Immunogenicity, safety, and efficacy of the HPV vaccines among people living with HIV: A systematic review and meta-analysis

HPV vaccination is highly effective and cost-effective for cervical cancer prevention in women living with HIV in China: A cost-effectiveness analysis

The presence of human immunodeficiency virus (HIV) infection increases the risk of acquiring human papillomavirus (HPV) infection and developing HPV-related adversities. We aimed to estimate the cost-effectiveness of HPV vaccination for women living with HIV in a Chinese setting. A decision-analysis Markov model was developed to estimate the cost-effectiveness of 36 HPV vaccination strategies for women living with HIV aged 18-45 years, from the healthcare system perspective. With the status quo, not vaccinating women living with HIV would lead to 51.99% (51,985/100,000) HIV-related deaths; 35.10% (35,098/100,000) would develop genital warts, 0.36% (355/100,000) develop cervical cancer, and among which 63.66% (226/355) die from cervical cancer over their lifetime (1,601,457 person-years). With a willingness to pay (WTP) threshold of three times gross domestic product (GDP), Gardasil 4 vaccination for all women living with HIV aged 18-45 years was the most cost-effective strategy (ICER = US $32,766/QALY gained). This strategy would reduce genital warts by 35.52% (12,467/35,098), cervical cancers by 12.96% (46/355), and cervical cancer deaths by 12.39% (28/226) over the lifetime of the cohort. If the future domestic Cecolin 9 vaccine is priced at 60% of Gardasil 9, vaccinating all women living with HIV aged 18-45 years with Cecolin 9 would be the most cost-effective strategy (ICER = US $30,493/QALY gained). Improving adherence to antiretroviral therapy for HIV may substantially improve the cost-effectiveness of both Gardasil 4 and Cecolin 9 vaccination.

Evaluation of preventive medicine amongst people living with human immunodeficiency virus attending a hospital-based care setting

BACKGROUND

With improved outcomes in human immunodeficiency virus (HIV) due to the use of anti-retroviral therapy, ensuring adequate preventative healthcare and management of HIV-related comorbidities is essential.

AIMS

To evaluate adherence with recommended guidelines for comorbidity and immunisation status screening amongst people living with HIV within a hospital-based setting across two timepoints.

METHODS

A single-centre retrospective case series was conducted at a hospital between 2011 and 2021. Inclusion criteria were ≥18 years, confirmed diagnosis of HIV and commencement of care within study period. Medical data were reviewed over two 12-month periods to capture comorbidity screening and vaccination adherence using established guidelines (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine, Alfred Screening tool and Australian Technical Advisory Group recommendations). Descriptive statistics were obtained with IBM spss (version 29.0).

RESULTS

Of 102 patients, 82 (80.4%) were male and 55 (53.9%) born overseas. Nineteen (18.6%) patients entered in 2011, with a median of 36.5 months from service entry to exit. Within 12 months of entry 56 (55.4%) participants had influenza vaccination recorded. Within the last 12 months, 94.8% had recorded COVID-19 vaccination, with improvements in pneumococcal (72.3%) and hepatitis B (82.8%) since service entry. Recording of comorbidity screening was >90% for blood pressure, weight and renal function at both timepoints, however, suboptimal (<10%) for substance misuse, cognitive and osteoporosis screening.

CONCLUSIONS

There is a disparity amongst comorbidity screening and documentation of vaccination status. Further measures are required to target improvements in immunisation, bone health, substance misuse and cognitive impairment screening.

Understanding human papillomavirus vaccine response and efficacy in people living with HIV: A systematic mixed studies review and meta-analysis

Coinfection with human papillomavirus (HPV) and HIV compounds the risks of developing cervical, anal, and HPV-associated oral neoplasia. Safe prophylactic vaccines are available to prevent HPV infections in people with HIV(PWH). Yet, vaccine efficacy and duration of protection remain questionable. Historically, the efficacy of vaccines has been suboptimal in PWH compared to people without HIV (PWoH).A systematic review of HPV vaccine trials in PWH was conducted using PRISMA guidelines. Outcomes of interest were vaccine efficacy, immunogenicity, and predictors of HPV vaccine efficacy. A secondary outcome was to assess age and sex differences. Efficacy was reviewed as cervical/anal/oral lesions or neoplasia, and incident or persistent HPV infection following vaccination. A random effects meta-analysis was performed comparing geometric mean titer (GMT) in PWH to PWoH. Twenty-eight studies out of 988 were eligible for inclusion in our study, and qualitatively synthesized. Eight of these studies were meta-analyzed. GMT results of HPV16 and HPV18 genotypes were significantly lower in PWH; Hedges's g -0.434 (95% CI: -0.823, -0.046) and Hedges's g -0.57 (95% CI: -0.72, -0.43), respectively. The mean difference in GMT for HPV18 between PWH and PWoH was -536.23 (95% CI: -830.66, -241.81); approximately 22 times higher than HPV18 seropositivity cut-offs, assuming milli-Merck Units per milliliter. Risk factors for incident or persistent infections in PWH included: failure to seroconvert after vaccination, baseline CD4+ T-cell count <500 cells/mm3, early age of sexual debut, HIV viral load ≥ 400 copies/mL. There was a trend towards decreased HPV vaccine efficacy in studies that included enrollees with a history of AIDS or AIDS-defining illness.Applying existing evidence of HPV vaccine efficacy on meaningful clinical outcomes in PWH is questionable. This could be influenced by the diversity of eligibility criteria across clinical trials of HPV vaccine efficacy. Precision medicine may offer novel alternatives for evaluating HPV vaccine efficacy in PWH.

Awareness, attendance, and attitudes toward cervical cancer screening among HIV-positive Chinese women in Yunnan province: a cross-sectional study

BACKGROUND

Cervical cancer is a major health threat in the female population. Human immunodeficiency virus (HIV)-positive women encounter a higher risk of cervical cancer. It is significant to promote cervical cancer screening attendance among HIV-positive women. Little is known about the awareness, attendance, and attitudes toward cervical cancer screening, as well as the associated factors, among Chinese HIV-positive women.

METHODS

A cross-sectional study was conducted among 411 HIV-positive women attending a large ART clinic in Yunnan, an HIV-endemic province in China. Participants were recruited using the convenient sampling method from January 2019 to August 2020. An interviewer-administered semi-structured questionnaire was utilized to collect information on socio-demographic and behavioral characteristics, clinical characteristics related to HIV infection, awareness, attendance, and attitudes toward cervical cancer screening. Binary logistic regression analyses were used to determine factors associated with awareness, attendance, and attitude toward cervical cancer screening.

RESULTS

Some 69.8% (287) of the participants were aware of cervical cancer screening, but only 27.7% (114) had attended screening within 3 years. After receiving a brief health education, 72.3% (297) of the participants exhibited a positive attitude toward cervical cancer screening. Participants with a higher education background and longer duration of antiretroviral therapy were more likely to be aware of cervical cancer screening and have up-to-date screening. The up-to-date screening attendance was also influenced by age, smoking status, and health insurance. Single participants were less likely to show a positive attitude toward cervical cancer screening compared married or cohabiting counterparts. The main facilitators to attending cervical cancer screening were health promotion activity and well-organized programs, while the main barriers were high costs of the service and inadequate awareness.

CONCLUSIONS

Although most HIV-positive women attending a large ART clinic in Yunnan were aware of cervical cancer screening, the up-to-date attendance was low. It is crucial to conduct health education and promotion through efficient channels to improve awareness and attendance. The discrepancy between awareness and attendance also emphasized the importance of adopting appropriate screening strategies and powerful health policies that can foster the attendance of cervical cancer screening among HIV-positive women. Efforts should be devoted to constructing a comprehensive healthcare system with high accessibility in China for cervical cancer prevention and management for HIV-positive women.

The Assessment of Knowledge About Cervical Cancer, HPV Vaccinations, and Screening Programs Among Women as an Element of Cervical Cancer Prevention in Poland

Introduction: Cervical cancer is the fourth most commonly diagnosed malignant tumor in women and the fourth leading cause of cancer-related deaths among this population. Since it is asymptomatic in its early stages, preventive screening plays a crucial role in rapid diagnosis. Such screenings are conducted in many countries worldwide, although their popularity varies. Given that nearly all cases of cervical cancer are linked to high-risk human papillomavirus (hrHPV) infection, vaccination against this virus could lead to a significant reduction in cancer incidence. It should be noted that the level of vaccination coverage against hrHPV varies significantly between countries, ranging from a few percent to over 90%. Globally, the vaccination coverage of the target population is estimated at only a few percent. Methods: This study was conducted using a proprietary, anonymous online questionnaire comprising 24 questions addressing various aspects of cervical cancer prevention. The newly designed questionnaire comprised 19 primary questions and 5 metric questions. The collected data were subjected to descriptive and statistical analysis. Results: The majority of respondents reported regularly participating in cervical cytology screening and gynecological visits. Non-participation in these screenings was primarily reported by younger respondents, not all of whom had indications for undergoing such examinations. Only 14% of the women surveyed had been vaccinated against hrHPV. However, it should be noted that, as the surveyed women were not covered by the relatively recently introduced vaccination program, they received their vaccinations through local programs conducted by certain cities or through private healthcare services. The respondents' primary sources of information on cervical cancer are the internet and medical personnel. Conclusions: The level of knowledge among the women surveyed regarding cervical cancer prevention was satisfactory, though improvement is needed in some areas. Despite relatively good awareness of HPV's role in cervical cancer development, the popularity of HPV vaccination remains unsatisfactory. The results should be interpreted with caution due to the small study group.

High prevalence of human papillomavirus (HPV) in unvaccinated adolescent girls in South Africa, particularly those living with HIV

INTRODUCTION

In 2014, South Africa implemented a national two-dose HPV vaccination programme using the bivalent vaccine for girls aged 9 years and older attending Grade 4 at public schools. We assessed HPV prevalence and risk factors among South African adolescent girls and young women (AGYW) aged 17-18 years who were ineligible for vaccination.

METHODS

From June to December 2019, we surveyed AGYW aged 17-18 years attending primary care clinics in four South African provinces. Consenting participants completed a questionnaire, underwent HIV counselling and testing, and self-collected a vaginal swab for HPV testing. Samples were tested by Seegene AnyPlex™ II HPV28. We used summary statistics to describe the population characteristics and logistic regression to examine the association between risk factors and high-risk HPV detection.

RESULTS

910 participants were screened, 900 enrolled, 896 had valid HPV results, and 819 were unvaccinated and included in this study. Of these, 248 (30.3 %) were living with HIV and 597 (72.9 %) reported ever having vaginal sex. Overall, 463 (56.5 %) had at least one high-risk HPV detected, and 177 (21.6 %) had HPV16/18 detected. AGYW living with HIV had a higher prevalence of any high-risk HPV (65.3 % vs 52.7 %, p < 0.001) and HPV 16/18 (29.4 % vs 18.2 %, p < 0.001) compared to those without HIV. Multiple infections were also more common in participants living with HIV, with three or more high-risk HPV types detected in 32.3 % compared with 15.4 % of those without HIV (p < 0.001). In multivariate analyses, HIV status (p < 0.001) and higher number of lifetime sexual partners (p-trend<0.001) were associated with high-risk HPV detection.

CONCLUSIONS

High-risk HPV was very common in unvaccinated South Africa AGYW, especially among those living with HIV, highlighting the importance of HPV vaccination in settings with high HIV prevalence.

HPV-associated cancers among people living with HIV: nationwide population-based retrospective cohort study 2004-21 in Estonia

Cancers represent the primary cause of mortality among people living with HIV (PLWH). However, comprehensive nationwide data regarding cancer incidence remains limited. Our objective was to evaluate the incidence rates of cancers, particularly those associated with human papillomavirus (HPV), within a nationwide study cohort. Using data from the Estonian Health Insurance Fund and the National Cancer Registry from 2004 to 2021, we calculated standardized incidence ratios (SIRs) for various cancer types among PLWH to compare to the general population with special emphases on HPV-associated cancers. A total of 7011 individuals (65.7% men) diagnosed with HIV were identified. HPV-associated cancers accounted for 21.4% of all incident cancer cases among PLWH. SIRs for HPV-associated cancers were 3.7 [95% confidence interval (CI) 2.2-6.2] among men living with HIV (MLWH) and 5.7 (95% CI 4.0-7.9) among women living with HIV (WLWH). In MLWH, the highest SIRs were for penile 12.5 (95% CI 4.0-38.7), followed by oropharyngeal 3.6 (95% CI 1.7-7.6) and anal-rectal cancers 2.7 (95% CI 1.1-6.4) in comparison to the general population. In WLWH, an increased incidence of cervical (SIR = 5.8, 95% CI 3.9-8.5), oropharyngeal (SIR = 6.1, 95% CI 1.5-24.3), and anal-rectal (SIR = 3.6, 95% CI 1.2-11.2) cancers was observed. A significantly increased risk of AIDS-defining and non-AIDS-defining cancers is reported. We demonstrate a substantially heightened risk of HPV-associated cancers among PLWH compared to the general population, underscoring the imperative for intensified screening and scaled-up vaccination along with improvement in adherence to antiretroviral therapy.

HPV Vaccine Awareness and Uptake Among Sexually Transmitted Infections Clinic Users: A Cross-Sectional Study in Bologna, Italy

Human Papillomavirus (HPV) infection poses a significant health risk, particularly for high-risk groups such as men who have sex with men (MSM), people living with HIV (PLHIV), and transgender individuals. Despite the availability of effective vaccines, uptake among these groups remains suboptimal due to various social and behavioral barriers (BeSD). A cross-sectional survey was conducted at the Sexually Transmitted Infections (STIs) clinic in Bologna, Italy, from 8 April to 12 April 2024 using a paper questionnaire, investigating HPV vaccine uptake and BeSD factors influencing vaccination decisions. Statistical analyses included descriptive statistics and multivariate logistic regression. Among the 236 respondents, PLHIV and transgender individuals demonstrated lower uptake rates (60.0% and 15.6%) if compared to women under 30 years old (72.7%). Concern about HPV infection varied significantly across groups, with MSM showing the highest worry (48.7%). Perceptions of vaccine safety and access were mixed, influencing vaccination decisions. Multivariate analysis indicated that age inversely correlated with infection worry (OR: 0.94, 95% CI: 0.91-0.98), while being a woman under 30 (OR: 164.0, 95% CI: 17.2-1560.18) or MSM (OR: 3.53, 95% CI: 1.37-9.11) was positively associated with vaccine uptake. The study identifies disparities in HPV vaccine uptake among STI clinic users in Bologna, Italy, emphasizing the need for targeted public health campaigns. These campaigns could engage STI clinics and address awareness, safety perceptions, and access barriers to enhance vaccination coverage among sexual and gender minorities.

Human papillomavirus infection among adolescents living with HIV: a focus on prevention

PURPOSE OF REVIEW

To highlight recent data on HPV infection and cervical precancerous lesions in adolescents with HIV, and priorities for primary and secondary HPV prevention.

RECENT FINDINGS

Incident and persistent high-risk HPV infections and cervical abnormalities are higher among young women with perinatally acquired HIV compared to their HIV-negative peers; data on HPV among males with perinatally acquired HIV are scarce. HPV vaccination is highly effective in preventing HPV-related disease, but antibody titers may decline in people with HIV. It remains unclear if emerging recommendations to reduce vaccine schedules from three doses to two or one dose are appropriate for children and adolescents with perinatally acquired HIV. Due to higher risks of HPV-related cancers, screening guidelines for cervical cancer differ in their frequency and age at initiation for women with HIV, but there are no recommendations for women with perinatally acquired HIV; nor for anal cancer screening for men with perinatally acquired HIV.

SUMMARY

Data on the effectiveness of reduced HPV vaccine schedules in children and adolescents with HIV are needed. Implementation research to guide strategies for vaccination, screening, and treatment should include children, adolescents, and young adults with perinatally acquired HIV to ensure they are not left behind.

Impact of single-dose HPV vaccination on HPV 16 and 18 prevalence in South African adolescent girls with and without HIV

BACKGROUND

The World Health Organization has endorsed single-dose human papillomavirus (HPV) vaccination, but data on the impact on HPV prevalence in high HIV burden settings are limited.

METHODS

A single-dose bivalent HPV vaccine was delivered to adolescent girls in grade 10 in a schools-based campaign in 1 district in South Africa. Impact on HPV 16 and 18 prevalence was evaluated using repeat cross-sectional surveys. A clinic-based survey in girls aged 17-18 years established HPV 16 and 18 prevalence in a prevaccine population (n = 506, including 157 living with HIV) in 2019 and was repeated in the same age group and sites in a single-dose eligible population in 2021 (n = 892, including 117 with HIV). HPV DNA was detected on self-collected vaginal swabs using the Seegene Anyplex II HPV 28. Population impact was estimated overall and by HIV status using prevalence ratios adjusted for differences in sexual behavior between surveys.

RESULTS

Single-dose vaccination campaign coverage was 72% (4807 of 6673) of eligible girls attending high school (n = 66) in the district. HPV 16 and 18 prevalence was 35% lower in the postvaccine survey overall (adjusted prevalence ratio = 0.65, 95% confidence interval [CI] = 0.51 to 0.83; P < .001) and 37% lower in those living with HIV (adjusted prevalence ratio = 0.63, 95% CI = 0.41 to 0.95; P  = .026). No protective effect was seen for nonvaccine oncogenic HPV types 33, 35, 39, 51, 52, 56, 58, 59, or 68 overall (adjusted prevalence ratio = 1.14, 95% CI = 1.03 to 1.26; P = .011) or in those living with HIV (adjusted prevalence ratio = 1.00, 95% CI = 0.83 to 1.21. P = 0.99).

CONCLUSION

These data provide reassuring evidence of single-dose impact on population-level HPV 16 and 18 prevalence in a South African population, irrespective of HIV status.

Trends in human papillomavirus infection and genotype distribution among males in Chongqing, China (2017-2022): an observational study

PURPOSE

This study aimed to investigate Human papillomavirus (HPV) infection and genotyping in men from Chongqing and analyze age-related trends to provide insights for HPV prevention and vaccination plans tailored for men in Chongqing, China.

METHODS

This study is an observational study. We investigated male patients who underwent HPV screening at two hospitals in Chongqing from 2017 to 2022, totaling 4,381 cases, aged 18 to 85. HPV genotyping was conducted using the Hybribio Rapid GenoArray kit.

RESULTS

Among the 4,381 men, the overall HPV prevalence was 14.9%, peaking at 19.3% in 2022. Single HPV infection was 11.5%, and multiple infection was 3.4%. The most prevalent genotypes were HPV-52, HPV-16, and HPV-58. Single high-risk HPV infection peaked in the 36-45 age group, while multiple high-risk HPV infection decreased with age (P-trend < 0.01). Prevalence in the ≤ 25 age group was 3.7%. Single low-risk HPV infection also decreased with age (P-trend = 0.03). Genotypes covered by the nonavalent vaccine had the highest prevalence, increasing with age. Co-infection of HPV-16 with HPV-52 and HPV-58 was common. Single HPV infections were prevalent in cases of urethritis (30.8%), anogenital warts (36.4%), and genital warts (26.3%), while multiple HPV infections were significant in anogenital warts (18.2%).

CONCLUSIONS

Single HPV infection was predominant in Chongqing, with HPV-52, HPV-16, HPV-58, HPV-53, and HPV-39 being the most prevalent genotypes. The prevalence of genotypes covered by the nonavalent vaccine increased with age. This study offers valuable insights for developing male-specific HPV prevention strategies in Chongqing.

Entangled Connections: HIV and HPV Interplay in Cervical Cancer-A Comprehensive Review

Cervical cancer (CC) remains a prevalent malignancy and a significant global public health concern, primarily driven by persistent human papillomavirus (HPV) infections. The infectious nature of HPV underscores the preventability of CC through vaccination and screening programs. In addition to HPV, factors such as age, parity, smoking, hormonal contraceptives, and HIV co-infection elevate the risk of CC. HIV-associated immunodeficiency exacerbates susceptibility to infections and cancers, making CC a defining condition for acquired immune deficiency syndrome (AIDS) and one of the most commonly diagnosed cancers among women living with HIV (WLWH). These women face higher risks of HPV exposure due to sexual behavior and often encounter economic, social, and psychological barriers to screening. HIV and HPV co-infection can potentially accelerate CC carcinogenesis, with WLWH typically being diagnosed with CC earlier than their HIV-negative counterparts. Antiretroviral therapy (ART), which reduces AIDS-related mortality, also lowers the risk of invasive CC. The interaction between HIV and HPV is intricate and bidirectional. This summary reviews current evidence on HPV infection and CC in WLWH, highlighting the connections across pathogenesis, prevention, diagnosis, and treatment.

Early adoption of innovation in HPV prevention strategies: closing the gap in cervical cancer

Cervical cancer (CC) is one of the highest prevailing causes of female cancer-related mortality globally. A significant discrepancy in incidence has been noted between high and low-middle-income countries. The origins of CC have been accredited to the human papillomavirus (HPV) with serotypes 16 and 18 being the most prevalent. HPV vaccines, with 90%-97% efficacy, have proven safe and currently function as the primary prevention method. In addition, secondary prevention by timely screening can potentially increase the 5-year survival rate by >90%. High-precision HPV DNA testing has proven to be both highly sensitive and specific for early detection and is advocated by the WHO. Lack of public awareness, poor screening infrastructure and access to vaccines, socio-cultural concerns, along with economic, workforce-associated barriers and the presence of marginalised communities unable to access services have contributed to a continued high incidence. This article comprehensively analyses the efficacy, coverage, benefits and cost-effectiveness of CC vaccines and screening strategies including the transition from cytological screening to HPV self-sampling, while simultaneously exploring the real-world disparities in their feasibility. Furthermore, it calls for the implementation of population-based approaches that address the obstacles faced in approaching the WHO 2030 targets for CC elimination.

The role of personal health beliefs and altruistic beliefs in young Chinese adult men's acceptance of the human papillomavirus vaccine

Administering the human papillomavirus (HPV) vaccine to men offers substantial health benefits for both themselves and their female partners. In mainland China, the HPV vaccine has not been approved for men, and little is known about their acceptance of it. This study aims to assess the acceptability of HPV vaccine among young Chinese adult men and examine the association between personal health beliefs, altruistic beliefs, and HPV vaccination intentions and behavioral attempts. A cross-sectional study was conducted among male university students using a multistage cluster sampling method in eight universities across five districts in Zhejiang Province, China. Data were collected from December 2020 to January 2021 using a self-administered, anonymous online questionnaire. Of the 1937 participants, 1009 who had heard of the HPV vaccine completed the questionnaire. Over one-third (40.4%, 408/1009) had high levels of HPV and HPV vaccine knowledge. A total of 695 of 1009 (68.9%) expressed an intention to receive the HPV vaccine when available, and 329 of 1009 (32.6%) had proactively inquired about male HPV vaccination. Perceived susceptibility, perceived benefits, perceived gender barriers, and perceived benefits of male HPV vaccination for female partner were associated with HPV vaccination intentions. Lower perceived vaccine barriers, greater perceived benefits, and stronger vaccination intentions were associated with higher HPV behavioral attempts. There is an emerging demand for HPV vaccinations among young adult men in mainland China. Personal health beliefs and altruistic beliefs are crucial in promoting young adult men's acceptance of the HPV vaccine. Emphasizing both male-specific benefits and altruistic motivations may enhance HPV vaccine acceptability among young adult men.

Looking Back, Moving Forward: Challenges and Opportunities for Global Cervical Cancer Prevention and Control

Despite the introduction of Pap testing for screening to prevent cervical cancer in the mid-20th century, cervical cancer remains a common cause of cancer-related mortality and morbidity globally. This is primarily due to differences in access to screening and care between low-income and high-income resource settings, resulting in cervical cancer being one of the cancers with the greatest health disparity. The discovery of human papillomavirus (HPV) as the near-obligate viral cause of cervical cancer can revolutionize how it can be prevented: HPV vaccination against infection for prophylaxis and HPV testing-based screening for the detection and treatment of cervical pre-cancers for interception. As a result of this progress, the World Health Organization has championed the elimination of cervical cancer as a global health problem. However, unless research, investments, and actions are taken to ensure equitable global access to these highly effective preventive interventions, there is a real threat to exacerbating the current health inequities in cervical cancer. In this review, the progress to date and the challenges and opportunities for fulfilling the potential of HPV-targeted prevention for global cervical cancer control are discussed.

Safety and Immunogenicity of the Nonavalent Human Papillomavirus Vaccine in Women Living with HIV

BACKGROUND

The objectives were to evaluate the safety and immunogenicity of the nonavalent human papillomavirus (nHPV) vaccine in adult Spanish women living with HIV (WLHIV); the prevalence of anal and cervical dysplasia and nHPV vaccine genotypes in the anus and cervix; and risk factors for high-risk HPV (HR-HPV) infection in anal mucosa.

METHODS

In this single-center, open-arm, non-randomized clinical trial, the nHPV vaccine was administered at 0, 2, and 6 months to WLHIV enrolled between February 2020 and November 2023, measuring vaccine antibody titers pre-vaccination and at 2, 6, and 7 months after the first dose. Cervical and anal cytology and HPV PCR genotyping studies were performed. Women with abnormal cytology and/or anal or cervical HPV infection at baseline underwent high-resolution anoscopy and/or colposcopy.

RESULTS

A total of 122 participants were included with mean age of 49.6 years: 52.5% smoked; 10.7% had anal-genital condylomatosis; 38.5% were infected by HR-HPV in the anus and 25.4% in the cervix, most frequently HPV 16; 19.1% had anal intraepithelial neoplasia 1-(AIN1); and 3.1% had cervical intraepithelial neoplasia 1 and 2 (CIN1/CIN2). Vaccine administration did not modify viral-immunological status (CD4 [809 ± 226.8 cells/uL vs. 792.35 ± 349.95; p = 0.357]) or plasma HIV load (3.38 ± 4.41 vs. 1.62 ± 2.55 cop/uL [log]; p = 0.125). Anti-HPV antibodies ([IQR: 0-0] vs. 7.63 nm [IQR: 3.46-19.7]; p = 0.0001) and seroconversion rate (8.2% vs. 96.7% [p = 0.0001]) were increased at 7 versus 0 months. There were no severe vaccine-related adverse reactions; injection-site pain was reported by around half of the participants. HR-HPV infection in the anus was solely associated with a concomitant cervix infection (HR 5.027; 95% CI: 1.009-25.042).

CONCLUSIONS

nHPV vaccine in adult WLHIV is immunogenic and safe.

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

Vaccine and Non-Vaccine HPV Types Presence in Adolescents with Vertically Acquired HIV Five Years Post Gardasil Quadrivalent Vaccination: The ZIMGARD Cohort

BACKGROUND

Human papillomavirus (HPV) vaccination programs are a key intervention in protecting individuals against HPV-related disease. HIV1-infected individuals are at increased risk of HPV-associated cancers. This study was conducted to evaluate the potential role of prophylactic HPV vaccines in preventing new HPV infections among participants with perinatally acquired HIV who received the quadrivalent HPV vaccine at least five years before this study.

METHODS

This cross-sectional study was conducted at Newlands Clinic, Harare, Zimbabwe. The clinic provided the Gardasil quadrivalent HPV vaccine (4vHPV) to 624 adolescents living with HIV starting in December 2015. Vaginal and penile swabs were collected and tested for HPV types from the study participants who had received the 4vHPV vaccine 5-6 years before enrolment.

RESULTS

We present the results of 98 participants (44.6% female) vaccinated at a median age of 15 years (IQR 12-16). The mean amount of time since vaccination was 6 years (SD: ±0.4). The HPV-positive rate amongst the analyzed swabs was 69% (68/98). Among 30/98 (31%) HPV-positive participants, 13/98 (13%) had low-risk HPV types, and 17/98 (17%) had high-risk HPV types. Twelve participants tested positive for HPV18, only one participant tested positive for HPV16, and an additional four (4.3%) tested positive for either type 6 or 11, with respect to vaccine-preventable low-risk HPV types.

CONCLUSION

The Gardasil quadrivalent HPV vaccine (4vHPV) was expected to protect against infection with HPV types 16, 18, 6, and 11. We demonstrated a possible waning of immunity to HPV18 in 17% of the participants, and an associated loss in cross-protection against HPV45. We observed a relatively high prevalence of 'opportunistic non-vaccine HPV types' or 'ecological niche occupiers' in this cohort, and suggest further research on the involvement of these types in cervical and other genital cancers. Our study is one of the few, if not the first, to report on HPV vaccine immunoprotection among people living with HIV (PLWH), thereby setting a baseline for further studies on HPV vaccine effectiveness among PLWH.

Impact of Human Papillomavirus Vaccine Against Anal Human Papillomavirus Infection, Anal Intraepithelial Neoplasia, and Recurrence of Anal Intraepithelial Neoplasia: A Systematic Review and Meta-analysis

BACKGROUND

We sought to summarize human papillomavirus (HPV) vaccine efficacy/effectiveness (VE) against anal HPV infection and anal intraepithelial neoplasia (AIN).

METHODS

We performed literature review and meta-analysis to estimate VE, stratified by age and analytic population (per-protocol efficacy [PPE] or intention-to-treat [ITT] population in clinical trials, or all participants in real-world studies).

RESULTS

We identified 6 clinical trials and 8 real-world studies. In participants vaccinated at age ≤26 years (mainly human immunodeficiency virus [HIV]-negative individuals), significant VE against incident/prevalent anal HPV infection was reported in clinical trials, with a higher estimate in PPE (2 studies with 2390 participants; VE, 84% [95% confidence interval (CI), 77%-90%]; I2 = 0%) than ITT (2 studies with 4885 participants; 55%, 39%-67%; I2 = 46%) populations or in real-world studies (4 studies with 2375 participants; 77%, 40%-91%; I2 = 81%). HPV vaccination at age ≤26 years was associated with significant VE in preventing persistent anal HPV infection and AIN. No significant VE against anal HPV infection or AIN was found in persons vaccinated at age >26 years (mainly people living with HIV).

CONCLUSIONS

There is strong evidence for high VE against anal HPV infection and AIN in HIV-negative individuals vaccinated at age ≤26 years. However, the lower impact in ITT than in PPE populations and the lack of significant effect in people living with HIV aged >26 years indicates that vaccines have the higher impact in populations with less sexual exposure to anal HPV.

HPV Infection Profiles among People Living with HIV and HPV Vaccine Acceptance among Individuals with Different HIV Infection Statuses in China: A Systematic Meta-Analysis

To understand the HPV infection profiles among Chinese HIV/AIDS patients and the HPV vaccine acceptance among unvaccinated Chinese people with different HIV infection statuses after the HPV vaccine launch in China, this study searched Web of Science, PubMed, Cochrane Library, Embase, Scopus, CNKI, WANFANG, SinoMed, and VIP databases up to 23 June 2023, according to the registered protocol (CRD42023449913). A total of 58 studies were included. The results showed that the HPV infection rate among Chinese HIV/AIDS patients was 52.54% (95% CI: 42.11-62.86%) and higher in males than in females (74.55% vs. 41.04%); meanwhile, the rate was higher in the anus than in the cervix (69.22% vs. 41.71%). Although there was no statistical difference, the high-risk HPV infection rate (38.98%) was higher than low-risk HPV (23.86%), and single infections were more common (28.84%) than multiple infections (19.23%). HPV vaccine acceptance among the unvaccinated Chinese population was 59.19% (95% CI: 52.50-65.89%), and was slightly higher among HIV-infected rather than non-HIV-infected individuals (67.72% vs. 59.58%). There was a difference in acceptance among respondents from different regions. Although the difference in acceptance rate between males and females was not statistically significant (61.10% vs. 61.18%), MSM had a higher acceptance rate than non-MSM (84.28% vs. 59.05%). HPV infection is prevalent among HIV patients, demonstrating the need to increase the frequency of HPV screening for PLWH. The HPV vaccine acceptance rate is higher than that of non-HIV-infected individuals. Male acceptance is almost the same as female's, with MSM acceptance higher than non-MSM, suggesting that using MSM, especially MSM in PLWH, as an entry point may be a practical avenue to explore to further expand the scope of HPV vaccination.

State-of-the-Science of human papillomavirus vaccination in women with human immunodeficiency Virus: Summary of a scientific workshop

The burden of cervical cancer is disproportionately distributed globally, with the vast majority of cases occurring in low- and middle-income countries. Women with human immunodeficiency virus (HIV) (WWH) are at increased risk of human papillomavirus (HPV) infection and cervical cancer as compared to HIV-negative individuals. HPV vaccination remains a priority in regions with a high burden of cervical cancer and high HIV prevalence. With HPV vaccines becoming more accessible, optimal use beyond the initial World Health Organization-recommended target population of 9 to 14-year-old girls is an important question. In March 2022, a group of experts in epidemiology, immunology, and vaccinology convened to discuss the state-of-the-science of HPV vaccination in WWH. This report summarizes the proceedings: review of HIV epidemiology and its intersection with cervical cancer burden, immunology, HPV vaccination including reduced-dose schedules and experience with other vaccines in people with HIV (PWH), HPV vaccination strategies and knowledge gaps, and outstanding research questions. Studies of HPV vaccine effectiveness among WWH, including duration of protection, are limited. Until data from ongoing research is available, the current recommendation for WWH remains for a multi-dose HPV vaccination regimen. A focus of the discussion included the potential impact of HIV acquisition following HPV vaccination. With no data currently existing for HPV vaccines and limited information from non-HPV vaccines, this question requires further research. Implementation research on optimal HPV vaccine delivery approaches for WWH and other priority populations is also urgently needed.

Anal Cancer and Anal Intraepithelial Neoplasia Risk among Patients Treated for HPV-Related Gynecological Diseases-A Systematic Review

BACKGROUND

The most important causative agent of neoplasms in the anogenital area is the human papillomavirus (HPV). Due to the anatomical proximity of the genital and anus area and the ease with which HPV infection is transmitted, it seems that patients after the treatment of HPV-related gynecological diseases may have an increased risk of developing a second HPV-related neoplasm anal cancer. The aim of this study was to determine the risk of anal intraepithelial neoplasia (AIN) and anal cancer (AC) among patients after the treatment of HPV-related gynecological diseases.

METHODS

We conducted a comprehensive review of the available literature from multiple databases. The study was performed following Cochrane Reviewers' Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Moreover, we assessed the quality of each study using QUADAS-2.

RESULTS

Twenty-five studies were included in the final analysis. Patients after the treatment of HPV-related gynecological diseases have a significantly higher risk of AC (mean standardized incidence ratio (SIR) = 5.387, mean incidence risk (IR) = 0.096%, mean IR per 100,000 person-years = 10.37) and AIN (mean IR = 23.683%) compared to the population risk.

CONCLUSIONS

patients with HPV-related gynecological diseases should constitute a group for which an appropriate primary and secondary screening for AC should be introduced.

Efficacy and Durability of Immune Response after Receipt of HPV Vaccines in People Living with HIV

People living with HIV (PLH) experience higher rates of HPV infection as well as an increased risk of HPV-related disease, including malignancies. Although they are considered a high-priority group for HPV vaccination, there are limited data regarding the long-term immunogenicity and efficacy of HPV vaccines in this population. Seroconversion rates and geometric mean titers elicited by vaccination are lower in PLH compared to immunocompetent participants, especially in individuals with CD4 counts below 200 cells/mm³ and a detectable viral load. The significance of these differences is still unclear, as a correlate of protection has not been identified. Few studies have focused on demonstrating vaccine efficacy in PLH, with variable results depending on the age at vaccination and baseline seropositivity. Although waning humoral immunity for HPV seems to be more rapid in this population, there is evidence that suggests that seropositivity lasts at least 2-4 years following vaccination. Further research is needed to determine the differences between vaccine formulations and the impact of administrating additional doses on durability of immune protection.

No woman left behind: achieving cervical cancer elimination among women living with HIV

Cervical cancer is the fourth most common malignancy in women of reproductive age globally. The burden of this disease is highest in low-income and middle-income countries, especially among women living with HIV. In 2018, WHO launched a global strategy to accelerate cervical cancer elimination through rapid scale-up of prophylactic vaccination, cervical screening, and treatment of precancers and cancers. This initiative was key in raising a call for action to address the stark global disparities in cervical cancer burden. However, achieving elimination of cervical cancer among women with HIV requires consideration of biological and social issues affecting this population. This Position Paper shows specific challenges and uncertainties on the way to cervical cancer elimination for women living with HIV and highlights the scarcity of evidence for the effect of interventions in this population. We argue that reaching equity of outcomes for women with HIV will require substantial advances in approaches to HPV vaccination and improved understanding of the long-term effectiveness of HPV vaccines in settings with high HIV burden cervical cancer, just as HIV, is affected by social and structural factors such as poverty, stigma, and gender discrimination, that place the elimination strategy at risk. Global efforts must, therefore, be galvanised to ensure women living with HIV have optimised interventions, given their substantial risk of this preventable malignancy.

Human Papillomavirus Vaccination

A 24-year-old woman is being seen for routine health care. She has not received any vaccinations against human papillomavirus (HPV). The patient initiated sexual activity at 18 years of age and has had three male sex partners. What would you recommend regarding HPV vaccination?

Living with HIV and Getting Vaccinated: A Narrative Review

After 40 years of its appearance, human immunodeficiency virus (HIV) infection remains a leading public health challenge worldwide. Since the introduction of antiretroviral treatment (ART), HIV infection has become a chronic condition, and people living with HIV could have life expectancies close to those of the general population. People with HIV often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases. Nowadays, several vaccines are available against bacteria and viruses. However, national and international vaccination guidelines for people with HIV are heterogeneous, and not every vaccine is included. For these reasons, we aimed to perform a narrative review about the vaccinations available for adults living with HIV, reporting the most updated studies performed for each vaccine among this population. We performed a comprehensive literature search through electronic databases (Pubmed-MEDLINE and Embase) and search engines (Google Scholar). We included English peer-reviewed publications (articles and reviews) on HIV and vaccination. Despite widespread use and guideline recommendations, few vaccine trials have been conducted in people with HIV. In addition, not all vaccines are recommended for people with HIV, especially for those with low CD4 cells count. Clinicians should carefully collect the history of vaccinations and patients' acceptance and preferences and regularly check the presence of antibodies for vaccine-preventable pathogens.

Estimating the effect of HIV on cervical cancer elimination in South Africa: Comparative modelling of the impact of vaccination and screening

Background

In 2020, the World Health Organization (WHO) launched its initiative to eliminate cervical cancer as a public health problem. To inform global efforts for countries with high HIV and cervical cancer burden, we assessed the impact of human papillomavirus (HPV) vaccination and cervical cancer screening and treatment in South Africa, on cervical cancer and the potential for achieving elimination before 2120, considering faster HPV disease progression and higher cervical cancer risk among women living with HIV(WLHIV) and HIV interventions.

Methods

Three independent transmission-dynamic models simulating HIV and HPV infections and disease progression were used to predict the impact on cervical cancer incidence of three scenarios for all women: 1) girls' vaccination (9-14 years old), 2) girls' vaccination plus 1 lifetime cervical screen (at 35 years), and 3) girls' vaccination plus 2 lifetime cervical screens (at 35 and 45 years) and three enhanced scenarios for WLHIV: 4) vaccination of young WLHIV aged 15-24 years, 5) three-yearly cervical screening of WLHIV aged 15-49 years, or 6) both. Vaccination assumed 90% coverage and 100% lifetime protection with the nonavalent vaccine (against HPV-16/18/31/33/45/52/58). Cervical cancer screening assumed HPV testing with uptake increasing from 45% (2023), 70% (2030) to 90% (2045+). We also assumed that UNAIDS 90-90-90 HIV treatment and 70% male circumcision targets are reached by 2030. We examined three elimination thresholds: age-standardised cervical cancer incidence rates below 4 or 10 per 100,000 women-years, and >85% reduction in cervical cancer incidence rate. We conducted sensitivity analyses and presented the median age-standardised predictions of outcomes of the three models (minimum-maximum across models).

Findings

Girls' vaccination could reduce age-standardised cervical cancer incidence from a median of 47.6 (40.9-79.2) in 2020 to 4.5 (3.2-6.3) per 100,000 women-years by 2120, averting on average ∼4% and ∼46% of age-standardised cumulative cervical cancer cases over 25 and 100 years, respectively, compared to the basecase. Adding 2 lifetime screens helped achieve elimination over the century among all women (2120 cervical cancer incidence: 3.6 (1.9-3.6) per 100,000 women-years), but not among WLHIV (10.8 (5.3-11.6)), and averted more cumulative cancer cases overall (∼45% over 25 years and ∼61% over 100 years compared to basecase) than girls' vaccination alone. Adding three-yearly cervical screening among WLHIV (to girls' vaccination and 2 lifetime cervical screens) further reduced age-standardised cervical cancer incidence to 3.3 (1.8-3.6) per 100,000 women-years overall and to 5.2 (3.9-8.5) among WLHIV by 2120 and averted on average 12-13% additional cumulative cancer cases among all women and 21-24% among WLHIV than girls' vaccination and 2 lifetime cervical screens over 25 years or longer. Long-term vaccine protection and using the nonavalent vaccine was required for elimination.

Interpretation

High HPV vaccination coverage of girls and 2 lifetime cervical screens could eliminate cervical cancer among women overall in South Africa by the end of the century and substantially decrease cases among all women and WLHIV over the short and medium term. Cervical cancer elimination in WLHIV would likely require enhanced prevention strategies for WLHIV. Screening of WLHIV remains an important strategy to reduce incidence and alleviate disparities in cervical cancer burden between women with and without HIV, despite HIV interventions scale-up.

Funding

World Health Organization. National Cancer Institute, National Institutes of Health. MRC Centre for Global Infectious Disease Analysis, UK Medical Research Council. National Institute of Child Health and Human Development research. Cancer Association of South Africa. Canadian Institutes of Health Research and the Fonds de recherche du Québec - Santé research.