Human papillomavirus infection is transient in young women: a population-based cohort study

Pap test results among low-income youth: prevalence of dysplasia and practice implications

OBJECTIVES

To describe Papanicolaou (Pap) test findings and identify prevalence and correlates of dysplastic cervical abnormalities in low-income adolescent females.

DESIGN AND SETTING

This cross-sectional study included a modified random sample of female students ages 16 to 25 years at 54 U.S. Job Corps centers.

PARTICIPANTS

5,734 female students enrolled in a federal job training program. Admission health records were reviewed and abstracted.

MAIN OUTCOME MEASURE

Pap test findings using the Bethesda classifications. Pap smear results indicating dysplasia (atypical squamous cells of undetermined significance [ASCUS] with dysplasia) or squamous intraepithelial lesions (low-grade squamous interepithelial lesions [LGSIL] or high-grade squamous intraepithelial lesions [HGSIL]). Participants with less severe findings were compared with those who needed follow-up.

RESULTS

For 71.4% of participants, no abnormalities were found. 15.6% had benign cellular changes, 9.2% had reactive changes, and 9.9% had epithelial cell abnormalities. Of those tested, 5.6% (+/- 0.8%) had dysplastic Pap smear findings, with 0.3% (n = 12) HGSIL. All groups were equally affected, with abnormalities not associated with race/ethnicity, age, geographic region, education level, size of city of residence, or receiving public assistance.

CONCLUSIONS

In this population, dysplastic Pap smear results were not uncommon. Findings indicate that Pap screening, alone or in combination with more sensitive tests, can identify cervical abnormalities, including HGSIL, that suggest a need for further evaluation or follow-up.

Interactions of the female hormonal environment, susceptibility to viral infections, and disease progression

Sex hormones influence susceptibility and disease predisposition for many genital tract infections. This review describes the mechanisms by which sex steroids affect mucosal immunity, with particular reference to human immunodeficiency virus (HIV) and genital herpes, and the stage-specific effects of hormonal contraception on human papillomavirus (HPV) infection. Estrogen's role is important in the early stages of several infections as it stimulates antibody- and cell-mediated immune responses. There is increased expression of some cytokines in peripheral blood and vaginal fluids during the follicular phase of the menstrual cycle and with use of hormonal contraception. Whether estrogen exerts a protective or deleterious influence depends on the infecting organism and stage of infection or disease. Estrogen apparently reduces susceptibility to primary HPV infection but in the event of persistent HPV infection, sex steroid hormones (estrogen and/or progesterone) are associated with progression to cervical cancer. It is important that these stage-specific effects are better described because most vaccines will try to prevent either infection or disease. Clinicians with patients at high risk of sexually transmitted infections, especially HIV, require better information on the risks associated with different hormonal contraceptive regimes.

Population-based type-specific prevalence of high-risk human papillomavirus infection in middle-aged Swedish women

Human papillomavirus (HPV) DNA testing can be used to identify women at risk of the development of cervical cancer. The cost-effectiveness of HPV screening is dependent on the type-specific HPV prevalence in the general population. The present study describes the prevalence and spectrum of high-risk HPV types found in a large real-life population-based HPV screening trial undertaken entirely within the cervical screening program offered to middle-aged Swedish women. Cervical brush samples from 6,123 women aged 32-38 years were analyzed using a general HPV primer (GP5+/6+) polymerase chain reaction-enzyme immunoassay (PCR-EIA) combined with reverse dot-blot hybridization for confirmation and HPV typing by a single assay. In this study, 6.8% (95% CI 6.2-7.5) (417/6,123) were confirmed as high-risk HPV positive. Infections with 13 different high-risk HPV types were detected, of which HPV 16 was the most prevalent type (2.1%; 128/6,123), followed by HPV 31 (1.1%; 67/6,123). Any one of the HPV types 18, 33, 35, 39, 45, 51, 52, 56, 58, 59, or 66 was detected in 3.6% (223/6,123) of the women. Infection with two, three, and five types simultaneously was identified in 32, 5, and 1 women, respectively. The combination of PCR-EIA as a screening test and reverse dot-blot hybridization as a confirmatory test, was found to be readily applicable to a real-life population-based cervical screening. The type-specific HPV prevalence found support in previous modeling studies suggesting that HPV screening may be a favorable cervical screening strategy.

Immunity to oncogenic human papillomaviruses

The establishment of human papillomavirus (HPV) infection as a major cause of several human cancer forms, notably cervical cancer, has spurred development of prophylactic and/or therapeutic HPV vaccines for prevention of cervical neoplasia. Knowledge of the immunity to HPV forms the basis for such endeavors.

METHOD

A literature review of humoral and cellular immunity to HPV. The overview on human leukocyte antigen (HLA) and cervical cancer was expanded to a formal metaanalysis, where relevant articles were located by Medline search and citation analysis and graded by preassigned quality criteria on study design.

RESULTS

The antibody response to the HPV particle is dominated by a neutralizing antibody response to a typespecific, conformationally dependent immunodominant epitope. Vaccines based on viral particles lacking the viral genome (virus-like particles, VLPs) have been highly successful in preventing and treating HPV infection in several animal model systems. In humans, the serum antibody response to VLPs is stable over time, also after the HPV infection has been cleared, resulting in HPV serology being used as a marker of cumulative HPV exposure in spite of the fact that a significant proportion of HPV-exposed subjects fail to seroconvert. More than 90% of HPV infections will clear spontaneously. The factors that determine whether an HPV infection is cleared or persists and increases the risk for cancer are not known, but cellular immunity is implicated. Several HLA class II haplotypes are associated with cervical cancer: DQw3 increases and DR13 decreases the risk for cervical cancer in general (odds ratios (OR) and 95% confidence intervals (CI): 1.25(1.15-1.37) and 0.69 (0.56-0.85), respectively); DR15 increases the risk for HPV16-carrying cancer (OR: 1.47; CI: 1.20-1.81); and DR7 may be either protective or increase the risk. Most cervical cancers have downregulated the expression of at least one HLA class I antigen, whereas class II expression is increased in infected epithelium. A Th2 cytokine profile is associated with progression to cervical cancer. HPV-antigen-specific proliferative responses have been detected in many studies, although it is not entirely clear whether these responses are HPV type specific or may be cross-reactive between HPV types. Specific cytotoxic T lymphocyte (CTL) responses were originally reported in only a minority of infected subjects, typically cancer patients, but with advancing technology, specific CTLs can be stimulated from about half of the women with HPV-carrying disease. In animal model systems, CTL responses can mediate clearance.

CONCLUSION

The antibody response to HPV is a mediator of type-specific protective immunity, which forms the basis for prophylactic vaccine candidates. The cellular immunity to HPV is implicated as an important factor in cervical carcinogenesis, but the main targets and types of responses that mediate HPV clearance are not established.

High- and intermediate-risk human papillomavirus infection in sexually active adolescent females

STUDY OBJECTIVE

To determine the prevalence of high- and intermediate-risk type human papillomavirus (HPV) infection and cervical dysplasia in an urban Swiss adolescent population attending the local Adolescent Clinic, using a liquid-based Pap test combined with risk type HPV DNA testing. To determine the prevalence of Chlamydia trachomatis in the same study population.

DESIGN

Observational study.

SETTING

The Adolescent Clinic of the Department of Obstetrics and Gynaecology at the University Clinic, Geneva, Switzerland.

PARTICIPANTS

134 women between 14 and 20 years of age were enrolled in the study.

MAIN OUTCOME MEASURES

A standardized patient file on demographic and sexual history information was compiled and completed by physical examination, including a Pap test with adjunct high- and intermediate-risk type HPV DNA detection.

RESULTS

Of the 134 specimens analyzed for HPV, 115 patients were negative and 19 (14.2%) were positive for HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, or 68. A significant association between HPV infection and having had more than one lifetime sexual partner was found (P <.05). Six (31.6%) of the HPV-positive and three (2.6%) of the HPV-negative specimens had a low-grade squamous intraepithelial lesion (SIL) by cytology. Abnormal Pap test was related to HPV infection (odds ratio, 46.2; 95% confidence interval, 7.4 to 287.4) and, inversely, to age at first sexual intercourse (odds ratio, 0.98; 95% confidence interval,.97 to 1.0).

CONCLUSION

High- and intermediate-risk type HPV infection is a frequent finding in our study group and is linked to having had more than one lifetime sexual partner. No association was found between HPV infection and other potential risk factors such as patient's age, age at first intercourse, frequency of intercourse during the three months prior to the investigation, smoking habits, or alcohol consumption.

Molecular detection and genotyping of human papillomavirus

Human papillomavirus infections are associated with the development of cervical neoplasia. Human papillomavirus is a group of heterogeneous viruses, comprising many genotypes, which can be divided into high-risk and low-risk types, depending on their association with disease. Therefore, accurate molecular diagnostic tools are required for detection and identification of human papillomavirus. Monitoring of human papillomavirus infection is necessary for adequate patient management and follow-up during treatment. This review describes the different molecular methods available for human papillomavirus detection and identification of genotypes.

Human papillomavirus and vulval intra-epithelial neoplasia

The association between human papillomavirus vulval skin infection and vulval intra-epithelial neoplasia is strong. Vulval skin carcinogenesis is, however, multifactorial. Both human papillomavirus oncogenic subtype infection and p53 mutations are likely to contribute to the risk of malignant transformation of normal epithelium. The long-term cumulative risk of developing vulval squamous carcinoma following the diagnosis of high-grade vulval intra-epithelial neoplasia is thought to be approximately 6% per decade, but observational data supporting this are mostly non-population based and retrospective. Surgical treatment may reduce this risk, but the rates of recurrence and treatment-related morbidity are high. Surveillance should therefore be discussed as an alternative. New treatments being researched include photodynamic therapy, human papillomavirus vaccines, immunotherapy, immune modulators and gene therapy. The advantages of these new modalities over surgery is the potential to preserve body image and sexual functioning while targeting more generalized epithelial molecular dysfunction.

Primary screening for human papillomavirus infection

As human papillomavirus infection is now known to be a necessary risk factor for at least 95% of cervical cancers, the medical community has a responsibility to assess and evaluate how this knowledge should best be used for the prevention of cervical cancer. Organized screening strategies combining cytological screening with human papillomavirus testing in older age groups could theoretically be more sensitive than current screening programmes in reducing the incidence of cervical cancer. If it is possible safely to extend the screening interval in human papillomavirus-negative women, such programmes could also both be more effective and more cost-efficient. Although some modelling studies have indicated that this could indeed be the case, evidence from clinical trials evaluating the long-term protective effect of primary human papillomavirus screening is still lacking. The key issues on the research agenda for primary human papillomavirus screening are reviewed.

An update on human papillomavirus infection and Papanicolaou smears in adolescents

Human papillomavirus infection is one of the most common sexually transmitted infections in young women, and may lead to clinical sequelae such as anogenital condylomata and cervical squamous cell carcinoma. Recent data on the biology and natural history of HPV infection in adolescents will have important implications for the development of adolescent-specific protocols for cervical cancer screening and for follow-up of abnormal cytology.

Human papillomavirus infection as a risk factor for squamous-cell carcinoma of the head and neck

BACKGROUND

Oncogenic human papillomaviruses (HPVs), especially HPV type 16 (HPV-16), cause anogenital epithelial cancers and are suspected of causing epithelial cancers of the head and neck.

METHODS

To examine the relation between head and neck cancers and HPVs, we performed a nested case-control study within a joint Nordic cohort in which serum samples were collected from almost 900,000 subjects. Samples collected at enrollment from 292 persons in whom squamous-cell carcinoma of the head and neck developed, on average, 9.4 years after enrollment and from 1568 matched controls were analyzed for antibodies against HPV-16, HPV-18, HPV-33, and HPV-73 and for cotinine levels as a marker of smoking habits. Polymerase-chain-reaction (PCR) analyses for HPV DNA were performed in tumor tissue from 160 of the study patients with cancer.

RESULTS

After adjustment for cotinine levels, the odds ratio for squamous-cell carcinoma of the head and neck in subjects who were seropositive for HPV-16 was 2.2 (95 percent confidence interval, 1.4 to 3.4). No increased risk was observed for other HPV types. Fifty percent of oropharyngeal and 14 percent of tongue cancers contained HPV-16 DNA, according to PCR analysis.

CONCLUSIONS

HPV-16 infection may be a risk factor for squamous-cell carcinoma of the head and neck.

Epidemiologic and mucosal immunologic aspects of HPV infection and HPV-related cervical neoplasia in the lower female genital tract: a review

Human papillomavirus (HPV) infections are known to play an important role in the pathogenesis of cervical neoplasia. Considering the morbidity and mortality of cervical cancer, infection with HPV can be regarded as a worldwide problem, especially in developing countries. Currently, many studies focus on the development of both prophylactic and therapeutic HPV vaccines. Crucial for these vaccination protocols to be successful is that they will result in a long-lasting ability to generate an immune response that will eliminate the virus. HPV transmission and subsequent infection is a local event in the lower female genital tract and therefore the efficacy of vaccines against this locally transmitted infection can be best assessed by parameters of local immunity. In this review we describe both the epidemiology of HPV-related cervical neoplasia and the general aspects of mucosal immunity in the female genital tract while focusing on the local humoral immunity in HPV-related cervical neoplasia.

Sexual behaviour and smoking as determinants of cervical HPV infection and of CIN3 among those infected: a case-control study nested within the Manchester cohort

To distinguish risk factors for acquisition of cervical human papillomavirus (HPV) infection from the determinants of neoplasia among infected individuals we have conducted a three-arm case-control study nested within a large population-based cohort of women (the Manchester cohort) screened for HPV at entry using L1 consensus primer PCR. The study includes 181 HPV-positive controls who did not develop high-grade cervical intraepithelial neoplasia (CIN3) during follow-up, 203 HPV-negative controls, and 199 HPV-positive cases with histologically confirmed CIN3. Detailed information on sexual, reproductive and gynaecological history, oral contraceptive use and smoking was obtained at face-to-face interview. There was a striking division between risk factors for infection and those predictive of disease. Comparing the HPV-positive against the HPV-negative controls, the only risk factors for infection were number of sexual partners (OR for six or more = 3.89; 95% Cl = 1.99-7.62), a relatively recent new sexual relationship (OR for a new partner within the previous 2 years = 4.17; 95% Cl = 2.13-8.33), and a history of previous miscarriage (OR = 2.59; 95% Cl = 1.28-5.21). The determinants of CIN3 among infected women were, in contrast, early age at first intercourse (OR for 16 years old or less = 3.23; 95% Cl = 1.33-7.69), a long time since starting a new sexual relationship (OR for 6 years or more = 4.94; 95% Cl = 2.51-9.71), and cigarette smoking, with strong evidence for a dose- response (OR for current smoking habit 20+ per day = 2.57; 95% Cl = 1.49-4.45). Oral contraceptive use was not significantly associated with either HPV infection or CIN3.

Presence of human papillomavirus and Epstein-Barr virus in the cervix of women infected with the human immunodeficiency virus

The presence of human papillomavirus (HPV) and Epstein-Barr virus (EBV) was sought in cervical scrapings from 110 human immunodeficiency virus (HIV)-infected women to evaluate the role of these viruses as risk factors for squamous intraepithelial lesions of the cervix. By using PCR, presence of HPV-DNA and EBV-DNA was found in 60.9% (67/110) and in 10% (11/110) of clinical samples, respectively. Identification of oncogenic group of HPV by hybrid capture (HC II, Murex-Digene) indicated the presence of low-risk HPV in 13 (19.4%) patients, high-risk HPV in 28 (41.8%), and both types of HPV in 26 (38.8%) patients. Squamous intraepithelial lesions were present in 59 cases, being low-grade (n = 52) and high-grade (n = 7) lesions. HPV was detected in 84.7% of patients with lesions, in association with low-grade (43/52) and high-grade lesions (7/7), and in 33% of patients without lesions. EBV-DNA was detected in 8 patients with low-grade lesions and in 3 patients without lesions. Concurrent genital HPV and EBV infection was observed in 9 cases. HPV was associated with detection of squamous intraepithelial lesions [OR = 3.55; 95% CI = (1.96; 6.48)]. No significant association was found between presence of EBV and detection of lesions, both in case of EBV infection alone [OR = 1.4; 95% CI = (0. 93; 2.12)] and in case of HPV/EBV combined infection [OR = 0.87; 95%CI = (0.54; 1.42)]. These data confirm the significant role of HPV as risk factor for squamous intraepithelial lesions and suggest that EBV could not be involved in the pathogenesis of the lesions that arise in the cervix of HIV-positive women.

Primary cervical carcinomas show 2 common regions of deletion at 3P, 1 within the FHIT gene: evaluation of allelic imbalance at FHIT, RB1 and TP53 in relation to survival

Chromosome arm 3p is re-arranged in many tumor types, including cervical carcinomas. Putative tumor-suppressor genes on 3p have been proposed, including the FHIT gene, which maps to chromosome band 3p14.2. We have analyzed 79 primary cervical carcinomas for allelic imbalance (AI) at 17 chromosome 3 loci, including 3 within the FHIT gene. Expression of the FHIT gene was evaluated after immunohistochemistry with an antibody against the pFHIT protein. Previously determined human papillomavirus status, defined after in situ hybridization, showed type 16 or 18 in 56/77 tumors. Tumors were also analyzed for AI at loci within the RB1 (chromosome band 13q14.2) and the TP53 (17p13) genes for AI. AI was found at 1 or more 3p loci in 50/79 tumors, at frequencies ranging from 30% to 52% at the individual loci. Two smallest regions of overlapping deletion (SROs) were found, 1 including parts of the FHIT gene (SRO flanked by D3S1481 and D3S1313) and another more distal SRO between D3S32 and D3S1286. FHIT protein expression was reduced in 57/69 (83%) tumors but not associated with AI at FHIT loci (p = 0.56). AI was found in TP53 and RB1 in 18% and 29% of the samples, respectively. Relapse-free survival was associated with AI in the TP53 gene in both a univariate (p = 0.0003) and a multivariate (p = 0.004) analysis. This study confirms a high frequency of AI at chromosome arm 3p in primary cervical carcinomas. The AI results and the reduced FHIT protein staining indicate that FHIT alterations are important in cervical carcinogenesis.

Trends over time in the incidence of cervical neoplasia in comparison to trends over time in human papillomavirus infection

INTRODUCTION

The establishment of human papillomavirus (HPV) infection as a major cause of cervical neoplasia has resulted in major efforts to develop prophylactic HPV vaccines for prevention of cervical neoplasia. Cervical cancer and the other HPV-associated cancers constitute a major public health burden and eradication of the major causative infection is certainly the most appealing long-term preventive measure. Nevertheless, the effects of preventive HPV vaccination will need to be estimated and compared for (cost-) efficacy with other primary prevention and with secondary prevention programs. However, estimating the effects of preventing a causative exposure is complicated when the exposure is a transmissible infection. The spread of the epidemic is dynamic and may change over time depending e.g. on the changes in human behavior. Depending on the circumstances, prevention of an infection may have either greater or lesser effects than the prevention of a non-infectious exposure. Estimating the time trends in HPV infections and the underlying trends in the risk of cervical neoplasia is important for estimating effects of interventions.

METHOD

A literature review on recent evidence on time trends in cervical neoplasia, compared with evidences on time trends in HPV infections and interactions between different types of HPV infections.

RESULTS

In Finland, there has between 1991 and 1995 been a 60% increase in the incidence of cervical cancer among women <55 years of age. Trends in detection rates of cervical cancer precursor lesions are consistent with an increase in the background cervical cancer risk. From the 1960s to 1980s, there has been a major increase in HPV seroprevalences over time in the Nordic countries. Increasing trends are also seen for other sexually transmitted diseases and smoking. Several studies indicate the existence of interaction between benign and oncogenic HPV types, thus making the relationship between the incidences in HPV infections and in cervical neoplasia complex.

CONCLUSION

The increase in cervical cancer is paralleled by increases in HPV infection, other STDs and smoking and changes in screening practices, all of which may have contributed. Prediction of the effect on cervical cancer incidence of changes in HPV incidences is complicated by the existence of several risk factors, the protective effect of screening and by the population dynamics of HPV infections.

Prerequisites for human papillomavirus vaccine trial: results of feasibility studies

BACKGROUND AND AIMS

Oncogenic human papillomaviruses (HPVs) are the major cause of cervical cancer and associated cancers. First generation preventive vaccines against HPVs are entering clinical trials. Therefore, it is time to consider prerequisites of field trials in Finland.

RESULTS

Incidence of cervical cancer is increasing in young women which is not unexpected since risk taking behavior among young women has also increased. In the developed countries up to 44% of cervical cancer cases are attributable to HPV16 infection alone. However, high risk HPV types other than HPV16 and HPV18 are emerging in the population based on HPV DNA pilot screening studies. Annual attack rates among young women less than 25 years of age is 2.3% for HPV16 infection, and 0.03% for CIN3 invasive cervic cancer. Thus, sample size estimates for HPV vaccine efficacy trial are approximately 1000 when the endpoint is HPV16 infection, and approximately 15000 when the endpoint is >/=CIN3 or worse assuming that the vaccine efficacy is 70%. Both HPV vaccine trial acceptability and compliance rates at routine visits of the general Finnish female population are going to be high based on a pilot study.

CONCLUSION

Prerequisites for large scale field trials on HPV vaccination are fulfilled in Finland.

A population-based five-year follow-up study of cervical human papillomavirus infection

OBJECTIVE

The purpose of this study was to determine the long-term tendency for cervical human papillomavirus infections to persist in the general population.

STUDY DESIGN

From 500 women who participated in a 1991 population-based survey, 90 healthy women with normal results of cytologic examination (women with human papillomavirus deoxyribonucleic acid detected and age-matched control women without human papillomavirus deoxyribonucleic acid detected) were interviewed and examined 5 years later colposcopically, cytologically, and with human papillomavirus serologic testing and human papillomavirus deoxyribonucleic acid testing by polymerase chain reaction with 2 different consensus primer pairs (MY09 and MY11 and GP5(+) and GP6(+)), type-specific polymerase chain reaction, and deoxyribonucleic acid sequencing.

RESULTS

The 5-year human papillomavirus clearance rate was 92%. Only human papillomavirus type 16 infections persisted. Colposcopic impression of grade 2 cervical intraepithelial neoplasia was associated with persistent human papillomavirus 16 infection (P <.03). Human papillomavirus detection was associated with sexual history. Human papillomavirus type was the only determinant of human papillomavirus persistence.

CONCLUSION

The high clearance rates in a population-based setting with a 5-year follow-up period imply that inclusion of human papillomavirus deoxyribonucleic acid testing in population-based cervical screening programs should target persistent infection.

Enhanced oncogenicity of human papillomavirus type 16 (HPV16) variants in Japanese population

To investigate whether HPV16 E6 variants carry an elevated risk for cervical cancer in Japanese population, we investigated the E6 sequence variation in 40 cervical intraepithelial neoplasias (CINs) I-III and 43 invasive cervical cancers (ICCs), all positive for HPV16. HPV16 E6 variants were frequently found in ICCs than in CINs (88 vs. 65%, P=0.01). The E6 D25E, a rare variant in Western countries, was most frequently observed in ICC (44%). CIN I/II lesions with HPV16 variants were less likely to regress than those with HPV16 prototype (P=0.048). The finding that HPV16 E6 variants represent a significant risk factor is common between Western and Japanese women despite the different distribution of each variant.

Recent advances in diagnosis and therapy of human papillomaviruses

Infection with human papillomavirus is extremely common throughout the world. Almost 50% of sexually active young women are infected with human papillomavirus and although most infections are transient, a subset has the potential to progress to invasive cancer. During the last 20 years, our understanding of the human papillomavirus life cycle and the role of human papillomavirus in human cancer has dramatically increased. Recent technological advances in human papillomavirus detection have provided the means to detect the presence of human papillomavirus with great sensitivity. In the context of patient care, there is still substantial debate regarding the optimal diagnostic and prognostic use of information derived from hybrid capture or polymerase chain reaction-based detection. The inventory of available treatment options is growing somewhat slowly. The most promising advances are being made in the clinical evaluation of candidates for prophylactic vaccination. This review is focused on the current status and future directions of prevention, diagnosis and therapy.

Concordance of human papillomavirus in the cervix and urine among inner city adolescents

OBJECTIVES

To evaluate concordance for human papillomaviruses (HPVs) between cervix and urine in sexually active adolescents.

METHODS

Cervical swabs and urine were collected from 80 adolescents in Baltimore, MD. Specimens were tested for 34 HPVs by PCR and for cancer-associated HPVs by Hybrid Capture (HC II) Probe B. Cervical vs. urine prevalence was evaluated by logistic regression with general estimating equations. Risk factors for prevalence and viral burden were evaluated by Fisher's exact and Kruskal-Wallis tests, respectively.

RESULTS

HPV prevalence by PCR, for any HPV, was very high in the cervix (90.0%) and somewhat lower in urine (75.0%) (odds ratio, 1.07; 95% confidence interval 1.07 to 1.34). Only one adolescent was HPV-positive in urine alone. Among HPV-PCR positives at either or both sites, concordance was 82% for presence of any HPV and 40% for specific HPV types. Multiple infections were common at both sites. On an average, HC II viral burden (relative light unit ratio) was 9-fold higher in cervix than in urine (median, 47.3 vs. 4.9; P = 0.005) but correlated poorly between the two sites of the same individual (r = 0.14). Compared with normal adolescents, those with squamous intraepithelial lesions had a much higher prevalence of HPV by HC II in cervix (100% vs. 28.6, P<0.0001) as well as in urine (86.7% vs. 35.4%, P = 0.002) and a significantly higher viral burden in the cervix (median, 141.8 vs. 7.3, P = 0.0045) but not in urine (median, 22.7 vs. 4.38; P = 0.13).

CONCLUSION

There was a very high prevalence of HPV in cervix and urine of sexually active adolescents. Testing urine for HPV may be useful in epidemiologic investigations and in monitoring of infected women.

IgG antibodies against human papillomavirus type 16 E7 proteins in cervicovaginal washing fluid from patients with cervical neoplasia

Little information is available about the cervicovaginal mucosal antibodies against human papillomavirus (HPV) proteins. In this study specific IgG antibodies against HPV 16 E7 protein were determined in paired samples of cervicovaginal washing fluid and serum from patients with cervical cancer (n = 22), cervical intraepithelial neoplasia (CIN) (n = 38), healthy individuals (n = 22), and serum from children (n = 41) by a radioactive immunoprecipitation assay (RIPA). HPV 16 E7 specific IgG antibodies were found in cervicovaginal washings (n = 8) and in sera (n = 8) of the patients with cervical cancer. About 60% of the patients with HPV 16 positive cervical cancer had HPV 16 E7 specific IgG antibodies. Titration studies showed that the IgG antibody reactivity in cervicovaginal washings was higher than in the paired serum samples of six patients with cervical cancer (P < 0.001). In the CIN group we found no IgG reactivity in the serum, but in five patients we found a low IgG reactivity in the cervicovaginal washings. No IgG reactivity was found in cervicovaginal washings and sera from healthy individuals and sera from children. HPV 16 E7 specific IgG antibodies seem to be locally produced in a number of patients with HPV 16 positive (pre)malignant cervical lesions. For more definitive evidence for the local production of these antibodies immunostaining should be performed to demonstrate the presence of specific anti-HPV 16 E7 IgG producing plasma cells in the cervical epithelium.

The effect of low-dose acetylsalicylic acid on bleeding after transurethral prostatectomy--a prospective, randomized, double-blind, placebo-controlled study

OBJECTIVE

An increase in the loss of blood after ingestion of acetylsalicylic acid (ASA) has been reported after several types of surgery, but randomized placebo-controlled studies have exclusively been performed after coronary artery bypass surgery. The reported effects of ASA on bleeding after transurethral prostatectomy (TURP) have been conflicting. We have studied the effect of low doses of ASA (150 mg) on bleeding after TURP in a prospective, randomized, double-blind, placebo-controlled trial.

PATIENTS AND METHODS

Patients were randomized to receive either 150 mg ASA (n = 26) or placebo (n = 27) 10 days before surgery. The weight of resected tissue, operation time and blood loss, transfusion requirements and complications were recorded.

RESULTS

There was no significant difference in the median operative blood loss between the groups (p = 0.528), but postoperatively the blood loss in the ASA group (median 284; quartiles 196-660 ml) was significantly higher than in the placebo group (median 144; quartiles 75-379 ml), (p = 0.011). No significant difference was observed between the groups regarding the amount of resected tissue (p = 0.209) or the operating time (p = 0.297). In both groups the operative blood loss was significantly related to the amount of resected tissue (p < 0.005) and the operating time (p < 0.005). No significant difference in transfusion requirements (p = 0.280), time to catheter removal (p = 0.455) and hospital stay (p = 0.820) were observed between the groups.

CONCLUSION

Long-term low-dose ASA therapy is associated with a significant increase in the postoperative blood loss after TURP, and although no significant difference in transfusion requirements was observed more units of blood were used in the ASA group. We advise that ASA therapy should be withdrawn 10 days before TURP.

Human papillomavirus DNA testing for cervical cancer screening in low-resource settings

BACKGROUND

In many low-resource settings, there are barriers to cytologic screening for cervical cancer. This study evaluates human papillomavirus (HPV) DNA testing as an alternative screening method.

METHODS

Cervical samples from 2944 previously unscreened South African women aged 35-65 years were tested for high-risk types of HPV with the use of the Hybrid Capture I (HCI) assay. Women also had a Pap smear, direct visual inspection of the cervix, and Cervicography(TM). Women positive on any screening test were referred for colposcopy. Samples from women with biopsy-confirmed, low-grade squamous intraepithelial lesions (SILs) (n = 95), high-grade SILs (n = 74), or invasive cervical cancer (n = 12) and a random sample of women with no cervical disease (n = 243) were retested for HPV DNA with the use of the more sensitive Hybrid Capture II (HCII) assay. All P values are two-sided.

RESULTS

High-risk HPV DNA was detected in 73.3% and 88.4% of 86 women with high-grade SIL or invasive cancer and in 12.2% of 2680 and 18.1% of 243 women without evidence of cervical disease, with the use of the HCI and HCII assays, respectively. HPV DNA testing with the HCII assay was more sensitive than cytology for detecting high-grade SIL and invasive cancer (McNemar's test, P =.04), and testing with the HCI assay was of equivalent sensitivity (P =.61). Cytology had a statistically significantly better specificity (96.8%) than either the HCI assay (87.8%) or the HCII assay (81.9%) (P<.01). Receiver operating characteristic curves identified test cutoff values that allow HPV DNA testing to identify 57% of women with high-grade SIL or cancer, while classifying less than 5% of women with no cervical disease as HPV DNA positive.

CONCLUSIONS

HPV DNA testing has a sensitivity equivalent to, or better than, that of cytology. Since HPV DNA testing programs may be easier to implement than cytologic screening, HPV testing should be considered for primary cervical cancer screening in low-resource settings.

[Comparison between reference oncologic colpocytology and severity of intraepithelial cervical lesions]

OBJECTIVE

The study was designed to compare the Pap smear results, performed on the public health service, with: the results of Pap smear collected on the reference service; the colposcopy and punch biopsy results.

METHODS

The total of 213 women assisted at the women's hospital from January 1989 to April 1991, and followed until July 1998 were selected. Ninety were referred because a Pap smears suggestive of Human Papillomavirus (HPV) induced lesion or cervical intraepithelial neoplasia (CIN) grade 1, and 123, CIN 2 or 3.

RESULTS

Among the 90 women referred because of HPV/CIN 1.49% presented CIN 2 or 3 in the Pap smears performed at this service. At the colposcopy, 16/90 women did not present suspicious lesions, and in 10 women, the squamous columnar junction was not observed. At biopsy, 42 (46%) presented CIN 2 or 3. Out of the 123 women referred with Pap smear of CIN 2 or 3.54% presented CIN 2 or 3 at this service. At the colposcopy, 24 women did not present suspicious lesions and the squamous columnar junction was not observed in 12. About biopsy, 61 (49%) presented CIN 2 or 3.

CONCLUSIONS

The expectant conduct in cases of Pap smear with HPV/CIN 1, should follow a criterion, involving qualified professionals to collect the Pap smear, and should provide people awareness as to control follow-up.

Knowledge of human papillomavirus infection among young adult men and women: implications for health education and research

Human papillomavirus (HPV) infection of the genital tract is one of the most common sexually transmitted diseases (STDs), and a subset of genital tract HPVs are etiologically associated with cervical cancer. The prevalence of HPV infection is highest among adolescents and young adults. This study was undertaken to explore first year college students' knowledge about HPVs and to determine whether there were gender differences in this knowledge. An anonymous survey was distributed to all first year students at a private university. The results were analyzed by gender. We found that 96.2% of males and 95.4% of females had heard of genital warts, although only 4.2% of males and 11.6% of females knew that HPV caused genital warts. Although there was a greater awareness of genital warts than HPV in this population, students were uncertain about modes of transmission of both genital warts and HPVs, and unclear about the importance of HPV infection relative to other STDs. For both men and women (87% and 87.4%, respectively), health education classes were the major source of information about STDs. We conclude that health education should be reconceptualized to incorporate a better understanding of STDs, including HPV infection, by engaging adolescents and young adults in exploring the biological and social context of STDs, their public health importance, strategies for prevention, and the uncertainty of our scientific knowledge.

Asymptomatic penile HPV infection: a prospective study

The occurrence of human papillomavirus (HPV) among males was analysed with the polymerase chain reaction (PCR) method. Penile brush samples were taken once from 147 males attending for a control or for HPV non-related reasons, and consecutive samples were collected from 88 males re-attending the clinic. Of the males attending once, 13% (19/147) were HPV DNA positive and among the re-attenders 14% (12/88) were initially positive as compared with 33% (29/88) who were positive at least at one visit. Totally, 22 different HPV types were detected of which HPV 16 was most common, found in 6.4% (15/235), followed by HPV 42 found in 3.8% (9/235). Among 14 HPV-positive males with at least one follow-up, 7 had persistent infections with at least one HPV type, and transient HPV types were observed in 9; but in 5 of them new types appeared at follow-up. Among sexually-active males subclinical/latent HPV infection is common and repeated sampling increases its prevalence.

Papillomavirus detection: demographic and behavioral characteristics influencing the identification of cervical disease

OBJECTIVE

This study was undertaken to assess the association between detection of high-risk types of human papillomavirus and various demographic and behavioral characteristics and to further relate this association to cervical histopathologic findings.

STUDY DESIGN

A total of 1007 patients with a Papanicolaou test result reported as high-grade squamous intraepithelial lesion or with 2 results reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion were referred from city and county clinics to a colposcopic clinic. All women had a cervical smear obtained, underwent colposcopically directed biopsy and endocervical curettage, and had a specimen taken for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction. Demographic information was obtained from each patient.

RESULTS

Human papillomavirus deoxyribonucleic acid was identified in 655 (66%) of the specimens. High-risk human papillomavirus types (16, 18, 31, 33, and 35) were detected in 463 (70.7%) of these specimens. The prevalence of evidence of human papillomavirus (koilocytosis) and grade 1 cervical intraepithelial neoplasia in the biopsy specimen decreased significantly with age, whereas the prevalence of grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen increased with age. There was a significant age-dependent decreasing trend in detection of high-risk human papillomavirus deoxyribonucleic acid among women who had human papillomavirus-associated changes, grade 1 cervical intraepithelial neoplasia, and grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen. The prevalences of high-risk human papillomavirus among patients with grade 1 cervical intraepithelial neoplasia and grade 2 or 3 cervical intraepithelial neoplasia were similar, and both were significantly higher than among women with no evidence of cervical intraepithelial neoplasia or koilocytosis in the biopsy specimen. Risk factors associated with grade 2 or 3 cervical intraepithelial neoplasia were different from those associated with human papillomavirus-associated changes and with grade 1 cervical intraepithelial neoplasia.

CONCLUSION

The detection of high-risk human papillomavirus was age-dependent for all histologic categories. Patients with grade 2 or 3 cervical intraepithelial neoplasia had a prevalence of high-risk human papillomavirus that was similar to that among women with grade 1 cervical intraepithelial neoplasia but significantly higher than that among women whose biopsy specimens appeared normal or demonstrated only the presence of human papillomavirus-induced changes (koilocytosis). This suggests that separation of human papillomavirus-associated changes only from grade 1 cervical intraepithelial neoplasia may be of significance in tissue diagnosis.

The serological response to papillomaviruses

The antibody response to papillomaviruses is a key determinant of protective immunity. HPV serology is also an important epidemiological tool for the assay of past and present HPV infections and for prediction of HPV-associated cancers and their precursor lesions. This review focuses on the assay of antibody responses to the HPV capsid, its use as a marker of cumulative HPV exposure and surveys how HPV seroepidemiology has been used to elucidate the spread of HPV infection in various populations, the natural history of HPV infection and that exposure to HPV is associated with increased risk for several human cancers.

Serological evidence for protection by human papillomavirus (HPV) type 6 infection against HPV type 16 cervical carcinogenesis

Human papillomavirus (HPV) exists as more than 100 genotypes. It is not well-established whether the different HPV types interfere with infection or pathogenesis by each other. Possible interactions in cervical carcinogenesis between infection with the most common HPV types (6, 11, 16, 18 and 33) were studied in a seroepidemiological case- control study of 218 women with primary untreated cervical cancer and 219 healthy age-matched control women. As previously shown, HPV-16 seropositivity was associated with cervical cancer risk [odds ratio (OR), 2.39], but HPV-16 was not associated with cervical cancer risk among HPV-6 seropositive women (OR, 1.0). The relative excess risk due to interaction between HPV-6 and -16 was -2. 35 (95% confidence interval, -0.04 to -4.65), indicating significant antagonism. The results suggest that infection with HPV-6 may interfere with HPV-16-associated cervical carcinogenesis.

Th1 cytokine patterns in cervical human papillomavirus infection

The host's immune response to cervical human papillomavirus (HPV) infection is poorly understood. In a longitudinal cohort of women with cervical HPV infections, defined by PCR-based HPV DNA testing, we used exfoliated cervical cells and reverse transcription-PCR to examine the cervical mucosal mRNA expression of cytokines involved in regulating cell-mediated immunity. We identified seven HPV-positive subjects who were found to have cleared their HPV infections 4 months later. In all seven, a T-helper type 1 (Th1) cytokine pattern (expression of gamma interferon and absence of interleukin-4) preceded clearance. The more variable cytokine patterns seen in HPV-negative subjects suggest that the Th1 pattern in the women with subsequent clearance was a response to the HPV infection. This contention is supported by additional cross-sectional data showing a Th1 pattern in a majority of HPV-positive women. This study establishes a feasible means for assessing local cytokine expression in the cervical milieu and demonstrates that a Th1 cytokine response is associated with subsequent clearance of cervical HPV infection.

Human papillomavirus infection in adolescents

The recent gain in knowledge of the genomic function of HPV has led to a greater understanding of the natural history of HPV infection in women, starting from infection to the development of invasive cancer. LSIL is reflective of a benign process associated with HPV replication, and in the majority of women, HPV is eradicated or put into some type of immunologic control so that it remains undetected. In contrast, in the minority of women who have persistent infection, HSIL and invasive cancer are more likely to occur. These findings can be translated clinically to suggest that LSIL can be followed up for a defined period of time and that HPV testing in older women may be useful to identify persistent HPV infections and subsequent risk for invasive cancers.

Genetic susceptibility to HPV infection and cervical cancer

Squamous cell carcinoma of the cervix (SCCC) is one of the leading causes of death in developing countries. Infection with high-risk human papillomavirus (HPV) is the major risk factor to develop malignant lesions in the cervix. Polymorphisms of the MHC and p53 genes seem to influence the outcome of HPV infection and progression to SCCC, although controversial data have been reported. MHC are highly polymorphic genes that encode molecules involved in antigen presentation, playing a key role in immune regulation, while p53 is a tumor suppressor gene that regulates cell proliferation. The HPV E6 protein from high-risk types binds p53 and mediates its degradation by the ubiquitin pathway. The role of these polymorphisms in genetic susceptibility to HPV infection and to SCCC remains under investigation.

Balance of IgG subclasses toward human papillomavirus type 16 (HPV16) L1-capsids is a possible predictor for the regression of HPV16-positive cervical intraepithelial neoplasia

Human papillomavirus type 16 (HPV16) is known to be a major causative agent of cervical cancer. To test the hypothesis that an enhanced Th1 response favors the natural course of cervical intraepithelial neoplasia (CIN), we measured IgG subclasses toward HPV16 L1-capsids because IgG1/IgG2 balance reflects Th2 and Th1 responses, respectively. We examined IgG2/IgG1 ratios in sera from 67 anti-HPV16 L1-positive women; 18 were cytologically normal women, 29 were CIN patients, and 20 were cervical cancer patients. The IgG2 dominance (IgG2/IgG1 ratio >1) was observed in 94, 48, and 5%, respectively (p < 0.001). The regression rate of CIN lesions was significantly different between patients with and without IgG2 dominance: 83.3% (5/6) versus 16.7% (1/6), respectively (p < 0.05). These findings raise the possibility that IgG2 dominance toward HPV16 L1-capsids, i.e., Th1 dominance, may be a useful marker to predict viral clearance or the regression of HPV16-positive CIN.

Epidemiology of genital human papillomavirus

Genital human papillomavirus (HPV) infection is the most common sexually transmitted viral infection and the major risk factor for cervical neoplasia worldwide; however, little is still known about the epidemiology and natural history of the disease. Prospective cohort studies currently being conducted will increase our knowledge and understanding of these issues and provide critical information for the formulation of future primary and secondary prevention strategies.

Immunoglobulin A, G, and M responses to L1 and L2 capsids of human papillomavirus types 6, 11, 16, 18, and 33 L1 after newly acquired infection

OBJECTIVES

We performed a study to establish the pattern of serological reactivity for immunoglobulins (Ig), to capsids of human papilloma virus (HPV) after new HPV infection in two groups of subjects.

METHODS

The pattern of serological reactivity after acquisition of infection with HPV was investigated by measuring IgA, IgM, and IgG antibodies to capsids containing L1 and L2 proteins of HPV types 6, 11, 16, 18, and 33 in longitudinal studies of groups with different patterns of sexual activity. Individuals who tested negative for HPV DNA by the polymerase chain reaction at enrolment, but who became HPV DNA positive during follow up, were examined for antibodies to HPV capsids by enzyme linked immunosorbent assay. One group consisted of 15 young girls (with eight controls who remained HPV DNA negative) who were becoming sexually active and the other comprised 12 male (with five controls) and 35 female (with seven controls) heterosexual attenders of a sexually transmitted disease clinic who had had multiple sexual partners.

RESULTS

The sexually inexperienced girls showed IgA and IgG responses, but seldom an IgM response to infection with HPV types 6/11, 16, and 18. No consistent pattern of serological reactivity was apparent for the heterosexuals with multiple partners. The lack of association between current HPV DNA positivity and detectable antibodies in these individuals was possibly related to the duration of infection or to prior exposure to HPV. For the latter group serological reactivity to HPV capsids was significantly greater in women than in men (p = 0.001, p = 0.003, and p = 0.024, for IgG to HPV 6, 11, and 16, respectively).

CONCLUSION

The sex difference in antibody response detected in previous studies with assays based on peptide antigens was thus corroborated in the present study with capsid based serological assays. This sex difference might reflect a difference in sexual activity and prior exposure to HPV between men and women in this particular group.

Human papillomavirus. Subclinical and atypical manifestations

Subclinical HPV infections, together with latent infections, are probably the most likely outcome after exposure to HPV. Subclinical infection is associated with symptoms such as burning, fissuring, and dyspareunia in some patients. Only these patients should be offered treatment. Diagnosing and treating asymptomatic HPV infection cannot be recommended until better knowledge about the infectious potential of the infection in that phase is obtained. Recently, results have been presented showing a median duration of HPV infection of only 8 months, and after 24 months, only 9% of the women studied continued to be infected. This provides the possibility to reassure patients with HPV infection that it is most likely a transient infection, and one should not worry unduly. In light of this knowledge, it seems unwise to diagnose an asymptomatic infection for which no effective treatment is available and for which the natural history and consequences remain unclear; however, if these lesions were found to have the potential to transmit HPV, the patient should be so counseled.

Human papillomavirus infection with particular reference to genital disease

HPV is the commonest sexually transmitted viral infection in the United Kingdom and as such poses a major public health problem. In addition to the potential physical morbidity associated with genital warts, abnormal cervical cytology, and anogenital dysplasia and neoplasia, the associated psychological morbidity should not be forgotten. Although our knowledge of viral function and disease pathogenesis has advanced appreciably in recent years, we are still some way from developing an in vitro method of viral propagation. Vaccination against HPV infection will hopefully be achieved within the next 10 years, but a prevention and treatment strategy which is appropriate for both developed and developing nations must be our major long term goal.

Low false-negative rate of PCR analysis for detecting human papillomavirus-related cervical lesions

Although PCR analysis is a sensitive test for detection of human papillomavirus (HPV) in the cervix, the proportion of cases of cervical dysplasia missed, or the false-negative rate, has been unknown. We determined the accuracy of PCR analysis for HPV DNA as a predictor of HPV-related cervical lesions in a cross-sectional study of sexually active women, aged 18 to 50 years, from the University of Michigan Family Medicine HPV study. Of 133 eligible participants, 41 underwent colposcopy because of a positive result for HPV of the cervix by the PCR method and 92 underwent screening colposcopy with biopsy prior to knowing the HPV PCR results. Twenty-four of those screened were subsequently found to also be HPV DNA positive. In those found to be HPV positive, histological studies revealed the presence of condyloma or cervical intraepithelial neoplasia in 16 women (24.6%) and changes suggestive of condyloma in 5 (7.6%). No HPV-negative woman had an abnormal biopsy or cytology report (P = 0. 000001). The false-negative rate (1 - sensitivity) for HPV PCR analysis for detection of the presence of a cervical HPV-related lesion was 0% (95% confidence interval, 0 to 0.047), and the specificity was 60.7%. In summary, PCR analysis for HPV DNA had a very low false-negative rate for predicting HPV-related lesions of the cervix in a community-based population. This supports the validity of using the absence of HPV at the cervix, as determined by PCR testing, as an inclusion criterion for patients in control groups in studies dealing with low-grade cervical lesions.

Prevalence of antibodies to human papillomaviruses in the general population of the Czech Republic

Sera from 450 individuals between the age of 1 and 80 years, representing the general population of the Czech Republic, were tested for the presence of antibodies to human-papillomavirus(HPV)-derived antigens. The following antigens were used: (i) HPV1 virions; (ii) HPV16, -18 and -33-virus-like particles (VLP); (iii) peptides derived from L2 open reading frames (ORFs) of HPV16 and HPV6/11; (iv) peptides derived from HPV16 E2, E4 and E7 ORFs of HPV16. The prevalence of antibodies reactive with the capsid-derived antigens was age-dependent, while no clear age dependence was observed in the distribution of antibodies to peptides derived from HPV16 early proteins. In individual sera, high correlations between the presence of antibodies reactive with the 2 L2 peptides, also between the antibodies reactive with different VLPs, were found. While the simultaneous presence of the 2 L2 antibodies was frequently detected in individual sera in all age groups, the simultaneous occurrence of VLP antibodies was detected mostly in subjects older than 20 years. There were no significant differences in HPV-antibody distribution between men and women.

Trends in seroprevalence of human papillomavirus type 16 among pregnant women in Stockholm, Sweden, during 1969-1989

To assess long-term trends in the prevalence of oncogenic human papillomavirus (HPV) infection, we performed a cross-sectional serosurvey of the seroprevalence of the major oncogenic HPV type, HPV16, among 3,512 pregnant women undergoing population-based serological screening at the first trimester of pregnancy in the same catchment area in Stockholm, Sweden, during 1969, 1983 or 1989. The overall HPV16 seroprevalence rates were 16% in 1969, 22% in 1983 and 21% in 1989. Seroprevalence was significantly increased, comparing both 1969 vs. 1983 (p = 0.0005) and 1969 vs. 1989 (p = 0.008). By comparison, the previously reported herpes simplex 2 (HSV-2) seroprevalence in the same women increased from 17% in 1969 to 32% in 1983 and 33% in 1989, whereas the seroprevalence rates of HSV-1 were the same (69% in 1969, 63% in 1983 and 68% in 1989). Odds ratios for HPV 16-positive women to also be HSV-2-positive were 1.8 in 1969 (p < 0.005), 1.1 in 1983 (p = NS) and 1.0 in 1989. Our results suggest that both HSV-2 and HPV16 became more generally spread in the Swedish population between 1969 and 1983 but that the spread has been stable during the 1980s.

A longitudinal study of human papillomavirus carriage in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women

OBJECTIVE

We sought to determine the relationship of human immunodeficiency virus serostatus to carriage of oncogenic human papillomavirus.

MATERIAL AND METHODS

A total of 268 human immunodeficiency virus-infected and 265 human immunodeficiency virus-uninfected women were seen every 6 months, at which time they had laboratory tests performed including a CD4 count. Human papillomavirus deoxyribonucleic acid was analyzed by polymerase chain reaction. Statistical methods included Kaplan-Meier and Cox's proportional hazard models.

RESULTS

The prevalence at baseline of any human papillomavirus type was 73% and 43% among human immunodeficiency virus-seropositive and seronegative women, respectively (p < 0.0001) and of oncogenic types was 32.5% and 17.0% (p < 0.001). The prevalence of oncogenic human papillomavirus was higher in women with CD4 counts <200 mm3 (p < 0.001). The rate of detection of new oncogenic human papillomavirus per 100 patient years of follow-up in human immunodeficiency virus-seropositive women was almost three times higher than among human immunodeficiency virus-seronegative women (p < 0.01). The rate of loss of an oncogenic human papillomavirus was higher in the human immunodeficiency virus-seronegative women but the difference was not significant. The relative risk of a human immunodeficiency virus-infected woman who did not initially have a specific type of oncogenic human papillomavirus having one detected during follow-up was 6.6 times greater than among human immunodeficiency virus-negative women (p < 0.001).

CONCLUSIONS

Human immunodeficiency virus-seropositive women are more likely to have newly detectable oncogenic types of human papillomavirus at follow-up and to show persistent carriage of oncogenic types of human papillomavirus types. Among human immunodeficiency virus-infected women, those with higher CD4 counts were more likely to have a newly detected oncogenic human papillomavirus during follow-up.

Detection of genital human papillomavirus and associated cytological abnormalities among college women

BACKGROUND AND OBJECTIVES

Human papillomavirus (HPV) is strongly implicated in the etiology of cervical neoplasia; however, the frequency, rate, and predictors of neoplastic progression are unknown.

GOAL

To measure the type-specific prevalence of cervical HPV and the rate of development of cytological abnormalities among a cohort of college women and to elucidate factors associated with acquisition of HPV DNA and progression to cytological abnormalities.

STUDY DESIGN

Women 18 to 40 years of age seeking routine gynecologic care at a university health center were enrolled in a cross-sectional study with prospective, longitudinal follow-up of a subset of women. Demographic and behavioral data were collected using a written questionnaire. HPV DNA was detected in cervical scrapes by polymerase chain reaction using L1 consensus primers and a generic and 25 type-specific probes, and cervical cytological abnormalities were identified by Papanicolaou's (Pap) smear.

RESULTS

HPV DNA was detected in 35% of the 414 women in the cross-sectional study; 66% of infections were with intermediate or high cancer risk HPV types. Multiple lifetime sex partners was an independent predictor of prevalent infection. Longitudinal analysis of 205 women showed that detection was transient (HPV DNA absent at follow-up) in 38% of the 84 women who were HPV-positive at enrollment. Persistent detection of the same HPV type at > or = 2 visits occurred in 14% of women and was significantly more common when intermediate or high cancer risk types were present. After 16 months of observation, 9% of HPV-infected women developed low-grade squamous intraepithelial lesions (SIL) and 5% developed high-grade SIL; the risk of incident SIL was 7.8-fold higher among women who had persistent HPV detection with the same type.

CONCLUSIONS

It was concluded that cervical HPV infection is highly prevalent among college women. Although most infections are caused by intermediate of high cancer risk types, few women (5%) developed high-grade SIL during 16 months of observation.

Natural history of cervicovaginal papillomavirus infection in young women

BACKGROUND

Genital human papillomavirus (HPV) infection is highly prevalent in sexually active young women. However, precise risk factors for HPV infection and its incidence and duration are not well known.

METHODS

We followed 608 college women at six-month intervals for three years. At each visit, we collected information about lifestyle and sexual behavior and obtained cervicovaginal-lavage samples for the detection of HPV DNA by polymerase chain reaction and Southern blot hybridization. Pap smears were obtained annually.

RESULTS

The cumulative 36-month incidence of HPV infection was 43 percent (95 percent confidence interval, 36 to 49 percent). An increased risk of HPV infection was significantly associated with younger age, Hispanic ethnicity, black race, an increased number of vaginal-sex partners, high frequencies of vaginal sex and alcohol consumption, anal sex, and certain characteristics of partners (regular partners having an increased number of lifetime partners and not being in school). The median duration of new infections was 8 months (95 percent confidence interval, 7 to 10 months). The persistence of HPV for > or =6 months was related to older age, types of HPV associated with cervical cancer, and infection with multiple types of HPV but not with smoking. The risk of an abnormal Pap smear increased with persistent HPV infection, particularly with high-risk types (relative risk, 37.2; 95 percent confidence interval, 14.6 to 94.8).

CONCLUSIONS

The incidence of HPV infection in sexually active young college women is high. The short duration of most HPV infections in these women suggests that the associated cervical dysplasia should be managed conservatively.