interact is still not known but is more likely to be linked to immune suppression rather than a direct interaction between viruses. The newly developed HPV vaccines will likely have a significant impact on HPV-related disease in immunocompetent individuals. It remains to be seen what impact these vaccine will have on the immune depressed.

Anal cancer: current and future methodology

Despite the small number of patients affected by carcinoma of the anal canal it remains one of the most challenging cancers to treat. For although it is one of the few malignancies that may be cured with chemoradiation alone, the use of combined modality therapy may result in significant treatment-related morbidity. Novel approaches currently are underway in this select patient population and will be addressed for the purposes of this manuscript.

Human papillomavirus: the burden of infection

Vaccines for preventing human papillomavirus (HPV) infection are far along in clinical development and testing, and hold great promise for reducing HPV infections and HPV-associated disease. HPV is the most common sexually transmitted infection in the United States, affecting an estimated 75% of the U.S. population. HPV infection is highly prevalent in sexually active adolescents and young adults. Sexual activity is the most important risk factor for infection, with 64% to 82% of sexually active adolescent girls testing positive for HPV. Clinical manifestations of HPV infection include genital warts, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer, all of which cause significant morbidity and, in the case of cervical cancer, mortality. The majority of HPV-associated disease is caused by 4 HPV types: HPV 6 and 11 are responsible for low-grade genital lesions and more than 90% of genital warts, and HPV 16 and 18 both account for approximately 70% of all high-grade CIN or dysplasia and invasive cervical cancer. Although current screening methods have proven effective in reducing cervical cancer incidence and associated mortality, more than 10,000 women are diagnosed annually and 4000 U.S. women die from the disease each year.

Identification of susceptibility loci for cervical carcinoma by genome scan of affected sib-pairs

Cervical cancer is caused by a combination of environmental and genetic risk factors. Infection by oncogenic types of human papillomavirus is recognized as the major environmental risk factor and epidemiological studies indicate that host genetic factors predispose to disease development. A number of genetic susceptibility factors have been proposed, but with exception of the human leukocyte antigen CHLA, class II, have not shown consistent results among studies. We have performed the first genomewide linkage scan using 278 affected sib-pairs to identify loci involved in susceptibility to cervical cancer. A two-step qualitative non-parametric linkage analysis using 387 microsatellites with an average spacing of 10.5 cM revealed excess allelic sharing at nine regions on eight chromosomes. These regions were further analysed with 125 markers to increase the map density to 1.28 cM. Nominal significant linkage was found for three of the nine loci [9q32 (maximum lod-score, MLS) =1.95, P<0.002), 12q24 (MLS=1.25, P<0.015) and 16q24 (MLS=1.35, P<0.012)]. These three regions have previously been connected to human cancers that share characteristics with cervical carcinoma, such as esophageal cancer and Hodgkin's lymphoma. A number of candidate genes involved in defence against viral infections, immune response and tumour suppression are found in these regions. One such gene is the thymic stromal co-transporter (TSCOT). Analyses of TSCOT single nucleotide polymorphisms further strengthen the linkage to this region (MLS=2.40, P<0.001). We propose that the 9q32 region contains susceptibility locus for cervical cancer and that TSCOT is a candidate gene potentially involved in the genetic predisposition to this disease.

Molecular biology of squamous cell carcinoma of the anus

BACKGROUND

Squamous cell carcinoma of the anal canal provides a model for studying the contribution of human papillomavirus (HPV) and human immunodeficiency virus (HIV) infection to the development of neoplasia. This paper reviews the existing literature relating to the molecular biology of anal squamous cell carcinoma and proposes a theory of pathogenesis.

METHODS

A Medline literature search was performed to identify English articles on the pathogenesis of squamous cell carcinoma of the anus; further articles were obtained from the references quoted in the literature initially reviewed.

RESULTS

HPV infection and subsequent HPV DNA integration are necessary, but not sufficient, to cause cancer progression. Loss of heterozygosity at 11q23 is the most consistent genomic change observed. Loss of heterozygosity at 17p, 18q and 5q is frequently observed in tumours of HIV-negative patients, but not in those of HIV-positive patients. Current data suggest that mutations in p53, DCC and APC tumour suppressor genes contribute to the stepwise progression of anal squamous cell carcinoma in immunocompetent individuals.

CONCLUSION

In comparison with immunocompetent individuals, HIV-positive patients have persistent HPV infection in the anal canal. In this population, microsatellite instability, rather than chromosomal instability, appears to be a preferred pathway for rapid progression towards invasive carcinoma.

Genital human papillomavirus infection in men

Genital human papillomavirus (HPV) infection, globally one of the most common sexually transmitted infections, is associated with cancers, genital warts, and other epithelial lesions. Although a consistent and coherent picture of the epidemiology and pathogenesis of genital HPV infections in women has developed over the past two decades, less is known about these infections in men. Available data suggest that, as with women, most genital HPV infections in men are symptomless and unapparent, and that HPV16 is probably the most frequently detected type. In populations of similar age, the prevalence of specific HPV types is usually lower in men than in women. Whether this observation relates to lower incidence or shorter duration of infection in men than in women has not yet been determined. Seroprevalence of specific anti-HPV antibodies also seems to be lower in men than in women of similar age, a difference that might be due to lower viral load, lower incidence or duration of infection or lower antibody responses, or both, in men compared with women. Differences in sexual behaviour may also be important predictors of genital HPV infection. With the anticipated availability of prophylactic HPV vaccines in the near future, it becomes increasingly important to understand the incidence and duration of HPV infections in men to develop cost-effective approaches to prevention through a combination of immunisation and promotion of risk-reduction strategies.

Incident High-Grade Squamous Intraepithelial Lesions in Senegalese Women With and Without Human Immunodeficiency Virus Type 1 (HIV-1) and HIV-2

BACKGROUND

Women infected with human immunodeficiency virus type 1 (HIV-1) and -2 may be at higher risk of developing cervical cancer than uninfected women. We assessed the relationships among human papillomavirus (HPV) types and persistence, HIV-1 and/or HIV-2 infection, and the development of high-grade cervical squamous intraepithelial lesions (HSILs) in a prospective study.

METHODS

We studied 627 women with and without HIV-1 and/or HIV-2 infection and high-risk HPV infection in Senegal, West Africa, who were assessed every 4 months for HSIL and HPV DNA over a mean follow-up of 2.2 years. Cox regression modeling was used to assess risks associated with development of HSIL.

RESULTS

During follow-up, 71 (11%) of 627 women developed HSIL as detected by cytology. HIV-infected women with high-risk HPV types were at greatest risk for development of HSIL. In multivariable modeling, infection with oncogenic HPV types--both persistent (hazard ratio [HR] = 47.1, 95% confidence interval [CI] = 16.3 to 136) and transient (HR = 14.0, 95% CI = 3.7 to 54)--was strongly associated with HSIL risk. In univariate analyses, HIV-positive women infected with HIV-2 were less likely to develop HSIL (HR = 0.3, 95% CI = 0.1 to 0.9) than HIV-positive women infected with HIV-1. HIV-positive women with CD4+ cell counts between 200 and 500 cells per microliter (HR = 2.2, 95% CI = 0.8 to 6.3) or fewer than 200 cells per milliliter (HR = 5.5, 95% CI = 2.0 to 15.2) were at greater risk of HSIL than HIV-positive women with CD4 counts of more than 500 cells per milliliter. High plasma HIV RNA levels were associated with increased HSIL risk (HR for each order of magnitude increase in the level of plasma HIV RNA = 1.4, 95% CI = 1.1 to 1.7; P = .005). After adjustment for HPV types and persistence, however, HIV type, plasma HIV RNA level, and CD4 count were no longer statistically significantly associated with increased risk of HSIL.

CONCLUSIONS

HIV-1 and HIV-2 are associated with increased risk for development of HSIL. This risk appears to be associated primarily with increased HPV persistence that may result from immunosuppression related to HIV-1 and/or HIV-2 infection.

Natural History and Possible Reactivation of Human Papillomavirus in Human Immunodeficiency Virus–Positive Women

BACKGROUND

Little is known in human immunodeficiency virus (HIV)-positive women about how the combination of plasma HIV RNA level and CD4+ T-cell count is associated with the natural history of human papillomavirus (HPV) infection or about HPV reactivation--whether it occurs and with what frequency in HIV-positive women.

METHODS

HIV-positive (n = 1848) and -negative (n = 514) women were assessed at semiannual visits (total person-years = 5661) for cervicovaginal HPV with polymerase chain reaction assays and for squamous intraepithelial lesions (SILs) by Pap smear. We studied the prevalent detection of HPV and SILs with generalized estimating equations and the incident detection and persistence of HPV and SILs with multivariable Cox models. All statistical tests were two-sided.

RESULTS

We observed a strong interaction between the associations of CD4+ and plasma HIV RNA strata with both prevalent (P(interaction) = .002) and incident (P(interaction) = .001) detection of HPV. Indeed, the hazard ratio for incident HPV detection peaked between 4.0 and 5.0, with either a CD4+ count of less than 200 cells per mm3 or an HIV RNA level of more than 100,000 copies per mL. Although incident HPV detection in all women was associated with the number of recent sex partners (P(trend)<.001), 22% of sexually inactive HIV-positive women with a CD4+ count of less than 200 cells/mm3 also had at least one incidentally detected HPV type. The association between CD4+/HIV RNA strata and HPV persistence was statistically significantly smaller (P<.001) than for incident HPV detection. SIL prevalence, incident detection, and persistence had similar associations with CD4+/HIV RNA strata as HPV (above).

CONCLUSION

In HIV-positive women, plasma HIV RNA level and CD4+ count in combination appear to have a strong and statistically interactive association with incident detection of HPV, some of which may reflect HPV reactivation (e.g., in sexually inactive women). The more moderate association between HIV coinfection and HPV persistence could partly explain why cervical cancer rates have not reached more epidemic proportions in HIV-positive women.

Anal intraepithelial neoplasia

Background

Anal intraepithelial neoplasia (AIN) is believed to be a precursor of anal squamous cell cancer and its incidence is rising in high-risk groups, particularly those infected with the human immunodeficiency virus (HIV). The natural history of AIN is unclear and management strategies are lacking.

Methods

This review is based on a literature search (Medline and PubMed) with manual cross-referencing of all articles related to AIN.

Results and conclusions

The aetiology of AIN is intricately linked with human papilloma viruses. The pathological processes involved in the progression of AIN are becoming clearer but the natural history, particularly the rate of progression to invasive cancer, remains unknown. There is no standard management for AIN and this is mainly due to difficulties in both diagnosis and treatment. A variety of treatment options have been tried with varying success. Surgery is associated with significant recurrence, particularly in HIV-positive patients. Non surgical approaches with imiquimod, photodynamic therapy and vaccination are appealing, and further work is required. Long-term follow-up of these patients is essential until the natural history of AIN becomes clearer.

Human papillomavirus, condylomata acuminata, and anal neoplasia

Genital human papillomavirus (HPV) infection is an increasingly common sexually transmitted disease. This virus causes condylomata acuminata and is associated with anal neoplasia. Management options are discussed.

Human papillomavirus infection and disease in HIV-infected individuals

The possibility of increases in both oral and anogenital pathologic conditions due to human papillomavirus (HPV) in patients infected with the human immunodeficiency virus (HIV) is of concern and is the focus of numerous current research studies. HIV-infected women are at higher risk for cervical HPV detection, for infection with high-oncogenic-risk types of HPV, for persistent HPV infection, for cervical cytologic abnormalities, and for cervical intraepithelial neoplasms. HIV-infected men are at increased risk for anal HPV infection, for anal infection with high oncogenic-risk types of HPV, for persistent anal HPV infection, and for anal intraepithelial defects. Recent studies have shown an increased risk of oral warts in HIV-infected individuals despite treatment with highly active antiretroviral therapy (HAART). Oral HPV infection rates have not declined since the initiation of HAART, and evidence suggests that the rates may have actually increased in white HIV-infected males.

Anal carcinoma: incidence and effect of cumulative infections

INTRODUCTION

Human papilloma virus (HPV) causes anal condyloma that is a risk factor for anal carcinoma. The incidence and mechanism of invasive anal carcinoma in patients with anal condyloma are prospectively determined.

PATIENTS AND METHODS

From 1993 to 2002, 228 consecutive patients (164 HIV positive) with anal canal condylomas were included in the study, after curing of their lesions. They were asked to attend follow-up visits at 3- or 6-month intervals. We checked for anal co-infection with syphilis, gonococci, viruses (Epstein-Barr virus, cytomegalovirus, herpes simplex, HPV types), and quantified Langerhans' cells (LC) in anal mucosa at baseline and during follow up. We cured and analysed relapsed condylomas during follow up (3-112 months; median 26). Serum HIV loads and CD4 T-lymphocyte counts were determined at each visit and the densities of LC in consecutive specimens from patients with cancers were compared with that for a matched control group (n = 23).

RESULTS

Analysis of 199 patients showed high-grade dysplasia (HGD) in 13.6% of patients, more in HIV-positive (16%) than in HIV-negative (6%) patients at baseline. During follow up, 3.5% (7/199; six HIV positive) patients developed invasive carcinoma after 13-108 months and 112 (56%) patients relapsed condylomas. HIV and anal co-infection were identified as independent risk factors (P < 0.01) for HGD and cancer: odd ratio (95% confidence interval) of 9.4 (2.4-37.4) and 3.67 (0.95-14.2), respectively. LC densities in anal mucosa were lower in patients with invasive carcinoma than in controls.

CONCLUSION

The risk of invasive carcinoma in HPV-infected patients is increased by HIV and anal co-infection. Decreases in LC numbers in anal mucosa may favour this outcome.

High prevalence of anal squamous intraepithelial lesions in HIV-positive men despite the use of highly active antiretroviral therapy

BACKGROUND

The impact of highly active antiretroviral therapy (HAART) on the natural history of HPV infection and anal squamous intraepithelial lesions (SIL) in HIV-infected men who have sex with men (MSM) is poorly documented. GOAL The goal of this study was to evaluate the prevalence of anal HPV infection and SIL inpatients under HAART.

STUDY DESIGN

Forty-five HIV-infected protease inhibitor-experienced MSM were enrolled in a cross-sectional study. Each patient provided anal samples for anal cytology, histology, and human papillomavirus (HPV) DNA testing.

RESULTS

The patients had previously received HAART for a median of 32 months. Anal cytology was abnormal in 32 of 45 (71%) patients, including high-grade SIL in 10 patients (22%), low-grade SIL in 19 patients (42%), and atypical squamous cells of undetermined significance in 3 patients (7%). HPV DNA was detected 36/45 men (80%). The prevalence of anal SIL and HPV infection were similar in patients exhibiting a significant increase in CD4+ cell count after HAART initiation compared with those who did not.

CONCLUSION

Our results demonstrate a high prevalence of anal SIL, including high-grade SIL, and anal HPV infection in HIV-infected MSM despite immune restoration under HAART.

A importância da anuscopia de alta resolução para o diagnóstico do papilomavírus humano anorretal na forma subclínica, das lesões anais intraepiteliais e do carcinoma "in situ"anal

OBJETIVO: A doença causada pelo Papilomavírus Humano (HPV) tem alta incidência na população e é considerada pré-neoplásica. O objetivo deste trabalho é estudar um método que detecte o HPV anorretal na sua forma subclínica e suas alterações neoplásicas, a incidência em pessoas com até três parceiros sexuais por ano e o resultado do tratamento com o uso de podofilina, ácido tricloroacético, eletrocauterização e ressecção local. MÉTODO: Vinte e dois pacientes foram submetidos ao exame de anuscopia de alta resolução. Os pacientes foram divididos em três grupos: o primeiro, formado por dez pacientes com prurido anal persistente mesmo após eliminadas causas como diabetes, doenças orificiais, outras doenças sexualmente transmissíveis, verminoses e submetidos a cuidados locais e dietéticos; o segundo e o terceiro, formados por seis pacientes com condiloma anal e seis pacientes com HPV genital respectivamente, ambos com alta do tratamento há mais de seis meses. Nenhum deles apresentava manifestação clínica da doença no momento do exame. Os casos com resultado positivo foram tratados com podofilina 25% e ácido tricloroacético, e os com carcinoma "in situ" com ressecção local e eletrocauterização da lesão. RESULTADOS: O exame de anuscopia de alta resolução proporcionou a colheita dirigida do material nas áreas positivas, cujo resultado anátomo-patológico foi positivo para HPV em 100% dos pacientes, sendo dois deles com carcinoma "in situ" e oito com lesões intraepiteliais concomitantes. Apenas 9% dos pacientes, tinham mais de três parceiros sexuais por ano. Todos os pacientes tratados com podofilina e ácido tricloroacético mantiveram as atipias coilocitóticas no controle após seis meses do início do tratamento. A ressecção local e eletrocauterização nos pacientes com carcinoma "in situ" possibilitou o desaparecimento da neoplasia em todos, mas manteve as atipias coilocitóticas. CONCLUSÕES: O exame de anuscopia de alta resolução possibilitou o diagnóstico de HPV anorretal na forma subclínica e suas alterações neoplásicas em 100% dos pacientes. O uso de podofilina e ácido tricloroacético não foi eficiente na erradicação das alterações anátomo-patológicas decorrentes do HPV subclínico anal, no controle após seis meses do início do tratamento. A ressecção local e eletrocauterização dos casos de carcinoma "in situ" foi efetiva para erradicar a neoplasia , no entanto, com manutenção das atipias coilocitóticas.