HPV vaccination for victims of childhood sexual abuse

HPV screening in the urine of transpeople - A prevalence study

BACKGROUND

There is limited data on human papillomaviruses (HPV) prevalence in transpeople due to low acceptance rate of screening methods. HPV tests from self-collected urine are gender-neutral, have a high acceptance, and have a comparable accuracy in females to clinician-collected samples. The aim of this study was to evaluate both the HPV prevalence in the urine in a large cohort of 200 transpeople with common risk profiles and the acceptability of such screening method.

METHODS

The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. 200 transpeople have been enrolled between May and October 2021. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills.Subjects were asked to answer a survey concerning gender identity, established risk factors for HPV infections as well as their preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample. Five patients not able to provide urine were excluded. HPV genotyping was performed using a validated multiplex real-time PCR assay, which simultaneously detects 28 HPV genotypes. This trial is registered at ClinicalTrials.gov, NCT04864951.

FINDINGS

Overall HPV positivity was 19·0% (37/195), 24·2% in female to male, 11·8% in male to female, 26·3% in genderqueer/non binary/other subjects, 27·9% in subjects currently having a cervix, and 26·0% in subjects born with cervix. Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Overall, 79·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected HPV screening.

INTERPRETATION

HPV testing in self-collected urine samples provides a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.

FUNDING

None.

Human Papillomavirus Vaccination After COVID-19

The current global novel coronavirus disease 2019 (COVID-19) pandemic threatens to derail the uptake of human papillomavirus (HPV) vaccination in low- and lower-middle income countries with major disruptions to routine immunization and the introduction of new vaccines delayed. This has a major impact on the World Health Organization cervical cancer elimination strategy, where it is dependent on HPV vaccination as well as cervical cancer screening and treatment. We discuss current opportunities and barriers to achieve high uptake of HPV vaccination in low- and lower-middle income countries as well as the impact of COVID-19. Implementation of 4 key recommendations for HPV vaccination in low- and lower-middle income countries is needed: increased global financial investment; improved vaccine supply and accelerated use of a single-dose schedule; education and social marketing; and adoption of universal school-based delivery. With the commitment of the global health community, the adoption of these strategies would underpin the effective elimination of cervical cancer.

Human Papilloma Virus Vaccination After Pediatric Sexual Abuse Evaluations in the Outpatient Child Sexual Abuse Subspecialty Clinic: A Quality Improvement Project

The nonavalent human papilloma virus (HPV) vaccination prophylactically contributes to the prevention of nine types of HPV-associated oral and genital cancers. HPV vaccination rates remain lower than the national Healthy People 2020 goal of 80%. Victims of pediatric sexual abuse are at a higher risk for acquiring and developing HPV-related outcomes. Current research supports vaccination after sexual abuse as soon as eligible and suggests utilizing multiple types of medical encounters to increase vaccination rates.An institutional-review-board-approved quality improvement project was developed to determine the impact of promoting and providing HPV vaccination during the medical encounter after pediatric sexual abuse in a child protection team (CPT) clinic. Twenty percent of the 111 total clinic patients evaluated in the preintervention period and 21% of the 99 patients evaluated in the postintervention period were HPV vaccine eligible, illustrating a significant opportunity for impact. During the intervention period, 62% of patients who were vaccine eligible and presented for their CPT clinic visit received HPV vaccine. Barriers to vaccination in the outpatient CPT clinic setting included high appointment no-show rates, high social and medical visit complexity, and absence of an appropriate consenting caretaker. Implications for forensic nursing practice are discussed.

HPV vaccine acceptance is high among adults in Mexico, particularly in people living with HIV

OBJECTIVE

To measure HPV vaccine acceptance in diverse Mexican adult popula-tions, taking into account HIV status.

MATERIALS AND METHODS

A total of 1 329 men and women, with and without HIV, participated in one of three intervention studies, offering HPV vaccination, carried out in the states of Morelos, Tlaxcala and Mexico City; either the bivalent (Morelos n=103, Tlaxcala n=127) or quadrivalent HPV-vaccine (Mexico City n=1 099) was offered.

RESULTS

HPV vaccine was accepted by 80.3% of participants; acceptance was higher in people living with HIV than those without (84.4 vs. 78%, p=0.004). Women had greater HPV infection knowledge (p<0.0001) than men and slightly higher (p=0.4) vaccine acceptance. The main reason for vaccine non-acceptance among HIV-positive participants was their doctor recommended they not get vaccinated.

CONCLUSIONS

Acceptance of HPV-vaccine was high in men and women regardless of HIV status. Even higher rates of acceptability may be achieved by educating healthcare providers to recommend HPV vaccine to their patients.

Incidence of external genital lesions related to human papillomavirus among Mexican men. A cohort study

OBJECTIVE

To determine external genital lesion (EGL) incidence -condyloma and penile intraepithelial neoplasia (PeIN)- and genital HPV-genotype progression to these EGLs.

MATERIALS AND METHODS

Participants (healthy males 18- 74y from Cuernavaca, Mexico, recruited 2005-2009, n=954) underwent a questionnaire, anogenital examination, and sample collection every six months;including excision biopsy on suspicious EGL with histological confirmation.Linear array assay PCR characterized 37 high/low-risk HPV-DNA types. EGL incidence and cumulative incidence were calculated, the latter with Kaplan-Meier.

RESULTS

EGL incidence was 1.84 (95%CI=1.42-2.39) per 100-person-years (py); 2.9% (95%CI=1.9-4.2) 12-month cumulative EGL.Highest EGL inci- dence was found in men 18-30 years:1.99 (95%CI=1.22-3.25) per 100py. Seven subjects had PeIN I-III (four with HPV16). HPV11 most commonly progresses to condyloma (6-month cumulative incidence=44.4%, 95%CI=14.3-137.8). Subject with high-risk sexual behavior had higher EGL incidence.

CONCLUSIONS

In Mexico, anogenital HPV infection in men is high and can cause condyloma. Estimation of EGL magnitude and associated healthcare costs is necessary to assess the need for male anti-HPV vaccination.

Factors associated with unwanted sexual experiences of young Australian females: an observational study

Background Behavioural and lifestyle factors associated with childhood unwanted sexual experiences (USE) have yet to be investigated in Australian females aged less than 18 years.

METHODS

Women aged 16-25 years living in Victoria were recruited via targeted advertising on Facebook. A web-based validated questionnaire was used to collect information on participant demographics, mental health, USE and sexual behaviours. Multivariable logistic regression was used to determine associations between a history of childhood (<16 years) and adolescent (16-18 years) USE and indices of sexual orientation.

RESULTS

Data were collected from 639 females (mean±s.d. age 22±3 years). Approximately 14% reported childhood USE and 15% reported adolescent USE. Approximately 37% of survivors of childhood USE reported penile-genital contact in relation to their USE. Participants who reported depression were almost four times as likely to have experienced childhood USE than those who did not report suffering from depression (odds ratio 3.6, 95% confidence interval 2.1-6.0, P<0.001). Positive associations between childhood USE, same-sex relationships and smoking were also detected.

CONCLUSIONS

A strong relationship between childhood USE, depression and same-sex sexual behaviours was found, but results did not determine the direction of this association. Longitudinal studies should be conducted to investigate whether there are groups of individuals who are at a high risk of experiencing childhood USE, so that appropriate support systems can be put in place.

Primary Prevention of Cervical Cancer: American Society of Clinical Oncology Resource-Stratified Guideline

PURPOSE

To provide resource-stratified (four tiers), evidence-based recommendations on the primary prevention of cervical cancer globally.

METHODS

The American Society of Clinical Oncology convened a multidisciplinary, multinational panel of oncology, obstetrics/gynecology, public health, cancer control, epidemiology/biostatistics, health economics, behavioral/implementation science, and patient advocacy experts. The Expert Panel reviewed existing guidelines and conducted a modified ADAPTE process and a formal consensus-based process with additional experts (consensus ratings group) for one round of formal ratings.

RESULTS

Existing sets of guidelines from five guideline developers were identified and reviewed; adapted recommendations formed the evidence base. Five systematic reviews, along with cost-effectiveness analyses, provided evidence to inform the formal consensus process, which resulted in agreement of ≥ 75%.

RECOMMENDATIONS

In all resource settings, two doses of human papillomavirus vaccine are recommended for girls age 9 to 14 years, with an interval of at least 6 months and possibly up to 12 to 15 months. Individuals with HIV positivity should receive three doses. Maximal and enhanced settings: if girls are age ≥ 15 years and received their first dose before age 15 years, they may complete the series; if no doses were received before age 15 years, three doses should be administered; in both scenarios, vaccination may be through age 26 years. Limited and basic settings: if sufficient resources remain after vaccinating girls age 9 to 14 years, girls who received one dose may receive additional doses between age 15 and 26 years. Maximal, enhanced, and limited settings: if ≥ 50% coverage in the priority female target population, sufficient resources, and cost effectiveness, boys may be vaccinated to prevent other noncervical human papillomavirus-related cancers and diseases. Basic settings: vaccinating boys is not recommended.

It is the view of the American Society of Clinical Oncology that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

A Discussion of High-Risk HPV in a 6-Year-Old Female Survivor of Child Sexual Abuse

Background

Human papilloma viruses (HPVs) cause a variety of clinical manifestations in children including skin warts, laryngeal papillomas, and condyloma acuminatum. Whereas the mode of transmission is well understood and management of HPV infection is clearly defined by guidelines in adults, less is known about the mode of transmission, natural history of disease, and appropriate management of high-risk anogenital HPV infections in children.

Case

The patient is a previously healthy 6-year-old female who presented with multiple vaginal lesions causing pain and discomfort and was diagnosed with HPV 18 positive CIN I.

Summary and Conclusion

Children infected with high-risk HPV subtypes remain a vulnerable patient population, and there is minimal literature on the natural history of disease and effects of overtreatment. Based on a literature review, conservative management, HPV vaccination, and consideration of the cervical cancer screening guidelines for adolescent females are an appropriate treatment course until more studies are reported on cervical cancer screening in survivors of child sexual abuse.

The Association Between Unwanted Sexual Experiences and Early-Onset Cervical Cancer and Precancer by Age 25: A Case-Control Study

BACKGROUND

We examined the association between unwanted sexual experiences and cervical cancer, cervical intraepithelial neoplasia 3, adenocarcinoma in situ, diagnosed ≤25 years of age.

METHODS

A case-control study of women ≤55 years who attended gynecological hospitals in Australia between 1983 and 2007. Cases were ≤25 years when diagnosed with disease, control group 1 were "older women" >25 years at diagnosis; control group 2 were "well women" ≤25 years attending preventive health clinics. A self-administered postal survey was utilized. The main outcome measures were prevalence of childhood sexual abuse (<16 years) and unwanted adolescent sexual experiences (between 16 and 18 years) in cases compared to controls.

RESULTS

Of 400 contactable subjects, 251 participated (62.8%). Prevalence of childhood sexual abuse in cases (26.6% [25/94]) was similar to other groups. Prevalence of childhood genital contact abuse in cases with cervical cancer was 45.5% [5/11], compared to older women (20% [10/50], p = 0.08) and well women (13.8% [8/58], p = 0.01), and was marginally more common compared to well women when adjusted for other lifestyle factors (odds ratio [OR]: 4.7 [1.0-22.6], p = 0.05). Prevalence of unwanted adolescent sexual experiences in cases was 28.9% [33/114]. Prevalence of adolescent penile-genital contact experiences in cervical cancer cases was 46.7% [7/15], compared to older women (9.4%, [6/64], p < 0.001) and well women (13.7%, [10/73], p = 0.003), and was more common compared to well women when adjusted for lifestyle (OR: 5.9 [1.4-24.9], p = 0.02) and sexual health risk factors (OR: 5.6 [1.4-22.1] p = 0.01).

CONCLUSIONS

Unwanted sexual experiences with genital contact were a risk factor for invasive cervical cancer ≤25 years, likely due to a complex interplay of biological and environmental factors.

HPV vaccines: how many doses are needed for protection?

HPV virus-like particle vaccines are highly immunogenic, well tolerated and are in the national immunization programs in more than 62 countries. Genital HPV is a sexually transmitted infection with first infection occurring just after the onset of sexual activity. The routine cohort for immunization in almost all countries are adolescent girls 9–15 years of age with or without catch-up for older adolescents and young women. In countries with vaccine coverage exceeding 50%, reductions in vaccine type HPV geno-prevalence and disease are being shown. The mechanism of protection is assumed to be via neutralizing antibody. Antibody concentration in adolescents less than 14 years of age after two doses of vaccine at 0 and 6 months are noninferior to women after three doses and in whom efficacy was demonstrated in randomized control trials. The original three-dose schedules have already been reduced in many countries, for those 14 years of age and under, to two doses at least 6 months apart for the licensed vaccines Cervarix® and GARDASIL®. There is preliminary evidence that one dose of vaccine is as effective as two or three doses at preventing persistent HPV infection in the cervix in young women and a one-dose schedule may be possible if supported by evidence from randomized controlled trials.