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Menon S, Rossi R, Kariisa M, Acharya SD, Zdraveska N, Mahmood S, Callens S, Ndizeye Z. Relationship between Highly Active Antiretroviral Therapy (HAART) and human papillomavirus type 16 (HPV 16) infection among women in Sub-Saharan Africa and public health implications: A systematic review. PLoS One 2019; 14:e0213086. [PMID: 30856196 PMCID: PMC6411162 DOI: 10.1371/journal.pone.0213086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 02/14/2019] [Indexed: 12/17/2022] Open
Abstract
Invasive cervical cancer is the most prevalent cancer among women in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) emitted recommendations to start Highly Active Antiretroviral Therapy (HAART) regardless of CD4 count. Although HAART has been shown to reduce the prevalence of high-risk human papillomavirus (HR-HPV) genotypes, it is unclear whether it confers a protective effect specifically for HPV 16. This review summarizes the existing evidence regarding the effect of HAART on HPV 16 infection, as this genotype may not be influenced by immunity level and explores its implications for Sub Saharan Africa. A comprehensive literature review was undertaken and quality assessment was carried out on the selected papers. Four cohort studies and three cross-sectional studies were identified for which the overall quality score assessment ranged from weak/moderate (Score of 1.8) to strong (Score of 3). The evidence yielded by our review was conflicting. Thus, the high heterogeneity between study populations and results did not allow us to draw any firm conclusions as to whether HAART has an impact on HPV 16 acquisition/prevalence. As only three studies were conducted in Africa, there are insufficient grounds for solid comparison between geographic regions. In light of inadequate data, HPV unvaccinated women on HAART should still receive more frequent follow-up.
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Affiliation(s)
- Sonia Menon
- International Centre for Reproductive Health (ICRH), Ghent University, De Pintelaan, Ghent, Belgium
- * E-mail:
| | - Rodolfo Rossi
- Primary Health Care Services, International Committee of the Red Cross, Geneva, Switzerland
| | - Mbabazi Kariisa
- March of Dimes Foundation, White Plains, New York, United States of America
| | | | - Natasha Zdraveska
- Faculty of Pharmacy, Department of Clinical Pharmacy, Saints Cyril and Methodius University (Alumni), Skopje, Republic of Macedonia
| | | | - Steven Callens
- Department of Internal Medicine & Infectious Diseases, University Hospital, Ghent, Belgium
| | - Zacharie Ndizeye
- Community Medicine Department, Faculty of Medicine, University of Burundi, Bujumbura, Burundi
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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Rad A, Sørbye SW, Dreyer G, Hovland S, Falang BM, Louw M, Skjeldestad FE. HPV types in cervical cancer tissue in South Africa: A head-to-head comparison by mRNA and DNA tests. Medicine (Baltimore) 2017; 96:e8752. [PMID: 29381969 PMCID: PMC5708968 DOI: 10.1097/md.0000000000008752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Accurate identification of human papillomavirus (HPV)-types in cervical cancer tissue may be important for tailoring tests for primary screening and types to be included in a vaccine. The aim of this study was to compare test-performance of a 45-type HPV deoxyribonucleic acid (DNA)-test with a 9-type HPV messenger ribonucleic acid (mRNA)-test in cervical cancer tissues.In a case-series design 188 women with diagnosed cervical cancer during the period January 2008 to July 1, 2011 at the Gynaecological Oncology Unit, University of Pretoria, South Africa were recruited to the study. After cases with negative internal controls for DNA/mRNA detection (n = 18) and unconfirmed histology (n = 3) of cervical cancer were excluded, 167 women remained eligible for analysis. We compared 45 DNA-types detected through general primer (GP)5/6 polymerase chain reaction (PCR) and reverse line blot (RLB) genotyping with a modified version of the mRNA test PreTect HPV-Proofer detecting 9 genotypes (16, 18, 31, 33, 35, 45, 51, 52, 58).Histological types were 92.2% squamous cell carcinoma, 4.8% adenocarcinoma, and 3.0% adenosquamous carcinoma. Overall, HPV was detected in 95.2% (159/167) of specimens. The DNA- and mRNA tests each rendered 153/167 (91.6%) HPV positive results. When restricting the analysis to the 9 high-risk HPV-types included in the mRNA test, 91.6% (153/167) and 88.0% (147/167) were positive by the mRNA- and DNA-tests (P = .28), respectively. After hierarchical categorization of 9 comparable types, we found concordance in 66 of 67 specimens for HPV16, 25 of 27 specimens for HPV18, 19 of 21 specimens for HPV45, and only in 33 of 45 for HPV31, 33, 35, 51, 52, 58. The positivity rate for the HPV types 16, 18, and 45 and the positivity rate for HPV 16, 18, 45, 33 and 35 by both tests was 66% to 68% and 80% to 83%, respectively.Overall and when considering established high-risk types, the mRNA test has at least as high detection rate as the DNA test. The mRNA test can be an appropriate research tool to describe causative HPV-types in cervical cancer tissue for health care planning purposes.
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Affiliation(s)
- Amir Rad
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway
| | | | - Greta Dreyer
- Department of Obstetrics and Gynaecology, University of Pretoria, Pretoria, South Africa
| | | | | | - Melanie Louw
- Department of Anatomical Pathology, University of Pretoria, Pretoria, South Africa
| | - Finn Egil Skjeldestad
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway
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The diversity of human papillomavirus infection among human immunodeficiency virus-infected women in Yunnan, China. Virol J 2014; 11:202. [PMID: 25481842 PMCID: PMC4279793 DOI: 10.1186/s12985-014-0202-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 11/14/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Yunnan has one of the oldest and the most severe human immunodeficiency virus (HIV) epidemics in China. We conducted an observational study to evaluate the human papillomavirus (HPV) genotype distribution in relation to cervical neoplastic disease risk among HIV-infected women in Yunnan. METHODS We screened 301 HIV-infected non-pregnant women in Mangshi prefecture in Yunnan province. All consenting participants underwent simultaneous and independent assessment by cervical cytology, colposcopy-histopathology, and HPV genotyping. Unadjusted and multivariable-adjusted multinomial logistic regression analysis was conducted to evaluate factors associated with single or multiple carcinogenic HPV genotypes. RESULTS HPV genotypes were present in 43.5% (131/301) overall, and carcinogenic HPV genotypes were present in 37.5% (113/301) women. Among women with carcinogenic HPV genotypes, 80 (70.8% of 113) had a single carcinogenic HPV type, while 33 (29.2%) women had multiple (2 or more) carcinogenic HPV types. Overall, the most common carcinogenic HPV types were HPV52 (7.3%), HPV58 (6.6%), HPV18 (6.3%), HPV16 (6.0%), and HPV33 (5.3%). In women with cervical precancerous lesions (i.e., high-grade squamous intraepithelial lesions [HSIL] on cytology or cervical intraepithelial neoplasia grade 2 or worse [CIN2+] detected on colposcopy-histology), the most commonly detected genotypes were HPV16 (28.6%), HPV52 (25.0%), HPV58 (17.9%), HPV18 (10.7%) and HPV31 (10.7%). Increasing age was an independent risk factor associated with presence of single carcinogenic HPV types (adjusted odds ratio: 1.04, 95%CI: 1.01-1.07, p = 0.012) but not with the presence of multiple carcinogenic types in the multivariable-adjusted models. CONCLUSIONS As HIV-infected women continue to live longer on antiretroviral therapy in China, it will be increasingly important to screen for, and prevent, HPV-associated cervical cancer in this population, especially given the wide diversity and multiplicity of HPV genotypes.
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Prevalence and Genotypes of HPV in Female Renal Transplant Recipients in North India. Int J Gynecol Pathol 2014; 33:537-42. [DOI: 10.1097/pgp.0b013e3182a54ada] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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De Vuyst H, Alemany L, Lacey C, Chibwesha CJ, Sahasrabuddhe V, Banura C, Denny L, Parham GP. The burden of human papillomavirus infections and related diseases in sub-saharan Africa. Vaccine 2014; 31 Suppl 5:F32-46. [PMID: 24331746 DOI: 10.1016/j.vaccine.2012.07.092] [Citation(s) in RCA: 158] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Revised: 07/06/2012] [Accepted: 07/10/2012] [Indexed: 11/17/2022]
Abstract
Despite the scarcity of high quality cancer registries and lack of reliable mortality data, it is clear that human papillomavirus (HPV)-associated diseases, particularly cervical cancer, are major causes of morbidity and mortality in sub-Saharan Africa (SSA). Cervical cancer incidence rates in SSA are the highest in the world and the disease is the most common cause of cancer death among women in the region. The high incidence of cervical cancer is a consequence of the inability of most countries to either initiate or sustain cervical cancer prevention services. In addition, it appears that the prevalence of HPV in women with normal cytology is higher than in more developed areas of the world, at an average of 24%. There is, however, significant regional variation in SSA, with the highest incidence of HPV infection and cervical cancer found in Eastern and Western Africa. It is expected that, due to aging and growth of the population, but also to lack of access to appropriate prevention services and the concomitant human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) epidemic, cervical cancer incidence and mortality rates in SSA will rise over the next 20 years. HPV16 and 18 are the most common genotypes in cervical cancer in SSA, although other carcinogenic HPV types, such as HPV45 and 35, are also relatively more frequent compared with other world regions. Data on other HPV-related anogenital cancers including those of the vulva, vagina, anus, and penis, are limited. Genital warts are common and associated with HPV types 6 and 11. HIV infection increases incidence and prevalence of all HPV-associated diseases. Sociocultural determinants of HPV-related disease, as well as the impact of forces that result in social destabilization, demand further study. Strategies to reduce the excessive burden of HPV-related diseases in SSA include age-appropriate prophylactic HPV vaccination, cervical cancer prevention services for women of the reproductive ages, and control of HIV/AIDS. This article forms part of a regional report entitled "Comprehensive Control of HPV Infections and Related Diseases in the Sub-Saharan Africa Region" Vaccine Volume 31, Supplement 5, 2013. Updates of the progress in the field are presented in a separate monograph entitled "Comprehensive Control of HPV Infections and Related Diseases" Vaccine Volume 30, Supplement 5, 2012.
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Affiliation(s)
- Hugo De Vuyst
- Infection and Cancer Epidemiology Group, International Agency for Research on Cancer (WHO-IARC), Lyon, France
| | - Laia Alemany
- Unit of Infections and Cancer (UNIC), Cancer Epidemiology Research Program (CERP), Institut Català d'Oncologia - Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat (Barcelona), Spain; CIBER en Epidemiología y Salud Pública (CIBERESP), Spain
| | - Charles Lacey
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, UK
| | - Carla J Chibwesha
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, U.S.A and Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Vikrant Sahasrabuddhe
- Hormonal and Reproductive Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cecily Banura
- Department of Child Health and Development Centre, Makerere University College of Health Sciences, Kampala, Uganda
| | - Lynette Denny
- Department of Obstetrics and Gynaecology and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Groote Schuur Hospital, Observatory, Cape Town, South Africa
| | - Groesbeck P Parham
- Department of Obstetrics and Gynecology, UNC Global Women's Health, University of North Carolina - Chapel Hill, North Carolina, USA.
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Mane A, Nirmalkar A, Risbud AR, Vermund SH, Mehendale SM, Sahasrabuddhe VV. HPV genotype distribution in cervical intraepithelial neoplasia among HIV-infected women in Pune, India. PLoS One 2012; 7:e38731. [PMID: 22723879 PMCID: PMC3378535 DOI: 10.1371/journal.pone.0038731] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 05/10/2012] [Indexed: 11/25/2022] Open
Abstract
Background The distribution of HPV genotypes, their association with rigorously confirmed cervical precancer endpoints, and factors associated with HPV infection have not been previously documented among HIV-infected women in India. We conducted an observational study to expand this evidence base in this population at high risk of cervical cancer. Methods HIV-infected women (N = 278) in Pune, India underwent HPV genotyping by Linear Array assay. Cervical intraepithelial neoplasia (CIN) disease ascertainment was maximized by detailed assessment using cytology, colposcopy, and histopathology and a composite endpoint. Results CIN2+ was detected in 11.2% while CIN3 was present in 4.7% participants. HPV genotypes were present in 52.5% (146/278) and ‘carcinogenic’ HPV genotypes were present in 35.3% (98/278) HIV-infected women. ‘Possibly carcinogenic’ and ‘non/unknown carcinogenic’ HPV genotypes were present in 14.7% and 29.5% participants respectively. Multiple (≥2) HPV genotypes were present in half (50.7%) of women with HPV, while multiple ‘carcinogenic’ HPV genotypes were present in just over a quarter (27.8%) of women with ‘carcinogenic’ HPV. HPV16 was the commonest genotype, present in 12% overall, as well as in 47% and 50% in CIN2+ and CIN3 lesions with a single carcinogenic HPV infection, respectively. The carcinogenic HPV genotypes in declining order of prevalence overall included HPV 16, 56, 18, 39, 35, 51, 31, 59, 33, 58, 68, 45 and 52. Factors independently associated with ‘carcinogenic’ HPV type detection were reporting ≥2 lifetime sexual partners and having lower CD4+ count. HPV16 detection was associated with lower CD4+ cell counts and currently receiving combination antiretroviral therapy. Conclusion HPV16 was the most common HPV genotype, although a wide diversity and high multiplicity of HPV genotypes was observed. Type-specific attribution of carcinogenic HPV genotypes in CIN3 lesions in HIV-infected women, and etiologic significance of concurrently present non/unknown carcinogenic HPV genotypes await larger studies.
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Affiliation(s)
- Arati Mane
- National AIDS Research Institute, Pune, India
| | | | | | - Sten H. Vermund
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
| | | | - Vikrant V. Sahasrabuddhe
- Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, United States of America
- * E-mail:
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Firnhaber C, Evans D, Friedman-Khalili R, Willliams S, Michelow P, Matlhagela K, Wester C, Grinsztejn B, Lockman S. Seroprevalence of HPV vaccine types 6, 11, 16 and 18 in HIV-infected women from South Africa, Brazil and Botswana. J Clin Virol 2011; 52:265-8. [PMID: 21908233 DOI: 10.1016/j.jcv.2011.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 08/04/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Many resource limited settings (RLS) suffer from high rates of both cervical cancer and HIV. Limited HPV serology data are available from RLS; such data could help describe local patterns of HPV infection and predict vaccine efficacy. OBJECTIVES To determine seropositivity to HPV types 6, 11, 16 and 18 in HIV-infected women from South Africa (SA), Botswana and Brazil. STUDY DESIGN HPV serotyping for high-risk types 6, 11, 16 and 18 was performed on samples collected from HIV-infected women from 2003-2010 using competitive Luminex Immuno Assay (HPV-4cLIA). We examined the association between seropositivity to these HPV types and country of enrollment, CD4, HIV-1 RNA level, and Pap smear. RESULTS HPV serology results were available for 487 HIV-infected women (157, 170 and 160 from SA, Botswana and Brazil respectively). Approximately 65% of women had serum antibodies to one of the 4 HPV types and less than 3% of women had antibodies all 4 serotypes. Approximately 30% women demonstrated antibodies to type 16 HPV. Rates of seropositivity to HPV 11, and HPV 16+18 varied significantly between countries. Statistical difference was also shown in women in different age categories in the different countries. There was no difference in serology results compared by CD4 count, HIV viral load or Pap smear results. CONCLUSIONS These data suggest that the quadrivalent vaccine may be effective in preventing HPV infection in these countries.
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Affiliation(s)
- C Firnhaber
- Clinical HIV Research Unit, Faculty of Health Science Center, Department of Medicine, University of Witwatersrand, Johannesburg, South Africa.
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Naucler P, Mabota da Costa F, da Costa JL, Ljungberg O, Bugalho A, Dillner J. Human papillomavirus type-specific risk of cervical cancer in a population with high human immunodeficiency virus prevalence: case-control study. J Gen Virol 2011; 92:2784-2791. [PMID: 21900420 DOI: 10.1099/vir.0.034298-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
There are limited data on human papillomavirus (HPV) type-specific cervical cancer risk among human immunodeficiency virus (HIV)-positive women. Previous studies have suggested that HPV 16 would be relatively less important as a causative agent among HIV-positive compared with HIV-negative women. This study investigates HPV type-specific cervical cancer risk in a population in which HIV is endemic. At the Central Hospital, Maputo, Mozambique, 221 cervical cancer cases and 203 hospital-based controls were consecutively enrolled. HPV typing from cervical samples, HIV testing and recording of socio-demographic factors were performed. Logistic regression modelling was used to assess HPV type-specific risk and effect modification between HIV and HPV infection. Infection with HPV 16, 18 and 'high-risk non-HPV 16/18 types' (HPV 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59) was associated with cervical cancer in both crude and adjusted analyses. HPV 16 and 18 were the most common types detected in cancer biopsies among both HIV-negative and HIV-positive women. There was no significant evidence of effect modification between any HPV type and HIV infection, and there were no significant differences in the HPV type-specific prevalence when cervical cancers among HIV-positive and HIV-negative women were compared. Within the limitations of the study, the relative importance of different HPV types in cervical carcinogenesis appears not to be modified greatly by HIV infection, suggesting that HPV vaccines might not need to be type-specifically modified to be suitable for populations where HIV is endemic.
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Affiliation(s)
- Pontus Naucler
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institute, Stockholm, Sweden
| | | | | | - Otto Ljungberg
- Department of Pathology, University Hospital Malmö, Lund University, Sweden
| | - Antonio Bugalho
- Department of Obstetrics and Gynecology, Central Hospital, Maputo, Mozambique
| | - Joakim Dillner
- Department of Medical Microbiology, Malmö University Hospital, Lund University and Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
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Firnhaber C, Van Le H, Pettifor A, Schulze D, Michelow P, Sanne IM, Lewis DA, Williamson AL, Allan B, Williams S, Rinas A, Levin S, Smith JS. Association between cervical dysplasia and human papillomavirus in HIV seropositive women from Johannesburg South Africa. Cancer Causes Control 2010; 21:433-43. [PMID: 19949850 PMCID: PMC2835728 DOI: 10.1007/s10552-009-9475-z] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2008] [Accepted: 11/10/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the association between CD4 counts, HPV infection and the risk of cervical neoplasia among HIV-seropositive women. METHODS A cross-sectional observational study was conducted among 1,010 HIV-seropositive women using cytology-based Pap smears. HPV DNA testing using Linear Array genotyping assay (Roche) was carried out in a subset of 191 patients. Multivariable-adjusted prevalence ratios (mPR) and 95% confidence intervals (CIs) were estimated with log-binomial regression. RESULTS Among 1,010 HIV-seropositive women, the prevalence of AGC/ASCUS, LSIL and HSIL or greater was 8.3, 23.5 and 18.0%, respectively. The risk of cervical lesions was higher with CD4 < 200 cells/mm(3) vs. CD4 levels > 500/mm(3). HPV types 16 (41.7%) and HPV 56 (22.2%) were the most common types in HSIL cases. Women with CD4 levels < 200/mm(3) had a higher prevalence of HPV types 16 (p < 0.01) and 66 (p = 0.04). No statistical relationship between cervical lesions and HAART use was found. CONCLUSION The burden of HPV infection and HSIL was high and correlated with HIV-induced immunosuppression. HPV 16 was the most common type in HSIL and increased in prevalence with greater immune suppression. Prophylactic HPV 16 vaccination could prevent approximately 40% of HSIL cases. Strengthening screening programs is imperative in this population.
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Affiliation(s)
- Cynthia Firnhaber
- Department of Medicine, Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Hoa Van Le
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Campus Box 7435, Chapel Hill, NC 27599 USA
| | - Audrey Pettifor
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Campus Box 7435, Chapel Hill, NC 27599 USA
| | - Doreen Schulze
- Department of Medicine, Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Pam Michelow
- Cytology Unit National Health Laboratory Service, Johannesburg, South Africa
- Department of Pathology, University of Witwatersrand, Johannesburg, South Africa
| | - Ian M. Sanne
- Department of Medicine, Clinical HIV Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - David A. Lewis
- STI Reference Centre, National Institute for Communicable Diseases (NHLS), Johannesburg, South Africa
- Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Anna-Lise Williamson
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - Bruce Allan
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Allen Rinas
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Campus Box 7435, Chapel Hill, NC 27599 USA
| | - Simon Levin
- Department of OB/Gyn, Cornation Hospital, University of Witswaterand, Johannesburg, South Africa
| | - Jennifer S. Smith
- Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Campus Box 7435, Chapel Hill, NC 27599 USA
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Louie KS, De Sanjose S, Mayaud P. Epidemiology and prevention of human papillomavirus and cervical cancer in sub-Saharan Africa: a comprehensive review. Trop Med Int Health 2009; 14:1287-302. [DOI: 10.1111/j.1365-3156.2009.02372.x] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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