Condom use and the risk of genital human papillomavirus infection in young women

Frequency and risk factors for prevalent, incident, and persistent genital carcinogenic human papillomavirus infection in sexually active women: community based cohort study

OBJECTIVE

To investigate frequency and risk factors for prevalent, incident, and persistent carcinogenic human papillomavirus (HPV) in young women before the introduction of immunisation against HPV types 16 and 18 for schoolgirls.

DESIGN

Cohort study

SETTING

20 London universities and further education colleges.

PARTICIPANTS

2185 sexually active female students, mean age 21 years (range 16-27), 38% from ethnic minorities, who took part in the POPI (prevention of pelvic infection) chlamydia screening trial in 2004-08 and who provided duplicate, self taken vaginal swabs and completed questionnaires at baseline. At follow-up, a median of 16 months later, 821 women (38%) returned repeat vaginal swabs by post. In 2009-10, stored samples were tested for HPV.

RESULTS

Samples from 404/2185 (18.5% (95% CI 16.9% to 20.2%)) of the cohort were positive for carcinogenic HPV at baseline, including 15.0% (327) positive for non-vaccine carcinogenic genotypes. Reporting two or more sexual partners in the previous year and concurrent Chlamydia trachomatis or bacterial vaginosis were independent risk factors for prevalent vaginal HPV infection. Infection with one or more new HPV types was found in 17.7% (145/821) of follow-up samples, giving an estimated annual incidence of carcinogenic HPV infection of 12.9% (95% CI 11.0% to 15.0%). Incident infection was more common in women reporting two or more partners in the previous year, aged<20, of black ethnicity, or with C trachomatis vaginosis at baseline. Multiple partners was the only independent risk factor for incident infection (adjusted relative risk 1.99 (95% CI 1.46 to 2.72)). Of 143 women with baseline carcinogenic HPV infection, 20 (14% (8.3% to 19.7%) had infection with the same carcinogenic HPV type(s) detected after 12-28 months. Of these women, 13 (65%) had redetected infection with HPV 16 or 18, and nine (45%) with non-vaccine carcinogenic HPV genotypes.

CONCLUSION

In the first UK cohort study of carcinogenic HPV in young women in the community, multiple sexual partners was an independent predictor of both prevalent and incident infection. Infection with non-vaccine carcinogenic genotypes was common. Although current HPV vaccines offer partial cross protection against some non-vaccine carcinogenic HPV types, immunised women will still need cervical screening.

Active squamous metaplasia of the cervical epithelium is associated with subsequent acquisition of human papillomavirus 16 infection among healthy young women

BACKGROUND

Vulnerability of younger women to human papillomavirus 16 (HPV16) infection has been attributed to the predominance of ectocervical columnar epithelia in this age group. However, squamous metaplastic tissue may be more influential. We examined the extent of ectopy and metaplastic activity as risks for HPV16 acquisition in a prospective cohort.

METHODS

Participants were HPV16 negative at the first two visits. Follow-up occurred every 4 months. Ectopy was quantitatively measured on colpophotographs. We calculated metaplastic rate as the difference in ectopy between visits. Cox proportional hazards models were constructed, adjusting for several covariates.

RESULTS

Analyses included 198 women (mean baseline age 17 years) for 1734 visits. Mean follow-up was 4.4 years. Incident HPV16 was detected in 36 (18%) women. Metaplastic rate between the two visits before HPV16 detection was significantly associated with incident infection (hazard ratio [HR], 1.17; confidence interval [CI], 1.02-1.33; P = .02). However, ectopy was not significant, whether measured before or concurrent to HPV16 detection (HR range, 0.99-1.00; CI range, .97-1.02; P range, .47-.65).

CONCLUSIONS

Dynamic metaplasia rather than the sheer extent of ectopy appears to increase risk for incident HPV16 in healthy young women. This in vivo observation is consistent with the HPV life cycle, during which host cell replication and differentiation supports viral replication.

Perspective for prophylaxis and treatment of cervical cancer: an immunological approach

As the second most common cause of cancer-related death in women, human papilloma virus (HPV) vaccines have been a major step in decreasing the morbidity and mortality associated with cervical cancer. An estimated 490,000 women are diagnosed with cervical cancer each year. Increasing knowledge of the HPV role in the etiology of cervical cancer has led to the development and introduction of HPV-based vaccines for active immunotherapy of cervical cancer. Immunotherapies directed at preventing HPV-persistent infections. These vaccines are already accessible for prophylaxis and in the near future, they will be available for the treatment of preexisting HPV-related neoplastic lesions.

[Do media reports and public brochures facilitate informed decision making about cervical cancer prevention?]

With the introduction and recommendation of the new HPV (human papillomavirus) vaccination in 2007, cervical cancer prevention has evoked large public interest. Is the public able to make informed decisions on the basis of media reports and brochures? To answer this question, an analysis of media coverage of HPV vaccination (Gardasil®) and Pap (Papanicolaou) screening was conducted from 2007-2009, which investigated the minimum requirement of completeness (pros and cons), transparency (absolute numbers), and correctness (references concerning outcome, uncertainty, magnitude) of the information. As a bench mark, facts boxes with concise data on epidemiology, etiology, benefits, harms, and costs were compiled in advance. Although all vaccination reports and brochures covered the impact of prevention, only 41% provided concrete numbers on effectiveness (90/220) and 2% on absolute risk reductions for the cancer surrogate dysplasia (5/220), whereby none of the latter numbers was correct. The prevention potential was correctly presented once. Only 48% (105/220) mentioned pros and cons. With regard to screening, 20% (4/20) provided explicit data on test quality and one expressed these in absolute numbers, while 25% (5/20) reported the prevention potential; all given numbers were correct. Finally, 25% (5/20) mentioned the possibility of false positive results. Minimum requirements were fulfilled by 1/220 vaccination and 1/20 screening reports. At present, informed decision making based on media coverage is hardly possible.

Updates on human papillomavirus and genital warts and counseling messages from the 2010 Sexually Transmitted Diseases Treatment Guidelines

BACKGROUND

In April 2009, experts on sexually transmitted diseases (STDs) were convened to review updates on STD prevention and treatment in preparation for the revision of the Centers for Disease Control and Prevention (CDC) STD Treatment Guidelines. At this meeting, there was a discussion of important updates on human papillomavirus (HPV), genital warts, and cervical cancer screening.

METHODS

Key questions were identified with assistance from an expert panel, and systematic reviews of the literature were conducted searching the English-language literature of the PubMed computerized database (US National Library of Medicine). The available evidence was reviewed, and new information was incorporated in the 2010 CDC STD Treatment Guidelines.

RESULTS

Two HPV vaccines are now available, the quadrivalent HPV vaccine and the bivalent HPV vaccine; either vaccine is recommended routinely for girls aged 11 or 12 years. The quadrivalent HPV vaccine may be given to boys and men aged 9-26 years. A new patient-applied treatment option for genital warts, sinecatechins 15% ointment, is available and recommended for treatment of external genital warts. This product is a mixture of active ingredients (catechins) from green tea. Finally, updated counseling guidelines and messages about HPV, genital warts, and cervical cancer are included.

CONCLUSIONS

This manuscript highlights updates to the 2010 CDC STD Treatment Guidelines for HPV and genital warts. Important additions to the 2010 STD Treatment Guidelines include information on prophylactic HPV vaccine recommendations, new patient-applied treatment options for genital warts, and counseling messages for patients on HPV, genital warts, cervical cancer screening, and HPV tests.

2012 European guideline for the management of anogenital warts

BACKGROUND

Although new HPV vaccines have been developed and are in the process of implementation, anogenital warts remain a very frequent problem in clinical practice.

OBJECTIVE

We wished to update previously published European guidelines for the management of anogenital warts.

METHODS

We performed a systematic review of randomized controlled trials for anogenital warts. The primary data were analyzed and collated, and the findings were formulated within the structure of a clinical guideline. The IUSTI Europe Editorial Board reviewed the draft guideline which was also posted on the web for comments which we incorporated into the final version of the guideline.

RESULTS

The data confirm that only surgical therapies have primary clearance rates approaching 100%. Recurrences, including new lesions at previously treated or new sites, occur after all therapies, and rates are often 20-30% or more. All therapies are associated with local skin reactions including itching, burning, erosions and pain.

CONCLUSIONS

Physicians treating patients with genital warts should develop their own treatment algorithms which include local practice and recommendations. Such patient level management protocols should incorporate medical review of cases at least every 4 weeks, with switching of treatments if an inadequate response is observed. First episode patients should be offered sexually transmitted disease screening. Management should include partner notification and health promotion.

Male human papillomavirus prevalence and association with condom use in Brazil, Mexico, and the United States

BACKGROUND

Reported associations of condom use and human papillomavirus (HPV) infection have been inconsistent. We investigated self-reported frequency of condom use and detection of genital HPV among men.

METHODS

A cross-sectional analysis was conducted in men aged 18-70 years from Brazil, Mexico, and the United States. Men completed questionnaires on sexual history, condom use, and sociodemographic characteristics. Among 2621 men reporting recent vaginal sex, prevalence of any HPV, any oncogenic type, and nononcogenic types only was estimated by frequency of condom use ("always" or "not always"). Multivariable models were used to estimate prevalence ratios (PRs) for HPV according to frequency of condom use.

RESULTS

The prevalence of any HPV was 70.5%; any oncogenic type, 34%, and nononcogenic types only, 22.2%. The adjusted PR for always vs not always using condoms was 0.87 (95% confidence interval [CI], .77-.97) for all countries combined. The association was stronger in the United States (PR, 0.70; CI, .55-.90) than in Brazil (PR, 0.84; CI, .71-1.01) or Mexico (PR, 1.05; CI, .89-1.25) (P for interaction = .025).

CONCLUSIONS

HPV prevalence was high even among those who reported always using condoms, and its associations with always using condoms varied among countries.

A multi-center survey of age of sexual debut and sexual behavior in Chinese women: suggestions for optimal age of human papillomavirus vaccination in China

OBJECTIVE

Cervical cancer is the second most common cancer among women worldwide, and over 85% of cervical cancers occur in developing countries such as China. Lack of resources for nationwide cervical cancer screening in China makes vaccination against oncogenic strains of HPV particularly important. Knowledge of age at sexual debut and sexual behavior is essential prior to implementation of a national vaccination program.

METHODS AND MATERIALS

A cross-sectional epidemiologic survey was conducted across 21 urban and rural sites in China to assess age at sexual debut and sexual behavior. 98.6% of the 11,852 recruited women aged 15-59 years were included in the analysis. Data were collected using a short, nurse-administered questionnaire and analyzed using standard descriptive statistics and survival analysis.

RESULTS

In urban areas, more than ten percent of the 15-19 year old age group were already sexually active at the time of interview; this number increased to nearly 44% in the 20-24 year old age group. Chinese young women with an occupation were more likely to be sexually active compared to female students of the same age, irrespective of area of residence. The crude median sexual debut age for the youngest age group was 17 years, earlier than the sexual debut age reported by older cohorts. Younger age cohorts had an earlier menarche age than older cohorts and were more likely to have more sexual partners than older women, and more likely to have partners with more than one female partner.

CONCLUSION

There is a trend towards earlier sexual debut and riskier sexual behaviors in younger age groups of Chinese women. These findings suggest that HPV vaccination of women between the ages of 13 and 15 years, before the completion of national compulsory education, is likely to contribute to the prevention of HPV infection and cervical cancer in China.

Viral infections of the pubis

There are no demographic data published on those with viral infections of the pubis (VIPs). We conducted a two-year prospective study to collect demographic information on patients with VIPs. Data were gathered on age, sex, diagnosis, low (≤10) or high (>10) lesion number, symptoms, how the patient discovered the lesions, localization, lesions beyond the pubis, risk factors, shaving habits, human papillomavirus (HPV) vaccination status and treatment. In a total of 61 patients, molluscum contagiosum (MC) was identified in 71%, condylomata acuminata (CA) in 11%, concomitant MC and CA infections in 11% and herpes simplex virus (HSV) infection in 4.8%. Shaving represented a risk factor for a high lesion number, but not for the extension beyond the pubis. MC, CA and HSV infections affecting the pubis are uncommon and often asymptomatic. As they may represent a hidden source of infection we recommend thorough inspection of the pubis during routine skin examination.

Condom effectiveness: where are we now?

After performing a review of prospective cohort evaluations, a focussed assessment of the current knowledge base and methodology pertaining to condom effectiveness against sexually transmissible infections, including HIV, was also conducted. Key observations included the point that studies of condom effectiveness are inherently complex and the potential forms of study bias all generally favour the null hypothesis. Perhaps the most challenging obstacle to rigor in these studies lies in determining which events of condom-protected sex occurred before infection as opposed to after infection when, in fact, infection occurs. This problem leads to misclassification bias; however, other sources of misclassification bias are common. Greater attention to the selection of a recall period, improved precision of self-reported measures, and accounting for condom use errors and problems are critical steps that must occur to promote rigor in these studies. Despite multiple shortcomings, prospective studies of condom effectiveness provide a reasonably favourable evaluation. Subsequent studies, however, should be designed to greatly reduce the error variance that predisposes condom effectiveness studies to type 2 errors that mask the potential value of condoms.

Condom use around the globe: how can we fulfil the prevention potential of male condoms?

Despite a global epidemic of sexually transmissible infections and the availability and endorsement of condoms as an effective intervention, the overall use of condoms remains low. This review explores various challenges and opportunities to fully realizing the prevention potential for condoms.

Interventions to prevent sexually transmitted infections, including HIV infection

The Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) Treatment Guidelines were last updated in 2006. To update the "Clinical Guide to Prevention Services" section of the 2010 CDC STD Treatment Guidelines, we reviewed the recent science with reference to interventions designed to prevent acquisition of STDs, including human immunodeficiency virus (HIV) infection. Major interval developments include (1) licensure and uptake of immunization against genital human papillomavirus, (2) validation of male circumcision as a potent prevention tool against acquisition of HIV and some other sexually transmitted infections (STIs), (3) failure of a promising HIV vaccine candidate to afford protection against HIV acquisition, (4) encouragement about the use of antiretroviral agents as preexposure prophylaxis to reduce risk of HIV and herpes simplex virus acquisition, (5) enhanced emphasis on expedited partner management and rescreening for persons infected with Chlamydia trachomatis and Neisseria gonorrhoeae, (6) recognition that behavioral interventions will be needed to address a new trend of sexually transmitted hepatitis C among men who have sex with men, and (7) the availability of a modified female condom. A range of preventive interventions is needed to reduce the risks of acquiring STI, including HIV infection, among sexually active people, and a flexible approach targeted to specific populations should integrate combinations of biomedical, behavioral, and structural interventions. These would ideally involve an array of prevention contexts, including (1) communications and practices among sexual partners, (2) transactions between individual clients and their healthcare providers, and (3) comprehensive population-level strategies for prioritizing prevention research, ensuring accurate outcome assessment, and formulating health policy.

Male circumcision and human papillomavirus infection in men: a systematic review and meta-analysis

BACKGROUND

We systematically reviewed the evidence for an association between male circumcision and Human Papillomavirus (HPV) infection and genital warts in men.

METHODS

PubMed and Embase were searched to 15 September 2010. The measure of effect was the adjusted odds ratio (OR) or rate ratio (RR) when present and the crude estimate otherwise. Random effects meta-analyses were used to calculate summary measures of effect.

RESULTS

We identified 23 papers about the association between circumcision and HPV DNA. Circumcised men were less likely to have prevalent genital HPV infection than uncircumcised men (summary OR, 0.57, 95% confidence interval [CI], 0.45-0.71) with between-study heterogeneity (P-heterogeneity = 0.006; I(2) = 50.5%; 19 studies). Similar summary associations were seen in clinical and methodological subgroups. The effect of circumcision was stronger at the glans/corona (OR, 0.47; 95% CI, 0.37-0.60) and urethra (OR, 0.35; 95% CI, 0.12-1.05) compared with sites more distal to the foreskin. There was weak evidence that circumcision was associated with decreased HPV incidence (summary RR, 0.75, 95% CI, 0.57-0.99; 3 studies) and increased HPV clearance (summary RR, 1.33; 95% CI, 0.89-1.98; 3 studies) but no evidence of an association with prevalent genital warts (OR, 0.93, 95% CI, 0.65-1.33; 15 studies).

CONCLUSIONS

Several countries are expanding access to voluntary medical male circumcision to reduce HIV prevalence. This could provide additional benefit in reducing HPV prevalence.

[HPV prophylactic vaccine coverage in France: Results of a survey among high school and university students in Marseilles' area]

OBJECTIVE

To assess HPV prophylactic vaccine coverage among French high school and university students as well as their level of education about this vaccine.

PATIENTS AND METHODS

An anonymous survey was conducted among 2500 high school and university students from the area of Marseilles, France, from December 2009 to April 2010.

RESULTS

A total of 2018 questionnaires were collected (80.7% participation rate). Mean age of participants was 20 years (range, 15-45 years). Only 671 (35.4%) participants reported having been vaccinated against HPV, of whom 510 (73.4%) had completed the three injections scheme. Practice of cytological cervical cancer screening was not significantly influenced by vaccination status. Thus, 578 (45.2%) participants who had not been vaccinated already had had a cervical cytology performed, versus 295 (43.3%) vaccinated ones (P=0.445). Among those not being vaccinated, 671 (49.8%) fulfilled criteria for a catch-up vaccination, of whom only 325 (48.4%) agreed for such a catch-up. Main reasons given for refusal for a catch-up vaccination were the lack of information about HPV vaccine and fear of side effects. In total, 1722 (90%) considered themselves as educated about the HPV vaccine. Source of education was attributed to doctors and media by 54.4% and 53.7% of participants, respectively. Educational role attributed to school and university was poor (3.4%).

CONCLUSION

Despite apparent satisfactory level of education, HPV prophylactic vaccine coverage among high school and university students appears to be insufficient.

Epidemiology and burden of HPV infection and related diseases: implications for prevention strategies

Human papillomavirus (HPV) infection is a necessary, although not sufficient cause of cervical cancer. Globally, HPV infection accounts for an estimated 530,000 cervical cancer cases (~270,000 deaths) annually, with the majority (86% of cases, 88% of deaths) occurring in developing countries. Approximately 90% of anal cancers and a smaller subset (<50%) of other cancers (oropharyngeal, penile, vaginal, vulvar) are also attributed to HPV. In total, HPV accounts for 5.2% of the worldwide cancer burden. HPVs 16 and 18 are responsible for 70% of cervical cancer cases and, especially HPV 16, for a large proportion of other cancers. Prophylactic vaccination targeting these genotypes is therefore expected to have a major impact on the burden of cervical cancer as well as that of other HPV-related cancers. Over the past 50 years, organized or opportunistic screening with Papanicolaou (Pap) cytology has led to major reductions in cervical cancer in most developed countries. However, due to lack of resources or inadequate infrastructure, many countries have failed to reduce cervical cancer mortality through screening. HPV DNA testing recently emerged as a likely candidate to replace Pap cytology for primary screening. It is less prone to human error and more sensitive than Pap in detecting high-grade cervical lesions. For countries with national vaccination programs, HPV testing may also serve as a low cost strategy to monitor long term vaccine efficacy. Introduction of well organized vaccination and screening programs should be a priority for all countries. Increased support from donors is needed to support this cause.

Intrauterine device use, cervical infection with human papillomavirus, and risk of cervical cancer: a pooled analysis of 26 epidemiological studies

BACKGROUND

Intrauterine device (IUD) use has been shown to reduce the risk of endometrial cancer, but little is known about its association with cervical cancer risk. We assessed whether IUD use affects cervical human papillomavirus (HPV) infection and the risk of developing cervical cancer.

METHODS

We did a pooled analysis of individual data from two large studies by the International Agency for Research on Cancer and Institut Català d'Oncologia research programme on HPV and cervical cancer; one study included data from ten case-control studies of cervical cancer done in eight countries, and the other included data from 16 HPV prevalence surveys of women from the general population in 14 countries. 2205 women with cervical cancer and 2214 matched control women without cervical cancer were included from the case-control studies, and 15,272 healthy women from the HPV surveys. Information on IUD use was obtained by personal interview. HPV DNA was tested by PCR-based assays. Odds ratios and 95% CIs were estimated using multivariate unconditional logistic regression for the associations between IUD use, cervical HPV DNA, and cervical cancer.

FINDINGS

After adjusting for relevant covariates, including cervical HPV DNA and number of previous Papanicolaou smears, a strong inverse association was found between ever use of IUDs and cervical cancer (odds ratio 0·55, 95% CI 0·42-0·70; p<0·0001). A protective association was noted for squamous-cell carcinoma (0·56, 0·43-0·72; p<0·0001), adenocarcinoma and adenosquamous carcinoma (0·46, 0·22-0·97; p=0·035), but not among HPV-positive women (0·68, 0·44-1·06; p=0·11). No association was found between IUD use and detection of cervical HPV DNA among women without cervical cancer.

INTERPRETATION

Our data suggest that IUD use might act as a protective cofactor in cervical carcinogenesis. Cellular immunity triggered by the device might be one of several mechanisms that could explain our findings.

FUNDING

Instituto de Salud Carlos III; Agència de Gestió d'Ajuts Universitaris i Recerca; Marató TV3 Foundation; Bill & Melinda Gates Foundation; International Agency for Research on Cancer; European Community; Fondo de Investigaciones Sanitarias, Spain; Preventiefonds, Netherlands; Programa Interministerial de Investigación y Desarrollo, Spain; Conselho Nacional de Desenvolvimiento Cientifico e Tecnologico, Brazil; and Department of Reproductive Health & Research, WHO.

Clinical perspectives on the role of the human papillomavirus vaccine in the prevention of cancer

The role of human papillomavirus (HPV) in the genesis of cervical cancer has been well documented, and an increasing body of literature exists with regard to the role of HPV in other cancers, including cancers of the head and neck. With the recent expansion of the United States Food and Drug Administration's approval of the quadrivalent HPV virus-like particle vaccine to include men and boys and approval of the bivalent vaccine this year, the controversies regarding who should be vaccinated, at what age is vaccination most appropriate, and the limitations of the available HPV vaccines are increasing. Health care providers are challenged with evaluating the current, but continually changing, clinical evidence when making critical decisions for their patients. A literature search of MEDLINE and SciVerse Scopus was conducted for articles published from 1998-April 2010 regarding HPV, HPV-related cancers, and HPV vaccines. Although both HPV vaccines were greater than 90% effective in the prevention of cervical cancer precursors in an according-to-protocol cohort, both vaccines were significantly less effective in the intent-to-treat population. In patients who achieved seroconversion, the geometric mean titers decrease dramatically within the first 2 years after vaccination, and then continue to decline at a slower rate. No effective antibody titer has been defined for either vaccine, and no studies have been conducted with documented HPV exposure after vaccination. With low efficacy rates in an intent-to-treat population and the potential for waning immunity, it is imperative for women to continue to receive regular Pap tests and gynecologic examinations. Although vaccine administration was shown to be cost-effective when administered to adolescent girls, many of these simulations overestimated the durability of protection, efficacy rates in sexually active women, impact of incomplete vaccination, or necessity of boosters in the future. Whereas the introduction of the HPV vaccine was an enormous advancement in the cancer prevention research arena, optimization of its clinical use is still needed.

HBV infection in relation to consistent condom use: a population-based study in Peru

Background

Data on hepatitis B virus (HBV) prevalence are limited in developing countries. There is also limited information of consistent condom use efficacy for reducing HBV transmission at the population level. The study goal was to evaluate the prevalence and factors associated with HBV infection in Peru, and the relationship between anti-HBc positivity and consistent condom use.

Methods and Findings

Data from two different surveys performed in 28 mid-sized Peruvian cities were analyzed. Participants aged 18–29 years were selected using a multistage cluster sampling. Information was collected through a validated two-part questionnaire. The first part (face-to-face) concerned demographic data, while the second part (self-administered using handheld computers) concerned sexual behavior. Hepatitis B core antibody (anti-HBc) was tested in 7,000 blood samples. Prevalences and associations were adjusted for sample strata, primary sampling units and population weights. Anti-HBc prevalence was 5.0% (95%CI 4.1%–5.9%), with the highest prevalence among jungle cities: 16.3% (95%CI 13.8%–19.1%). In the multivariable analysis, Anti-HBc positivity was directly associated with geographic region (highlands OR = 2.05; 95%CI 1.28–3.27, and jungle OR = 4.86; 95%CI 3.05–7.74; compared to coastal region); and inversely associated with age at sexual debut (OR = 0.90; 95%CI 0.85–0.97). Consistent condom use, evaluated in about 40% of participants, was associated with reduced prevalence (OR = 0.34; 95%CI 0.15–0.79) after adjusting for gender, geographic region, education level, lifetime number of sex partners, age at sexual debut and year of survey.

Conclusion

Residence in highlands or jungle cities is associated with higher anti-HBc prevalences, whereas increasing age at sexual debut were associated with lower prevalences. Consistent condom use was associated with decreased risk of anti-HBc. Findings from this study emphasize the need of primary prevention programs (vaccination) especially in the jungle population, and imply that condom use promotion might be a potential strategy to prevent HBV infection.

Serum antibody response following genital {alpha}9 human papillomavirus infection in young men

Background. Although the prevalence of human papillomavirus (HPV) genital infection is similarly high in males and females, seroprevalence is lower in males. This study assessed rates and determinants of seroconversion after detection of genital HPV infection in young men. Methods. We investigated HPV type-specific seroconversion in a cohort of heterosexual male university students who had an α9 HPV type (HPV-16, -31, -33, -35, -52, -58, or -67) detected in the genital tract (n = 156). HPV DNA and antibodies were detected and typed using liquid bead-based multiplex assays. We calculated seroconversion using Kaplan-Meier survival analysis. Cox proportional hazards models with generalized estimating equations were used to examine associations with seroconversion. Results. Within 24 months of detecting genital HPV infection, type-specific seroconversion ranged from 4% for HPV-52 to 36% for HPV-31. HPV-16 seroconversion at 24 months was 13% (95% confidence interval [CI], 7%-25%). Among incident HPV infections, ever cigarette smoking and infection site(s) (shaft/scrotum and glans/urine vs shaft/scrotum or glans/urine only) were positively associated with type-specific seroconversion. Conclusions. For each of the α9 HPV types, type-specific seroconversion within 24 months was observed in 36% or less of infected men. Seroconversion might be related to cigarette smoking and genital site(s) infected.

The human papillomavirus (HPV) vaccine and cervical cancer: uptake and next steps

Infection with a high-risk type of the human papillomavirus (HPV) is a major contributing factor in the vast majority of cervical cancers. Dissemination of the HPV vaccine is critical in reducing the risk of the disease. This descriptive review of HPV vaccine uptake in papers published between 2006 and 2011 focuses on studies conducted in girls and young women. In the United States, rates of immunization as per the protocol for teens (age 13-17 years) range from 6% to 75% and those for young women (age 18-26 years) range from 4% to 79%, although the samples and data collection methods vary. The epidemiology of HPV, the mechanisms of action, protocols for vaccine immunization, rates of uptake, and barriers to vaccination at the policy, provider, and patient levels are reviewed. Various intervention techniques are described, and policy-level programs, such as legislation supporting mandates, subsidized public education, and cost-reduction initiatives, are also explored. Increased distribution of the HPV vaccine in school-based clinics, evidencebased scripts for provider counseling of young patients and their parents, concurrent immunizations to adolescents, prevention visits, greater patient education and outreach, and the dissemination of academic detailing can help to boost vaccine uptake, particularly in underresourced communities. Population-based surveillance is necessary for robust estimates of uptake over time. Additional research is needed to comprehensively examine socio-demographic, psychosocial, and sociocultural factors that predict vaccine uptake according to the protocol. Increased study of the vaccine's long-term effectiveness, in both males and females and among extended age groups, is warranted.

Incomplete knowledge--unclarified roles in sex education: results of a national survey about human papillomavirus infections

The purpose of this study was to evaluate the awareness of human papillomavirus (HPV) infections both in male and female adults in Hungary. A self-administered, anonymous questionnaire was completed by 785 college students and parents between January and May, 2009. The results were analysed by gender and age. Participants' knowledge about HPV and HPV-associated conditions was relatively incomplete. One-third of the respondents had never heard about HPV prior to the survey. Almost half of the respondents (42%) thought that the only sexual way of spreading HPV was vaginal intercourse, while the role of skin-to-skin contact was disregarded (6%). More than one-third of the participants (38%) believed that condoms give full protection from HPV infection. Encouragingly, the majority of respondents (64%) were open to further information about sexually transmitted diseases. The most trusted sources of information were health professionals. When talking about children, parents attributed the major role in delivering information about sexually transmitted diseases to schools. Primary prevention through carefully planned educational programmes may further raise the awareness about HPV-associated conditions, thus reducing the comparatively high mortality of cervical carcinoma in Hungary.

Aspects of prophylactic vaccination against cervical cancer and other human papillomavirus-related cancers in developing countries

Cervical cancer and other human papillomavirus- (HPV-) related cancers are preventable, but preventive measures implemented in developing countries and especially in low-income rural regions have not been effective. Cervical cancer burden derived from sexually transmitted HPV infections is the heaviest in developing countries, and a dramatic increase in the number of cervical cancer cases is predicted, if no intervention is implemented in the near future. HPV vaccines offer an efficient way to prevent related cancers. Recently implemented school-based HPV vaccination demonstration programmes can help tackle the challenges linked with vaccine coverage, and access to vaccination and health services, but prevention strategies need to be modified according to regional characteristics. In urban regions WHO-recommended vaccination strategies might be enough to significantly reduce HPV-related disease burden, but in the rural regions additional vaccination strategies, vaccinating both sexes rather than only females when school attendance is the highest and applying a two-dose regime, need to be considered. From the point of view of both public health and ethics identification of the most effective prevention strategies is pivotal, especially when access to health services is limited. Considering cost-effectiveness versus justice further research on optional vaccination strategies is warranted.

[Epidemiology, characterization of genotypes of human papillomavirus in a population of women in Ouagadougou]

OBJECTIVES

This work was carried out in order to determine the prevalence of different HPV genotypes in a population of women attending gynecological consultation.

MATERIAL AND METHODS

From May to June 2010, cervical samples were obtained from 300 women attending gynecological consultation in two health centers in Ouagadougou. The strains of HPV genotyping was done using the technique of polymerase chain reaction (PCR) followed by reverse hybridization on nitrocellulose strips.

RESULTS

Among the 73 women(24.3%) infected with HPV, only 27.4% (20/73) of them were infected with a HPV low risk (BR), the 72.6% (53/73). Other women were infected with at least one high risk HPV (HR). By combining the HPV genotypes found without taking into account the number of infected women, we found a total of 84 HPV among whom we have high-risk HPV : HPV-50'S(26/84 or 31.0%), HPV-18 (12/84 or 14.3%), HPV-16 (9/84 or 10.7%), HPV-30'S (5/84 or 5.9%), HPV-HR (5/84 or 5.9%) and HPV-45 (3/84 or 3.6%) and low-risk HPV: HPV-6 (15/84 or 17.9%) and HPV-BR (9/84 or 10.7%). We have found no HPV-11.

DISCUSSION AND CONCLUSION

The prevalence of HPV found in our series is comparable to that found in the world. To complete this study, it would be necessary to investigate the prevalence of HPV found in cervical lesions in Burkina Faso.

Assessing perceived risk and STI prevention behavior: a national population-based study with special reference to HPV

INTRODUCTION

To better understand trends in sexually transmitted infection (STI) prevention, specifically low prevalence of condom use with temporary partners, the aim of this study was to examine factors associated with condom use and perceptions of STI risk amongst individuals at risk, with the underlying assumption that STI risk perceptions and STI prevention behaviors are correlated.

METHODS

A national population-based survey on human papillomavirus (HPV) and sexual habits of young adults aged 18-30 was conducted in Sweden in 2007, with 1712 men and 8855 women participating. Regression analyses stratified by gender were performed to measure condom use with temporary partners and STI risk perception.

RESULTS

Men's condom use was not associated with STI risk perception while women's was. Awareness of and disease severity perceptions were not associated with either condom use or risk perception though education level correlated with condom use. Women's young age at sexual debut was associated with a higher risk of non-condom use later in life (OR 1.95 95% CI: 1.46-2.60). Women with immigrant mothers were less likely to report seldom/never use of condoms with temporary partners compared to women with Swedish-born mothers (OR 0.53 95% CI: 0.37-0.77). Correlates to STI risk perception differ substantially between sexes. Number of reported temporary partners was the only factor associated for both men and women with condom use and STI risk perception.

CONCLUSIONS

Public health interventions advocating condom use with new partners could consider employing tactics besides those which primarily aim to increase knowledge or self-perceived risk if they are to be more effective in STI reduction. Gender-specific prevention strategies could be effective considering the differences found in this study.

Factors associated with intention to vaccinate a daughter against HPV: a statewide survey in Alabama

PURPOSE

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Adolescent and young adults aged 15-24 were estimated to account for three quarters of new infections in 2000. Two HPV vaccines are currently available. The vaccine is recommended for girls aged 11-12 years. Previous research has indicated that African-American and Asian-American parents are less likely than Caucasians to vaccinate their daughters. This investigation examines the relationship between demographic, medical, and behavioral risk factors for HPV vaccine acceptability among Alabama residents.

METHODS

The cross-sectional survey was conducted using random digit dialing. Eligible participants were female caregivers of adolescent girls between the ages of 10 and 14 years. Factors related to intention to vaccinate a daughter within the next six months were examined using chi-square and logistic regression.

RESULTS

Caregivers who were informed about HPV vaccination from a health care provider were more likely to intend to vaccinate their daughter within the next six months compared with caregivers who did not report this source of information (OR = 3.59, 95% CI = 1.52, 8.45). Race, education, county of residence, child's age, religious attendance, knowledge and history of HPV, perceived susceptibility, and severity of infection were not significantly related to intention to vaccinate against HPV.

CONCLUSION

Caregivers who were informed of the vaccine by their health care provider were more likely to vaccinate their adolescent daughters. Provider attitudes and caregiver education is an essential link to improvement of HPV vaccination uptake in Alabama.

Evaluation of type-specific HPV persistence and high-risk HPV viral load quantitation in HPV positive women under 30 with normal cervical cytology

The persistence of high-risk HPV (HR-HPV) infection is necessary for the development of cervical intraepithelial neoplasia. The aim of this study was to evaluate if HR-HPV typing and HPV16, 18, 31, and 33 quantitation are predictive for type-specific infection persistence and/or the development of CIN in women under 30 with normal cervical cytology. Young women (under 30) attending a family planning clinic who were HPV positive with normal cervical cytology were included. HPV genotyping was assessed by MY09/MY11 PCR, sequencing, phylogenetic analysis, and cloning when necessary. HR-HPV viral load was quantified using duplex real-time PCR. Study patients were offered for a second smear and HR-HPV detection and quantitation after 12 months. HR-HPV was identified in 43 (21.9%) of the 199 included women. Of these, 39 patients had a second cervical sample taken within a mean interval of 11.7 months (8.8-18.3 months). The mean HR-HPV 16, 18, 31, and 33 initial viral load was 1.9 × 10(6) copies/million cells. The level of viral load did not reveal any significant association with type-specific HR-HPV persistence or the subsequent development of cervical intraepithelial neoplasia. Only HPV16 infection was significantly more likely to persist (91.7% vs. 33.1%, P=0.001) and to develop CIN (33.3% vs. 3.7%, P=0.025). In women under 30 with normal cytology, HR-HPV viral load is common and is not predictive of HPV persistence or the development of cervical intraepithelial neoplasia. HPV16 positive women are significantly more likely to have persistent infection and to develop cervical intraepithelial neoplasia.

The Strong Protective Effect of Circumcision against Cancer of the Penis

Male circumcision protects against cancer of the penis, the invasive form of which is a devastating disease confined almost exclusively to uncircumcised men. Major etiological factors are phimosis, balanitis, and high-risk types of human papillomavirus (HPV), which are more prevalent in the glans penis and coronal sulcus covered by the foreskin, as well as on the penile shaft, of uncircumcised men. Circumcised men clear HPV infections more quickly. Phimosis (a constricted foreskin opening impeding the passage of urine) is confined to uncircumcised men, in whom balanitis (affecting 10%) is more common than in circumcised men. Each is strongly associated with risk of penile cancer. These findings have led to calls for promotion of male circumcision, especially in infancy, to help reduce the global burden of penile cancer. Even more relevant globally is protection from cervical cancer, which is 10-times more common, being much higher in women with uncircumcised male partners. Male circumcision also provides indirect protection against various other infections in women, along with direct protection for men from a number of genital tract infections, including HIV. Given that adverse consequences of medical male circumcision, especially when performed in infancy, are rare, this simple prophylactic procedure should be promoted.

Adherence to dual-method contraceptive use

BACKGROUND

Patient characteristics associated with adherence to dual-method contraceptive use are not known.

STUDY DESIGN

Project PROTECT was a 24-month-long randomized trial designed to promote the use of dual methods of contraception using an individualized computer-based intervention or enhanced standard care counseling intervention. We analyzed 463 women with follow-up data and examined sustained dual-method use (reported at 2+ interviews).

RESULTS

While 32% initiated dual-method contraceptive use, only 9% reported sustained use. Education increased (RR(adj)=4.42; 95% confidence interval [CI] 1.19-16.42), substance abuse decreased (adjusted relative risk [RR(adj)]=0.49; 95% CI 0.24-0.97), no contraceptive use at baseline decreased (RR(adj)=0.32; 95% CI 0.11-0.92) and contraceptive stage of change increased (RR(adj)=5.04; 95% CI 1.09-23.4) adherence to dual-method use.

CONCLUSION

To effectively prevent sexually transmitted diseases and unplanned pregnancies, dual-method use must be consistent and sustained. Future interventions to promote dual-method use should focus on high-risk groups and additional dual-method combinations (e.g., barrier plus intrauterine devices or implants).

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Early natural history of incident, type-specific human papillomavirus infections in newly sexually active young women

BACKGROUND

Characterizing short-term detection patterns of young women's incident α-genus human papillomavirus (HPV) infections may further our understanding of HPV transmission.

METHODS

Between 2000 and 2007, we followed 18- to 22-year-old female university students with triannual HPV DNA and Papanicolaou testing. Using Kaplan-Meier methods, we estimated duration of detectable, type-specific incident infections; time to redetection (among infections that became undetectable); and time to cervical lesion development after incident infection. We evaluated risk factors for short-term persistent versus transient infection with logistic regression.

RESULTS

Three hundred three incident, type-specific infections were detected in 85 sexually active women. Median time to first negative test after incident infection was 9.4 (95% CI: 7.8-11.2) months; 90.6% of infections became undetectable within 2 years. About 19.4% of infections that became undetectable were redetected within 1 year. Cervical lesions were common and 60% were positive for multiple HPV types in concurrent cervical swabs. Incident HPV detection in the cervix only (vs. the vulva/vagina only or both sites) was associated with short-term transience.

CONCLUSIONS

Although most incident infections became undetectable within 2 years, redetection was common. Cervical lesions were a common early manifestation of HPV infection.

IMPACT

It remains unclear whether potentially modifiable risk factors can be identified to reduce infection duration (and transmission likelihood).

Pathology and epidemiology of HPV infection in females

Human papillomaviruses (HPVs) are a large family of small double-stranded DNA viruses that infect squamous epithelia. It has been established that infection with specific HPV types is a contributing factor to different types of anogenital cancer, including vulval, vaginal, anal, penile, and head and neck cancers. Approximately 4% of all cancers are associated with HPV. HPV infection is the major cause of cervical cancer and genital warts. Genital HPV infections are very common, are sexually transmitted, and have a peak prevalence between ages 18 and 30. Most of these infections clear spontaneously, but in 10-20% of women, these infections remain persistent and are at risk of progression to grade 2/3 cervical intraepithelial neoplasm (CIN) and eventually to invasive cancer of the cervix (ICC). CINs are genetically unstable lesions with a 30-40% risk of progression to ICC. If left untreated, they form a spectrum of increasing cytological atypia, ranging from low-grade CIN1 to high-grade CIN3; the latter are caused almost exclusively by high-risk HPVs, HPV 16 and 18. Infection with HPV requires a microabrasion in the genital epithelium. The oncogenic properties of high-risk HPV reside in the E6 and E7 genes, which if inappropriately expressed in dividing cells deregulate cell division and differentiation. HPV DNA testing has been shown consistently to be superior to cytology in terms of sensitivity and positive predictive value and will become a major tool in cervical cancer screening, at least in the developed countries.

Prevalence and patient characteristics associated with CIN 3 in adolescents

OBJECTIVE

We sought to identify patient characteristics associated with cervical intraepithelial neoplasia (CIN) 3 in adolescents.

STUDY DESIGN

A cross-sectional cohort study was done using a colposcopic database. Data collected included demographic and clinical information as well as cytologic and histologic results. Variables associated with CIN 3 in the univariable analysis (P ≤ .10) were included in a multivariable logistic regression model.

RESULTS

Of 614 adolescents evaluated, 48 (8%; 95% confidence interval, 6-10%) had CIN 3. No cancers were detected. In the univariable analysis, parity, ≥ 4 lifetime male sexual partners, and a history of sexually transmitted infections were associated with an increased risk of CIN 3. In the final model, only ≥ 4 sexual partners (compared to <4; adjusted odds ratio, 3.66; 95% confidence interval, 1.26-10.61) was significantly associated with the finding of CIN 3.

CONCLUSION

CIN 3 was infrequently encountered in adolescents, and those with multiple sexual partners were at increased risk for CIN 3.

The ethics of implementing human papillomavirus vaccination in developed countries

Human papillomavirus (HPV) infection is the world's most common sexually transmitted infection. It is a prerequisite for cervical cancer, the second most common cause of death in cancer among women worldwide, and is also believed to cause other anogenital and head and neck cancers. Vaccines that protect against the most common cancer-causing HPV types have recently become available, and different countries have taken different approaches to implementing vaccination. This paper examines the ethics of alternative HPV vaccination strategies. It devotes particular attention to the major arguments for and against one strategy: voluntary, publicly funded vaccination for all adolescent boys and girls. This approach seems attractive because it would protect more people against cervical cancer and other HPV-related cancers than less inclusive alternatives, without the sacrifice of autonomy that a comparably broad compulsory programme would require. Also, the herd immunity that it would likely generate would protect those who remain unvaccinated, a major advantage from a justice perspective. However, there is a possibility that a HPV vaccination programme targeting all adolescents of both sexes is not considered sufficiently cost-effective. Also, it might pose more difficulties for achieving informed consent than comparable vaccination programmes against other diseases. Ultimately, society's choice of HPV vaccination strategy requires careful consideration not only of the values at stake but also of available and emerging scientific evidence.

Knowledge of human papillomavirus among high school students can be increased by an educational intervention

The aim of this study was to evaluate the effect of an educational intervention concerning human papillomavirus (HPV) directed at Swedish first year high school students. The intervention consisted of a class room lesson, a website and a folder. Outcome variables were knowledge of HPV and attitudes to preventive methods such as HPV vaccination, condom use and Pap smear testing. An intervention group (n = 92) was matched with two comparison groups (n = 184). At baseline, the median score for HPV knowledge was one out of 10 in both groups. At follow-up, the median knowledge score had increased to six in the intervention group, but was still one in the comparison group (P < 0.001). Attitudes to HPV vaccination, condom use and Pap smear testing remained the same (P > 0.05). In conclusion, a short school-based intervention can greatly increase the students' knowledge about HPV, but attitudes and behaviours are less easy to influence.