Comparison of Adolescent and Young Adult Self-Collected and Clinician-Collected Samples for Human Papillomavirus

Non-Vaccine-Type Human Papillomavirus Prevalence After Vaccine Introduction: No Evidence for Type Replacement but Evidence for Cross-Protection

BACKGROUND

We examined non-vaccine-type human papillomavirus (HPV) prevalence in a community before and during the first 8 years after vaccine introduction, to assess for (1) type replacement with any non-vaccine-type HPV and (2) cross-protection with non-vaccine types genetically related to vaccine-type HPV.

METHODS

Sexually experienced 13- to- 26-year-old women were recruited for 3 cross-sectional studies from 2006 to 2014 (N = 1180). Outcome variables were as follows: (1) prevalence of at least 1 of 32 anogenital non-vaccine-type HPVs and (2) prevalence of at least 1 HPV type genetically related to HPV-16 and HPV-18. We determined changes in proportions of non-vaccine-type HPV prevalence across the study waves using logistic regression with propensity score inverse probability weighting.

RESULTS

Vaccine initiation rates increased from 0% to 71.3%. Logistic regression demonstrated that from 2006 to 2014, there was no increase in non-vaccine-type HPV among vaccinated women (adjusted odds ratio [AOR], 1.02; 95% confidence interval [CI], 0.73-1.42), but an increase among unvaccinated women (AOR, 1.88; 95% CI, 1.16-3.04). Conversely, there was a decrease in types genetically related to HPV-16 among vaccinated (AOR, 0.57; 95% CI, 0.38-0.88) but not unvaccinated women (AOR, 1.33; 95% CI, 0.81-2.17).

CONCLUSIONS

We did not find evidence of type replacement, but did find evidence of cross-protection against types genetically related to HPV-16. These findings have implications for cost-effectiveness analyses, which may impact vaccine-related policies, and provide information to assess the differential risk for cervical cancer in unvaccinated and vaccinated women, which may influence clinical screening recommendations. The findings also have implications for public health programs, such as health messaging for adolescents, parents, and clinicians about HPV vaccination.

Self-Collection and Molecular Diagnosis for Detection of Human Papillomavirus: Why Incorporate It?

PURPOSE OF REVIEW

Cervical cancer, the third cause of death by cancer among Brazil's women, is associated with human papillomavirus (HPV) infection. In some countries of South America, North America, Europe, and Oceania, initial screening for HPV DNA and subsequent follow-up with HPV-positive patients using colposcopy and cytological testing are used as preventative measures.

RECENT FINDINGS

For HPV DNA detection, it is necessary to obtain cervical cells by conventional clinical collection method or self-collection of the cells that flake off from the uterine cervix and vaginal canal. Self-collection has been shown to be a viable option for obtaining samples and is a less invasive method that is more accepted by women. Thus, it can potentially decrease the limitations of the conventional clinical collection methods. The efficiency of the self-collection method aligned with the implementation of HPV molecular testing, if adopted by public and private health care systems, may extend the reach of current cervical cancer prevention efforts. In addition, considering all phases from triage to treatment, this method may reduce health care costs and the time spent by patients and health care teams to conduct examinations and collect samples.

Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women

BACKGROUND

Clinical trials of the 4-valent human papillomavirus (HPV) vaccine demonstrate high efficacy, but surveillance studies are essential to examine the long-term impact of vaccine introduction on HPV prevalence in community settings. The aims of this study were to determine during the 11 years after vaccine introduction the prevalence of (1) vaccine-type HPV in adolescent and young adult women who were vaccinated (to assess vaccine effectiveness) and (2) vaccine-type HPV in women who were unvaccinated (to assess herd protection).

METHODS

Young women 13 to 26 years of age were recruited from hospital-based and community health clinics for 4 surveillance studies from 2006 to 2017. We determined the proportion of vaccinated and unvaccinated women who were positive for vaccine-type HPV across the studies, and the odds of positivity for vaccine-type HPV using logistic regression; all analyses were propensity score-adjusted to control for between-wave differences in participant characteristics.

RESULTS

Vaccination rates increased from 0% to 84.3% (97% of study participants received the 4-valent vaccine). Among women who were vaccinated, 4-valent vaccine-type HPV detection decreased from 35% to 6.7% (80.9% decline; odds ratio 0.13, 95% confidence interval 0.08 to 0.22). Among women who were unvaccinated, 4-valent vaccine-type HPV detection decreased from 32.4% to 19.4% (40% decline; odds ratio 0.50, 95% confidence interval 0.26 to 0.97). Estimated vaccine effectiveness was 90.6% in wave 3 and 80.1% in wave 4.

CONCLUSIONS

In this study in which trends in HPV in a US community >10 years after 4-valent HPV vaccine introduction and after 9-valent vaccine introduction were examined, we found evidence of vaccine effectiveness and herd protection. Further research is needed to examine trends in 9-valent vaccine-type HPV after higher rates of vaccination are achieved.

Human Papillomavirus Infection in Women Who Submit Self-collected Vaginal Swabs After Internet Recruitment

Submission of vaginal samples collected at home could remove barriers that women face in getting screened for cervical cancer. From December 2013 to January 2014, women aged 21-30 years were recruited online to participate in either (1) self-collected testing for human papillomavirus (HPV) infection and an online survey, or (2) an online survey regarding their perceptions of self-collected testing for HPV infection. Demographics, risk factors, testing perceptions, and satisfaction with self-collected testing were assessed with online questionnaires. Women who performed self-collection were sent a home sampling kit by US mail, which was returned via US mail for HPV testing. A total of 197 women were enrolled, with 130 completing the online survey and 67 participating in both the survey and self-collection. Of the 67 women who were sent kits, 62 (92.5%) were returned for testing. Sixty kits contained a sample sufficient for testing. The overall prevalence of HPV infection was 17.8%, however 6 women (9.7%) were infected with >1 type of HPV. Women who self-collected a sample reported more favorable attributes of self-collection compared to women who only participated in the online survey, including ease of sampling (87.1 vs. 18.9%), no pain during sampling (72.6 vs. 5.6%), and lack of embarrassment (67.7 vs. 12.9%). A high prevalence of HPV infection was demonstrated among women recruited via the internet. Online recruitment and at home screening methods have the potential to engage women in screening by offering an approach that might be more acceptable to women of different backgrounds.

Acceptability and usability of self-collected sampling for HPV testing among African-American women living in the Mississippi Delta

BACKGROUND

Human papillomavirus (HPV) DNA testing has been shown to be an effective approach to cervical cancer screening, and self-collection sampling for HPV testing could be a potential alternative to Pap test, provided that women who tested positive by any method get timely follow-up and care. This feasibility study examined acceptability and usability of self-collected sampling for HPV testing among African-American (AA) women in the Mississippi Delta to inform the development of interventions to promote cervical cancer screening in this population.

METHODS

The study consisted of two phases. Phase I consisted of eight focus groups (n = 87) with AA women to explore knowledge, attitudes, and beliefs about cervical cancer and HPV infection as well as acceptability of self-collected sampling for HPV testing. In phase II, we examined the usability of this technology through one discussion group (n = 9). The Health Belief Model guided data collection and analysis.

RESULTS

Although participants perceived themselves as susceptible to cervical cancer and acknowledged its severity, there was a lack of knowledge of the link between HPV and cervical cancer, and they expressed a number of misconceptions. The most frequent barriers to screening included embarrassment, discomfort, and fear of the results. Women in both phases were receptive to self-collected sampling for HPV testing. All participants in the usability phase expressed that self-collection was easy and they did not experience any difficulties.

CONCLUSION

Self-collection for HPV testing is an acceptable and feasible method among AA women in the Mississippi Delta to complement current cytology cervical cancer screening programs.

A Viable and Simple Self-Sampling Method for Human Papillomavirus Detection among South African Adolescents

BACKGROUND

Self-sampling for Human Papillomavirus (HPV) testing may offer improved patient acceptability, decreased cost, and greater practicality than clinician collection of specimens. HPV testing among adolescents is necessary to conduct vaccine surveillance and may play a role in cervical cancer screening among some populations.

METHODS

A cross-sectional prevalence study was conducted to compare the results of self-collected and clinician-collected specimens for Human papillomavirus (HPV) testing among South African adolescent females. All participants provided self-sampled vaginal swabs and underwent clinician-collection of cervical swabs for HPV DNA analysis. The level of agreement between HPV DNA results from the two specimen collection methods was measured.

RESULTS

The level of agreement between HPV DNA results from self-collected and clinician-collected specimens was high (κ=86.7; p<0.001). A high prevalence of HPV overall was found by both specimen collection methods (57%; 95% CI 0.37-0.75). Low-risk HPV (LR-HPV) types were found slightly more frequently in self-collected specimens.

CONCLUSION

There is a high level of agreement between the HPV DNA results from self-collected and clinician-collected specimens. Self-collection of specimens for HPV testing is a viable alternative among adolescents.

Evaluation of dry and wet transport of at-home self-collected vaginal swabs for human papillomavirus testing

Our objective was to compare human papillomavirus (HPV) detection in paired self-collected vaginal samples transported by overnight mail in liquid specimen transport medium (STM) (wet) or in dry tubes (dry). Women aged 18-24 years were recruited online to self-collect vaginal swab samples at home for HPV testing and 159 women returned paired wet and dry samples. Dry samples were rehydrated with STM upon arrival at the laboratory. HPV was detected by the Roche Linear Array HPV genotyping test (37 genotypes) and Kappa and McNemar statistics were used to compare wet versus dry samples for detecting HPV. Of the subjects tested in this study, 51 % were HPV-positive (in either sample) and 40 % were positive for high-risk HPV. A total of 216 type-specific infections were detected among the 80 HPV-positive women. Almost perfect agreement was observed between paired samples for detecting any HPV (subject-level positive agreement: 91.9 %, κ: 0.85) or type-specific HPV (positive agreement across types: 90.1 %, κ: 0.90). Similar agreement between sample types was seen when testing for high-risk types and 81.9 % of all type-specific infections were detected in both samples. Among discordant pairs, wet samples were 3.3 times more likely to be positive for type-specific HPV than dry samples (P = 0.02). However, in 63.6 % of wet-positive/dry-negative discordant pairs analysed for viral load, type-specific HPV was either undetectable or detected at a low level (<100 copies) in the wet samples, suggesting that the majority of infections missed by using dry samples are less likely to be clinically relevant. Our results indicate that dry transport is a feasible option for transporting at-home self-collected vaginal samples for HPV DNA testing.

Dry self-sampling versus provider-sampling of cervicovaginal specimens for human papillomavirus detection in the Inuit population of Nunavik, Quebec

OBJECTIVE

To assess the comparability of self-collected cervicovaginal samples and provider-collected cervical samples for the detection of human papillomavirus (HPV) DNA among Inuit women in Nunavik, Quebec, avoiding the use of liquid-based storage and transport of the self-collected samples.

METHODS

Ninety-three women aged 18-69 years were recruited from a previously formed cohort on the natural history of HPV to this cross-sectional measurement study. This study utilized HPV DNA test results from 89 paired specimens collected by study participant and health provider with Dacron swabs. Samples were tested for 36 HPV types with the PGMY-primer PCR protocol and genotyping with the linear array method. Unweighted kappa statistics and McNemar tests were used to measure the agreement between sampling techniques.

RESULTS

In the self-collected samples, 30 different HPV types were found, compared with 29 types found in the provider-collected samples. The prevalence of high-risk (HR) HPV was 38.2% in the self-collected samples and 28.1% in the provider-collected samples. The agreement between collection methods for the detection of HR-HPV DNA (85.4%) was good. HR-HPV and type-specific HPV 16/18 were as likely to be detected in the self-collected samples compared with the provider-obtained samples.

CONCLUSIONS

Women in this population were easily able to collect adequate cervicovaginal specimens for HPV testing. As self-sampling has a high recovery of HR-HPV and is comparable with provider-sampling, we conclude that self-sampling with dry storage and transport could be a good cervical cancer screening alternative for Inuit women in Nunavik who have traditionally avoided speculum examination.

Acceptability of self-testing for trichomoniasis increases with experience

OBJECTIVES

Self-testing and point-of-care (POC) tests could improve the detection of sexually transmitted infections (STIs) in adolescents. This study aimed to (1) validate a scale measuring acceptability of self-testing for trichomoniasis, (2) compare acceptability of self versus clinician testing using a POC test for trichomoniasis, (3) examine changes in acceptability after experience and review of results, and (4) examine predictors of acceptability.

METHODS

Women (14-22 years old) performed the POC test and completed surveys assessing acceptability of self and clinician testing at baseline, after testing, and after discussion of results. Factor analysis examined scale structure; changes in mean scale scores were assessed with mixed models. Generalised linear models examined predictors of acceptability.

RESULTS

Of 247 participants, 54 (22%) had a positive POC test for trichomoniasis. Factor analysis confirmed four acceptability subscales: trust of results, confidence, comfort, and effects of testing. At baseline, trust and confidence were higher, and comfort was lower, for clinician versus self testing. For self-testing, all subscale scores increased from baseline to after testing, and trust increased from after testing to after discussion. Trust of self and clinician results was not significantly different after discussion. A positive attitude towards home testing predicted higher self-test acceptability on all subscales. Tampon use was associated with increased self-test comfort at baseline. Concordance between self and clinician results predicted increased trust of self testing after discussion.

CONCLUSIONS

Many young women lack confidence in their ability to self-test for trichomoniasis. Allowing women to try a POC test and review the results with a clinician increases acceptability of self-testing.

Improving behaviour in self-testing (IBIS): Study on frequency of use, consequences, information needs and use, and quality of currently available consumer information (protocol)

BACKGROUND

Self-tests are available to consumers for more than 25 conditions, ranging from infectious diseases to cardiovascular risk factors. Self-tests are defined as in-vitro tests on body materials such as blood, urine, faeces, or saliva that are initiated by consumers to diagnose a particular disorder or risk factor without involving a medical professional. In 2006, 16% of a sample of Dutch Internet users had ever used at least one self-test and 17% intended to use a self-test in the future. The objectives of this study are to determine (1) the frequency of self-test use, (2) the consumers' reasons for using or not using a self-test, (3) the information that is used by self-testers in the different self-test stages and the consumers' interpretation of the quality of this information, (4) the consumers' response to self-test results in terms of their confidence in the result, reassurance by the test result, and follow-up behaviour, (5) the information consumers report to need in the decision making process of using or not using a self-test, and in further management on the basis of the self-test result, and (6) the quality of the currently available consumer information on a selected set of self-tests.

METHODS

Mixed methods study with (1) a cross-sectional study consisting of a two-phase Internet-questionnaire, (2) semi-structured interviews with self-testers and consumers who intend to use a self-test, and (3) the assessment of the quality of consumer information of self-tests. The Health Belief Model and the Theory of Planned Behaviour will serve as the theoretical basis for the questionnaires and the interview topic guides.

CONCLUSIONS

The self-testing area is still in a state of flux and therefore it is expected that self-test use will increase in the future. To the best of our knowledge, this is the first study which combines quantitative and qualitative research to identify consumers' information needs and use concerning self-testing, and the consumers' actual follow-up behaviour based on the self-test result, and simultaneously investigates the quality of the currently available consumer information. The results of this study will be used as an input in developing consumer information on self-testing.

Accuracy and cost-effectiveness of cervical cancer screening by high-risk human papillomavirus DNA testing of self-collected vaginal samples

OBJECTIVE

Estimate the accuracy and cost-effectiveness of cervical cancer screening strategies based on high-risk human papillomavirus (HPV) DNA testing of self-collected vaginal samples.

MATERIALS AND METHODS

A subset of 1,665 women (age range, 18-50 y) participating in a cervical cancer screening study were screened by liquid-based cytology and by high-risk HPV DNA testing of both self-collected vaginal swab samples and clinician-collected cervical samples. Women with positive/abnormal screening test results and a subset of women with negative screening test results were triaged to colposcopy. On the basis of individual and combined test results, 5 screening strategies were defined. Estimates of sensitivity and specificity for cervical intraepithelial neoplasia grade 2 or worse were calculated, and a Markov model was used to estimate the incremental cost-effectiveness ratios for each strategy.

RESULTS

Compared with cytology-based screening, high-risk HPV DNA testing of self-collected vaginal samples was more sensitive (68%, 95% CI = 58%-78% vs 85%, 95% CI = 76%-94%) but less specific (89%, 95% CI = 86%-91% vs 73%, 95% CI = 67%-79%). A strategy of high-risk HPV DNA testing of self-collected vaginal samples followed by cytology triage of HPV-positive women was comparably sensitive (75%, 95% CI = 64%-86%) and specific (88%, 95% CI = 85%-92%) to cytology-based screening. In-home self-collection for high-risk HPV DNA detection followed by in-clinic cytology triage had a slightly lower lifetime cost and a slightly higher quality-adjusted life year (QALY) expectancy than did cytology-based screening (incremental cost-effectiveness ratio of triennial screening compared with no screening was $9,871/QALY and $12,878/QALY, respectively).

CONCLUSIONS

Triennial screening by high-risk HPV DNA testing of in-home, self-collected vaginal samples followed by in-clinic cytology triage was cost-effective.

Epidemiology and risk factors for human papillomavirus infection in a diverse sample of low-income young women

BACKGROUND

Two HPV vaccines prevent infection with HPV-16 and HPV-18, high-risk (cancer-associated) HPV types which together cause approximately 70% of cervical cancers; one vaccine also prevents HPV-6 and HPV-11, which together cause approximately 90% of anogenital warts. Defining type-specific HPV epidemiology in sexually experienced women will help estimate the potential clinical benefits of vaccinating this population.

OBJECTIVES

To examine HPV epidemiology in a diverse sample of sexually experienced women, and to determine factors associated with high-risk HPV and vaccine-type HPV (HPV-6, HPV-11, HPV-16 and HPV-18).

STUDY DESIGN

Cross-sectional study of 13-26-year-old women (N=409) who completed a questionnaire and provided a cervicovaginal swab. Swabs were genotyped for HPV using PCR amplification. Logistic regression models were used to determine whether participant characteristics, knowledge, and behaviors were associated with high-risk and vaccine-type HPV.

RESULTS

Most women (68.4%) were positive for >or=1 HPV type, 59.5% were positive for >or=1 high-risk type, 33.1% were positive for >or=1 vaccine-type HPV, and 3.5% were positive for both HPV-16 and HPV-18: none was positive for all four vaccine types. In adjusted logistic regression models, Black race (OR 2.03, 95% CI 1.21-3.41) and lifetime number of male sexual partners (OR 4.79, 95% CI 2.04-11.23 for >or=10 partner vs. <or=1 partner) were independently associated with high-risk HPV infection.

CONCLUSIONS

HPV prevalence was very high in this sample of sexually active young women, but <5% were positive for both HPV-16 and HPV-18, suggesting that vaccination could be beneficial for many individual women who are sexually experienced.

Determinants of incidence and clearance of high-risk human papillomavirus infections in rural Rakai, Uganda

BACKGROUND

We used self-administered vaginal swabs to assess the incidence and clearance of carcinogenic human papillomavirus (HPV) infections in rural Rakai, Uganda.

METHODS

Women provided self-administered vaginal swab at annual home-based visits. Type-specific carcinogenic HPV incidence and clearance and risk factors were assessed.

RESULTS

Carcinogenic HPV incidence was 17.3 per 100 person-years among HIV-positive women compared with 7.0 per 100 person-years among HIV-negative women (P < 0.001). HPV-51 had the highest incidence followed by HPV-16 (1.8 per 100 and 1.5 per 100 person-years, respectively). In multivariate model, HIV-positive women were twice as likely to have incident infection compared with HIV-negative women. Younger women were at higher risk for incident infection, as were women with higher lifetime and recent sexual partners, and high perception of AIDS. Married women were less likely to have incident infection. Approximately half of all carcinogenic HPV infections cleared over the study follow-up of 3 years. HPV-31, HPV-35, and HPV-16 had the lowest clearance (16.7%, 27.9%, and 38.3%, respectively). In multivariate model, HIV-positive, women over 30 years with higher HPV viral, burden and more lifetime sex partners were less likely to clear infections.

CONCLUSIONS

Self-collected vaginal swabs provide accurate HPV exposure assessment for studying HPV exposure and epidemiology and can be an important tool for research in populations unwilling to undergo pelvic exam.

Rates of human papillomavirus vaccination, attitudes about vaccination, and human papillomavirus prevalence in young women

OBJECTIVE

To estimate rates of human papillomavirus (HPV) vaccination, factors associated with intention and belief in one's ability (self-efficacy) to receive the vaccine, and prevalence of vaccine-type HPV during the first year after an HPV-6, HPV-11, HPV-16, HPV-18 vaccine was licensed.

METHODS

Sexually experienced females 13-26 years of age (N=409) were recruited from three primary care clinics, completed a questionnaire, and underwent cervicovaginal HPV DNA testing. Outcome measures were HPV vaccination, intention and belief in one's ability to receive the HPV vaccine in the next year, and prevalence of vaccine-type HPV. Factors independently associated with intention and belief in one's ability to receive the HPV vaccine were determined by logistic regression.

RESULTS

Five percent of participants had received at least one HPV vaccine dose, 66% intended to receive the vaccine, 65% were confident they could find the time to get vaccinated, 54% believed that they could receive all three shots, and 42% believed that they could afford vaccination. Sixty-eight percent of women were HPV-positive: 9% for HPV-6, 3% for HPV-11, 17% for HPV-16, and 12% for HPV-18. Factors independently associated with intention included believing that influential people would approve of vaccination, higher perceived severity of cervical cancer or genital warts, fewer safety barriers, and pregnancy history. Factors associated with a high belief in one's ability to receive the vaccine included perceived severity of HPV, sexually transmitted disease history, insurance coverage, and fewer practical barriers to vaccination.

CONCLUSION

Interventions that aim to increase intention and belief in one's ability to receive HPV vaccines, which may lead to higher vaccination rates, should address personal beliefs about vaccination as well as systemic barriers to vaccination.

LEVEL OF EVIDENCE

III.

Baseline assessment of prevalence and geographical distribution of HPV types in Chile using self-collected vaginal samples

BACKGROUND

Chile has broad variations in weather, economics and population from the far desert north (Region 1) to the cold, icy south (Region 12). A home-based self-collected vaginal sampling was nested in the 2003 Chilean population-based health survey in order to explore the possibility of a type-specific geographical variation for human papillomavirus

METHODS

The population was a national probability sample of people 17 years of age and over. Consenting women provided self-collected cervicovaginal swabs in universal collection media (UCM). DNA was extracted and typed to 37 HPV genotypes using PGMY consensus PCR and line blot assay. Weighted prevalence rates and adjusted OR were calculated.

RESULTS

Of the 1,883 women participating in the health survey, 1,219 (64.7%) provided a cervicovaginal sample and in 1,110 (56.2% of participants and 66.5% of those eligible) the samples were adequate for analysis. Refusal rate was 16.9%. HPV prevalence was 29.2% (15.1% high-risk HPV and 14.1% low-risk HPV). Predominant high-risk types were HPV 16, 52, 51, 56 and 58. Predominant low-risk HPVs were HPV 84, CP6108, 62, 53 and 61. High-risk and low-risk HPV rates were inversely correlated between the regions. High-risk HPV prevalence was highest among the youngest women, whereas low-risk HPV increased slightly with age.

CONCLUSION

Self-obtained vaginal sampling is adequate for monitoring HPV in the community, for identifying high-risk areas, and for surveying the long term impact of interventions.

From the NIH: proceedings of a workshop on the importance of self-obtained vaginal specimens for detection of sexually transmitted infections

On June 27, 2006, the NIH conducted a workshop to review published data and current field practices supporting the use of self-obtained vaginal swabs (SOVs) as specimens for diagnosis of sexually transmitted infections (STIs). The workshop also explored the design of studies that could support FDA clearance of SOVs for STI testing, particularly for specimens collected in nonclinical settings including patients' homes. This report summarizes the workshop findings and recommendations. Participants concluded that self-obtained vaginal swabs are well accepted by women of all ages and that SOVs perform as well as or better than other specimen types for Chlamydia trachomatis and Neisseria gonorrhoeae detection using transcription-mediated amplification. In addition, workshop participants recommended the validation of SOV testing by public health practitioners and manufacturers of STI diagnostic tests to expedite incorporation of SOVs as a diagnostic option in clinical and nonclinical settings for Chlamydia trachomatis and Neisseria gonorrhoeae testing. Similarly, SOVs should be explored for use in the diagnosis of other sexually transmitted pathogens.

Self-Collected Samples for Testing of Oncogenic Human Papillomavirus: A Systematic Review

BACKGROUND

To investigate the role of self-sampling for human papillomavirus (HPV) testing as an alternative to cervical cancer screening by clinicians (i.e., Papanicolaou [Pap] test).

METHODS

A systematic search of MEDLINE, EMBASE, Cochrane Library, and other sources for evidence related to the efficacy and feasibility of HPV DNA self-collection.

RESULTS

A total of 25 studies were identified. In 22 comparisons across 19 studies, the concordance between samples collected by patients and those obtained by clinicians was reasonably high in the majority of cases. Women in many countries across wide age ranges were successful in collecting samples for HPV DNA testing. In four studies, the quality of the cytology from patient samples was as good as clinician samples, with more than 95% of samples yielding HPV DNA results. The studies that examined acceptability found that women were generally very positive about collecting their own samples, although some concerns were noted. No study evaluated the effect of HPV DNA self-sampling on screening participation rates, early detection, survival, or quality of life.

CONCLUSIONS

Self-sampling for HPV DNA testing is a viable screening option, but there is insufficient evidence to conclude that self-sampling for HPV DNA testing is an alternative to the Pap test. Although HPV DNA testing using self-collected samples holds promise for use in under-resourced areas or for women who are reluctant to participate in Pap testing programs, the evidence supporting it is limited. Further definitive research is needed to provide a solid evidence base to inform the use of self-sampling for HPV DNA testing for the purpose of increasing screening rates, especially in women who are never or seldom screened.

Adolescent cervical dysplasia: histologic evaluation, treatment, and outcomes

OBJECTIVE

The purpose of this study was to evaluate histologic findings and outcomes among adolescents with cervical dysplasia.

STUDY DESIGN

Patient charts (2001-2005) were reviewed. Prevalence of cervical intraepithelial neoplasia (CIN) grades 2 and 3 and progression and regression were recorded.

RESULTS

Five hundred one patients were identified. On biopsy, 324 patients (65%) had CIN 1 or less, and 177 patients (35%) had CIN > or = 2. Twenty-nine percent of the patients with CIN 2 opted for conservative treatment vs excision. Over 18 months, the condition of 65% of the patients regressed; the condition of 20% of the patients was stable, and the condition of 5% of the patients progressed without cancer. Of the patients who underwent excision (follow-up median, 26 months), 84% experienced regression of their condition; the condition of 11% was persistent, and 5% progressed with no cancer.

CONCLUSION

CIN > or = 2 is present in 35% of our cohort. Most had CIN 2, and most experienced regression. Our observation supports continued vigilance in the evaluation of adolescents but suggests that less intervention for CIN 2 may be acceptable.

Sociodemographic factors associated with high-risk human papillomavirus infection

OBJECTIVE

To determine the prevalence of high-risk (cancer-associated) human papillomavirus (HPV) infection in U.S. women, identify sociodemographic factors associated with infection, and explore the implications for prevention of HPV-related disease in the vaccination era.

METHODS

Women aged 14-59 years (n=1,921) participating in the 2003-2004 National Health and Nutrition Examination Survey provided a vaginal swab which was evaluated for 37 HPV types. We determined which sociodemographic characteristics were associated with high-risk HPV, using logistic regression models.

RESULTS

High-risk HPV infection was present in 15.6% (95% confidence interval [CI] 12.6-18.6%) of participants, corresponding to a population prevalence of 12,028,293 U.S. women. Women living below the poverty line, compared with those living three or more times above it, were more likely to be positive for high-risk HPV (23% versus 12%, P = .03). Among participants living below the poverty line, only Mexican-American ethnicity (odds ratio [OR] 0.4, 95% CI 0.2-0.9) and unmarried status (OR 3.3, 95% CI 1.2-8.9) were associated with HPV prevalence. In contrast, several factors were associated with HPV among participants living above the poverty line, including black race (OR 1.4, 95% CI 1.0-2.0), income (OR 0.92, 95% CI 0.84-0.99), unmarried status (OR 2.0, 95% CI 1.3-3.0), and age (OR for 22-25 year olds 2.4, 95% CI 1.4-4.0).

CONCLUSION

High-risk HPV infection is common in U.S. women, particularly in poor women. Cervical cancer prevention efforts in the vaccination era must ensure that all low-income women have access to preventive services including education, Pap test screening, and HPV vaccines. Otherwise, existing disparities in cervical cancer could worsen.

Comparability of self-collected vaginal swabs and physician-collected cervical swabs for detection of human papillomavirus infections in Rakai, Uganda

OBJECTIVE

The objective of this study was to compare human papillomavirus (HPV) DNA testing between self-administered vaginal swabs and physician-administered cervical swabs in women from rural Rakai District, Uganda.

STUDY DESIGN

Between 2002 and 2003, women from a population-based cohort participated in an HPV study. Women collected self-administered vaginal swabs and were also offered a pelvic examination, which included physician-collected cervical samples.

METHODS

Hybrid-capture 2 was used to determine carcinogenic HPV status. Polymerase chain reaction was used to determine HPV genotypes. Unweighted kappa statistics were used to determine agreement.

RESULTS

Compliance with self-collected swabs was > or =86%; however, only 51% accepted a pelvic examination. Carcinogenic HPV prevalence was 19% in self-collected and 19% in physician-collected samples. Agreement among paired observations was 92% with a kappa of 0.75. Kappa between self- and physician-collected samples was similar in HIV strata (k = 0.71 and 0.75 for HIV-positive and HIV-negative, respectively).

DISCUSSION

In this community-based setting, detection of carcinogenic HPV was comparable among self- and physician-administered samples. Self-collection is a feasible and accurate means of obtaining HPV samples from women in resource-poor settings or persons reluctant to undergo a pelvic examination.

Concordance of self-collected and clinician-collected swab samples for detecting human papillomavirus DNA in women 18 to 32 years of age

OBJECTIVE

The objective of this study was to determine whether self- and clinician-collected samples are comparable for human papillomavirus (HPV) detection.

STUDY DESIGN

Three hundred seventy-four women aged 23 to 32 (population 1) and 211 women aged 18 to 25 (population 2) contributed self-collected vaginal and clinician-collected cervical and vulvovaginal samples for HPV DNA testing. Eighty-six women mailed in self-collected samples.

RESULTS

Agreement between self-collected vaginal and clinician-collected combined cervical/vulvovaginal samples was excellent (population 1:92.0%, kappa = 0.81; population 2: 96.4%, kappa = 0.88), but self-collected samples were more concordant with clinician-collected cervical samples in population 2 (kappa = 0.84) than population 1 (kappa = 0.65) (P = 0.01). Age-adjusted HPV prevalence was slightly lower in mailed-in (21.5%) than in-clinic self-collected samples (26.8%).

CONCLUSIONS

The combined clinician-collected cervical/vulvovaginal sample is most sensitive for detecting all female genital tract HPV infections. HPV concordance between cervical and vaginal samples may be better for newer infections. Larger studies are needed to determine whether mailed-in self-samples are as effective as those collected in a clinical setting.

Agreement between self- and clinician-collected specimen results for detection and typing of high-risk human papillomavirus in specimens from women in Gugulethu, South Africa

We assessed the agreement in detection of high-risk human papillomavirus (HPV), as well as specific HPV types, between self- and clinician-obtained specimens for 450 women over 18 years of age attending a community health center in Gugulethu, South Africa. Both self-collected swabs and tampons had high agreement with clinician-obtained brushes when the Roche Reverse Line Blot Assay (RLBA) was used (for swabs, 86% concordance, with a kappa statistic [kappa] of 0.71; for tampons, 89% concordance, with kappa of 0.75). Agreement was lower, although still fair, with the Digene Hybrid Capture 2 test (HC2), with kappa higher for swabs than for tampons (for swabs, 81% concordance, with kappa of 0.61; for tampons, 82% concordance, with kappa of 0.55). Low-risk HPV types were nearly two times more common in self-collected specimens than in clinician-collected specimens tested by RLBA. All 15 women diagnosed with high-grade lesions by cytology tested positive for high-risk HPV with clinician-collected specimens tested by RLBA and HC2, while 11 out of 15 tested positive with self-collected specimens by HC2 and 5 out of 6 tested positive by RLBA. Self-collected specimens can provide valid specimens for HPV testing using nucleic acid amplification tests, although a few cytological abnormalities may be missed.

Are self-collected samples comparable to physician-collected cervical specimens for human papillomavirus DNA testing? A systematic review and meta-analysis

OBJECTIVE

To compare the detection rate of genital human papillomavirus (HPV) infection in self- and physician-obtained samples.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Studies published between 1966 and November 2005 identified through Medline and Embase that compared both sampling methods.

MAIN OUTCOME MEASURES

We calculated the concordance and kappa statistic between physician- and self-sampling and the difference between proportions of HPV positive samples. Weighted averages were reported with 95% confidence intervals (CI) using a random-effects model.

RESULTS

Eighteen studies (5441 participants) were included that evaluated broad HPV type categories, 10 (3688 patients) that of high-risk (HR) HPV and three (530) that of low-risk (LR) HPV. A high level of concordance of 0.87 (95%CI, 0.82 to 0.91) between self- and physician-sampling was obtained for detection of HPV DNA (kappa 0.66, 95%CI, 0.56 to 0.76). The prevalence difference of HPV DNA between sampling methods was -0.5 (95%CI, -2.8 to 1.8). Results were similar when restricting the analysis to HR-HPV but the prevalence of LR-HPV types was higher in self-collected samples.

CONCLUSION

Self-sampling was as sensitive as physician-obtained sampling to detect HR-HPV or HPV DNA. Self-sampling may be a suitable alternative method for studies on HPV transmission and vaccine trials.

Human papillomavirus: the burden of infection

Vaccines for preventing human papillomavirus (HPV) infection are far along in clinical development and testing, and hold great promise for reducing HPV infections and HPV-associated disease. HPV is the most common sexually transmitted infection in the United States, affecting an estimated 75% of the U.S. population. HPV infection is highly prevalent in sexually active adolescents and young adults. Sexual activity is the most important risk factor for infection, with 64% to 82% of sexually active adolescent girls testing positive for HPV. Clinical manifestations of HPV infection include genital warts, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer, all of which cause significant morbidity and, in the case of cervical cancer, mortality. The majority of HPV-associated disease is caused by 4 HPV types: HPV 6 and 11 are responsible for low-grade genital lesions and more than 90% of genital warts, and HPV 16 and 18 both account for approximately 70% of all high-grade CIN or dysplasia and invasive cervical cancer. Although current screening methods have proven effective in reducing cervical cancer incidence and associated mortality, more than 10,000 women are diagnosed annually and 4000 U.S. women die from the disease each year.

Acceptability of human papillomavirus self testing in female adolescents

OBJECTIVES

To develop scales assessing acceptability of human papillomavirus (HPV) testing in adolescents, to compare acceptability of self to clinician testing, and to identify adolescent characteristics associated with acceptability.

METHODS

Female adolescents 14-21 years of age attending a hospital based teen health centre self collected vaginal samples and a clinician, using a speculum, collected cervicovaginal samples for HPV DNA. Acceptability of and preferences for self and clinician testing were assessed at baseline and 2 week visits.

RESULTS

The mean age of the 121 participants was 17.8 years and 82% were black. The acceptability scales demonstrated good internal consistency, reliability, test-retest reliability, and factorial validity. Scores were significantly lower for self testing than clinician testing on the acceptability scale and three subscales measuring trust of the test result, confidence in one's ability to collect a specimen, and perceived effects of testing (p < 0.01). Of those who reported a preference, 73% preferred clinician to self testing. Acceptability scores for both self and clinician testing increased significantly pre-examination to post-examination (p < 0.01). Multivariable analyses demonstrated that race was independently associated with pre-examination and post-examination acceptability of self testing, and that sexual behaviours and gynaecological experiences were associated with specific acceptability subscales.

CONCLUSIONS

This sample of adolescents found clinician testing for HPV to be more acceptable than self testing and preferred clinician to self testing. If self testing for HPV is offered in the future, clinicians should not assume that adolescent patients will prefer self testing. Instead, they should educate adolescents about available testing options and discuss any concerns regarding self collection technique or accuracy of test results.

Self-Sampling Is Associated with Increased Detection of Human Papillomavirus DNA in the Genital Tract of HIV-Seropositive Women

BACKGROUND

Analysis of self-collected swab samples from the genital tract could improve accrual and retention of women in studies of human papillomavirus (HPV) infection and precancerous cervical lesions. Self-collected vaginal swab specimens and physician-collected cervical swab specimens were compared for detection and typing of HPV DNA in 158 HIV-seropositive women.

METHODS

Paired samples were collected for 157 participants. Beta-globin was not detected in 6 (3.3%) physician-collected specimens and 8 (4.3%) self-obtained specimens collected from 11 women, leaving 146 paired samples suitable for PCR analysis. HPV DNA was amplified with the HPV primers PGMY09 and PGMY11 and typed using the line blot assay.

RESULTS

HPV DNA was detected more frequently in self-collected samples (95 [65.1%] of 146), compared with physician-collected samples (78 [53.4%] of 146) (P = .04). Self-collected samples contained a greater number of types (mean +/- SD, 1.60 +/- 1.80 types; 95% confidence interval [CI], 1.31-1.90), compared with physician-collected samples (mean +/- SD, 1.25 +/- 1.66 types; 95% CI, 0.98-1.52) (P = .04). A good agreement between sampling methods was achieved for detection of any HPV DNA (kappa = 0.73; 95% CI, 0.58-0.89), high-risk types (kappa = 0.84; 95% CI, 0.68-0.99), and low-risk types (kappa = 0.71; 95% CI, 0.67-0.75). Agreement between sampling methods for detection of HPV DNA was found for 24 (88.8%) of 27 follow-up samples collected from a total of 20 women. A comparison of samples collected at consecutive visits revealed agreements for detection of any HPV DNA, detection of high-risk HPV, and HPV typing results between visits of 88.9% (24 of 27 samples), 81.5% (22 of 27), and 55.5% (15 of 27), respectively, for physician-collected samples, and 96.3% (26 of 27 samples), 92.6% (25 of 27), and 55.5% (15 of 27), respectively, for self-collected samples.

CONCLUSION

Analysis of self-collected vaginal swab samples improved the detection rate of HPV, suggesting that such samples might be of greater value than physician-obtained samples in studies of HPV transmission.

Reproductive and obstetric characteristics of adolescent pregnancies in Turkish women

OBJECTIVE

To evaluate reproductive and obstetric characteristics of adolescent pregnancies in Turkish population.

DESIGN

Retrospective study.

SETTING

Social Security Agency (SSK) Aegean Obstetrics and Gynecology Teaching Hospital (tertiary referral center).

PATIENTS

One thousand and eight hundred adolescent pregnant women who referred to our center, between January 12, 2002 and March 15, 2003. The adolescent age group was defined as young women between the ages of 13 and 19.

INTERVENTIONS

None.

OUTCOME MEASURES

Socio-demographic characteristics, contraceptive histories, sexually transmitted infections (STI), and obstetric outcomes of the patients.

RESULTS

Mean age was 17.3 (range 13-19) years. Among all adolescent pregnancies 1368 (76%) cases were planned, and 1512 (84%) cases were married. Approximately 70% of the patients with a non-planned pregnancy were not using any contraceptive methods. Although there were no patients with HIV infection, there were a considerable percentage of patients with positive cervical screening tests for Human Papilloma Virus (8.05%). A majority of adolescent mothers (77%) lacked prenatal care; mean gestational week at the first prenatal visit of the patients taking prenatal care was 28.2 (range 6-39) weeks. There were 249 (13.83%) abortions. Mean gestational age at delivery was 36 +/- 2 (range 25-41) weeks. The most common obstetric complication was low birth weight (28.72%).

CONCLUSIONS

Adolescent pregnancy rate in Turkey is similar to those in developed countries. However, there are considerable differences which possible reflect ethnic and socio-cultural differences, in between two populations. Our major problems seem to be the low rate of previous effective contraceptive use for unintended adolescent pregnant women and the high rate of inadequate prenatal care for adolescent pregnant women, even if their pregnancies are intended.

Urine nucleic acid amplification tests for the diagnosis of sexually transmitted infections in clinical practice

PURPOSE OF REVIEW

With the advent of highly sensitive and specific nucleic acid amplification assays, this report will demonstrate that self-collected genital specimens, such as urine or even vaginal swabs can be accurately used to diagnose sexually transmitted infections.

RECENT FINDINGS

Use of self collected samples can eliminate the necessity of a clinician to perform a pelvic examination for women or collect a urethral swab for men, thus extending the diagnostic capability for sexually transmitted infections to non-clinic screening venues. As many sexually transmitted infections are asymptomatic, this ability to use self-sampling greatly increases the numbers of patients that can be screened, and has the potential to augment public health programs designed to control the epidemic of sexually transmitted infections in the community. Patient collected samples are highly acceptable, highly accurate, and are becoming widely used. Self-sampling also allows clinicians to easily screen patients in the clinic, who are not presenting for pelvic or urogenital examinations, for sexually transmitted infections.

SUMMARY

Highly accurate molecular tests and easily obtained self-collected urogenital samples represent the ideal combination for obtaining the public health goal of decreasing the sexually transmitted infection epidemic among sexually active persons in the United States today.

Social and cultural barriers to Papanicolaou test screening in an urban population

OBJECTIVE

To define screening behaviors, attitudes, and beliefs regarding cancer and its treatment among women with cervical cancer.

METHODS

Between August 2000 and July 2002, 148 consecutive women with invasive cervical cancer were queried about barriers to screening. Women presented to outpatient clinics, emergency departments, or inpatient units of 3 urban hospitals. Two groups of women were identified: those who denied having had a Papanicolaou (Pap) test and those who had recalled having Pap test in the past. Responses were compared using t tests, chi(2) tests, and binary logistic regression.

RESULTS

The 146 (99%) respondents were predominantly African Americans (50%) or Hispanic (27%). Thirty-six (25%) women reported no prior screening. Women never screened were significantly more likely to be Hispanic (odds ratio [OR] 3.0, 95% confidence interval [CI] 1.4-6.7), recent immigrants (OR 5.7, 95% CI 2.0-16), less educated (OR 3.6, 95% CI 1.6-8.0), and uninsured (OR 3.9, 95% CI 1.6-9.7). They were more likely to lack family support (adjusted OR 3.5, 95% CI 1.1-11) and lack knowledge about their risk for cervical cancer (adjusted OR 2.6, 95% CI 1.1-6.4). Unscreened women displayed fatalistic attitudes, believing cancer is bad luck (adjusted OR 2.6, 95% CI 1.0-6.9) and not wanting to know they had cancer (adjusted OR 3.0, 95% CI 1.0-9.4)..

CONCLUSION

We have identified factors and beliefs that are barriers to Pap test screening in urban cervical cancer patients. Further studies should evaluate effects of addressing cultural, cognitive, and financial barriers on Pap test compliance.