Level of HIV serodiscordance and associated factors among heterosexual couples in Ethiopia: A systematic review and meta-analysis

HIV-related causes accounted for approximately 770,000 deaths globally in 2018. Globally, there were 1.7 million new infections, and approximately 37.9 million people were living with HIV by the end of 2018. According to the WHO 2018 study, the African Region was the most affected, with 25.7 million people living with HIV in 2018. In Africa, married and cohabiting couples have a high prevalence of HIV discordance, ranging from 3% to 20% in the general population. Therefore, it is crucial to understand the level of HIV serodiscordance among married couples in Ethiopia and the contributing factors. Studies were systematically searched, utilizing international databases such as PubMed, Google Scholar, Cochrane Library, and Embase. The level of quality of the included articles, which employed cross-sectional and cohort study designs, was evaluated using the New Castle Ottawa scale. The systematic review employed a random-effects approach, and statistical analysis was conducted using STATA version 17 software. The presence of statistical heterogeneity within the included studies was assessed using the I-squared statistic. The random-effects meta-analysis model was used to estimate the pooled level of HIV serodiscordance. The results were reported following the Preferred Reporting Item for Systematic Review and Meta-Analyses (PRISMA) guideline. A total of ten (10) observational studies were included in this review. The pooled level of HIV serodiscordance among married heterosexual couples in Ethiopia was found to be 11.4% (95% CI = 7% -15.7%). The results from the meta-analysis indicated a significant positive association between HIV serodiscordance and the variables studied. Specifically, consistently using condoms (OR = 1.82; 95% CI: 1.08-2.56), having a CD4 count of >200 cells/mm3 (OR = 1.45; 95% CI: 1.12-1.77), and having a premarital sexual relationship (OR = 1.93; 95% CI: 1.28-2.57) were strongly linked to couples' serodiscordance. To protect a seronegative partner in a serodiscordant relationship from acquiring HIV infection, it is crucial to implement preventive measures. These measures include providing comprehensive health education on the correct and consistent use of condoms, ensuring regular monitoring and care at an antiretroviral therapy (ART) clinic, and offering voluntary counseling and testing (VCT) services to both sexual partners.

Cervical cancer prevention in Southern Africa: A review of national cervical cancer screening guidelines in the Southern African development community

BACKGROUND

Cervical cancer poses a significant burden, particularly in low-and-middle income countries (LMIC) with limited access to healthcare. High-income countries have made progress in prevention, while LMIC face unacceptably high incidence and mortality rates, often lacking official screening recommendations. We analysed the presence and content of cervical cancer screening guidelines for the secondary prevention of cervical cancer in the Southern African Development Community (SADC) and compared it to the current World Health Organization (WHO) guidelines for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention.

METHODS

A review of national cervical cancer guidelines across the SADC region was conducted. Data was obtained from government websites, international cancer control platforms, and WHO resources. Search terms included "cervical cancer" and "cervical cancer control guidelines", amongst others. There were no limitations on publication years, and the most recent versions of the guidelines were analysed, regardless of language. Each guideline was assessed for specific screening and treatment recommendations, in relation to the current WHO guidelines. Points were assigned for each data element.

RESULTS

While most countries contributed data to this analysis there was a notable absence of adherence to the WHO guidelines. The most common screening method was naked eye visual inspection. There was a consensus on the age of screening initiation. Most countries recommended treatment by cryotherapy and loop excision.

CONCLUSION

Effective cervical cancer screening programmes, guided by evidence-based recommendations, can enhance early intervention and outcomes. This study highlights the need for standardized and evidence-based cervical cancer screening guidelines in the SADC region, to reduce the burden of cervical cancer and improve the health outcomes of women in these areas.

Unraveling Immunological Dynamics: HPV Infection in Women-Insights from Pregnancy

During pregnancy, hormonal and immune adaptations are vital for supporting the genetically distinct fetus during elevated infection risks. The global prevalence of HPV necessitates its consideration during pregnancy. Despite a seemingly mild immune response, historical gestational viral infections underscore its significance. Acknowledging the established HPV infection risks during pregnancy, our review explores the unfolding immunological changes in pregnant women with HPV. Our analysis aims to uncover strategies for safely modulating the immune system, mitigating adverse pregnancy consequences, and enhancing maternal and child health. This comprehensive narrative review delves into the existing knowledge and studies on this topic.

Global and regional estimates of genital human papillomavirus prevalence among men: a systematic review and meta-analysis

BACKGROUND

The epidemiology of human papillomavirus (HPV) in women has been well documented. Less is known about the epidemiology of HPV in men. We aim to provide updated global and regional pooled overall, type-specific, and age-specific prevalence estimates of genital HPV infection in men.

METHODS

We conducted a systematic review and meta-analysis to assess the prevalence of genital HPV infection in the general male population. We searched Embase, Ovid MEDLINE, and the Global Index Medicus for studies published between Jan 1, 1995, and June 1, 2022. Inclusion criteria were population-based surveys in men aged 15 years or older or HPV prevalence studies with a sample size of at least 50 men with no HPV-related pathology or known risk factors for HPV infection that collected samples from anogenital sites and used PCR or hybrid capture 2 techniques for HPV DNA detection. Exclusion criteria were studies conducted among populations at increased risk of HPV infection, exclusively conducted among circumcised men, and based on urine or semen samples. We screened identified reports and extracted summary-level data from those that were eligible. Data were extracted by two researchers independently and reviewed by a third, and discrepancies were resolved by consensus. We extracted only data on mucosal α-genus HPVs. Global and regional age-specific prevalences for any HPV, high-risk (HR)-HPV, and individual HPV types were estimated using random-effects models for meta-analysis and grouped by UN Sustainable Development Goals geographical classification.

FINDINGS

We identified 5685 publications from database searches, of which 65 studies (comprising 44 769 men) were included from 35 countries. The global pooled prevalence was 31% (95% CI 27-35) for any HPV and 21% (18-24) for HR-HPV. HPV-16 was the most prevalent HPV genotype (5%, 95% CI 4-7) followed by HPV-6 (4%, 3-5). HPV prevalence was high in young adults, reaching a maximum between the ages of 25 years and 29 years, and stabilised or slightly decreased thereafter. Pooled prevalence estimates were similar for the UN Sustainable Development Goal geographical regions of Europe and Northern America, Sub-Saharan Africa, Latin America and the Caribbean, and Australia and New Zealand (Oceania). The estimates for Eastern and South-Eastern Asia were half that of the other regions.

INTERPRETATION

Almost one in three men worldwide are infected with at least one genital HPV type and around one in five men are infected with one or more HR-HPV types. Our findings show that HPV prevalence is high in men over the age of 15 years and support that sexually active men, regardless of age, are an important reservoir of HPV genital infection. These estimates emphasise the importance of incorporating men in comprehensive HPV prevention strategies to reduce HPV-related morbidity and mortality in men and ultimately achieve elimination of cervical cancer and other HPV-related diseases.

FUNDING

Instituto de Salud Carlos III, European Regional Development Fund, Secretariat for Universities and Research of the Department of Business and Knowledge of the Government of Catalonia, and Horizon 2020.

TRANSLATIONS

For the Spanish and French translations of the abstract see Supplementary Materials section.

Task-shifting for point-of-care cervical cancer prevention in low- and middle-income countries: a case study from Uganda

Cervical cancer remains the leading cause of female cancer deaths in sub-Saharan Africa. This is despite cervical cancer being both preventable and curable if detected early and treated adequately. This paper reports on a series of action-research 'cycles' designed to progressively integrate a comprehensive, task-shifted, point-of-care, prevention program in a community-based public health facility in Uganda. The work has been undertaken through a UK-Ugandan Health Partnership coordinated by Knowledge for Change, a UK-registered Charity. The intervention demonstrates the effectiveness of task-shifting responsibility to Community Health Workers combined with the use of Geographic Information Systems to strategically guide health awareness-raising and the deployment of medical devices supporting respectful and sustainable point-of-care screen-and-treat services. The integration of this with public human immunodeficiency virus services demonstrates the ability to engage hard-to-reach 'key populations' at greatest risk of cervical cancer. The findings also demonstrate the impact of external influences including the Results Based Financing approach, adopted by many foreign Non-Governmental Organizations. The model presents opportunities for policy transfer to other areas of health promotion and prevention with important lessons for international Health partnership engagement. The paper concludes by outlining plans for a subsequent action-research cycle embracing and evaluating the potential of Artificial Intelligence to enhance service efficacy.

Prevalence and distribution of selected cervical human papillomavirus types in HIV infected and HIV uninfected women in South Africa, 1989-2021: A narrative review

Background

Human papillomavirus infection, a causative agent of cervical cancer, is of great concern, more so in populations with high HIV prevalence, such as South Africa.

Aim

This review aimed to examine the prevalence and distribution of selected cervical human papillomavirus (HPV) types in HIV infected and HIV uninfected women in South Africa.

Methods

PubMed and Web of Science databases were searched using key words. For data integrity, data was assessed by two authors independently. The study inclusion criteria comprised records on cervical HPV, HPV genotyping and HPV type distribution among South African women. Statistical analysis was performed using Social Science Statistics.

Results

Sixty-nine articles met the inclusion criteria for analysis. Data on cervical HPV prevalence and type distribution was available only for five of the nine provinces of South Africa. Only 4/69 studies used sequencing as an approach to identify HPV types. In a general population, HPV type 16 was the most frequent (8.80%), followed by types 35 (4.86%), 18 (4.14%), 58 and 52 with the frequency of 3.65% and 3.62%, respectively. Furthermore, the least frequent type was HPV 70 (0.74%). Both HIV infected and HIV uninfected populations had a higher prevalence of high-risk human papillomavirus (hrHPV) types 16, 18 and 35 than other HPV types; while HPV types 6, 11 and 70 were the least frequent types from these populations. Lastly, HPV 16 was the most predominant type among women with normal (2.03%) and abnormal cervical cytology (6.60%).

Conclusion

Expanding on HPV genotyping will improve the knowledge in patterns of HPV type distribution in South Africa that will further help in decision making to improve current diagnostics, and future vaccine development and assessment.

Human papillomavirus prevalence and risk factors among HIV-negative and HIV-positive women residing in rural Eastern Cape, South Africa

OBJECTIVES

To investigate the prevalence of high-risk (HR) human papillomavirus (HPV) and factors associated with HR-HPV infection among women from rural Eastern Cape, South Africa.

METHODS

HPV prevalence was determined by Hybrid Capture 2 assay in cervical specimens from 417 women aged ≥30 years (median 46 years) recruited from the community health clinic in the Eastern Cape.

RESULTS

HR-HPV prevalence was 28.5% (119/417), and HIV-positive women had significantly higher HR-HPV prevalence than HIV-negative women (40.6%, 63/155 vs 21.4%, 56/262, respectively; p = 0.001). HIV-positive status (odds ratio (OR) 2.52, 95% confidence interval (CI) 1.63-3.90), having ≥3 lifetime sexual partners (OR 2.12, 95% CI 1.16-3.89), having ≥1 sexual partner in the last month (OR 1.89, 95% CI 1.21-2.92), ≥4 times frequency of vaginal sex in the past 1 month (OR 2.40, 95% CI 1.32-4.35), and having a vaginal discharge currently/in the previous week (OR 2.13, 95% CI 1.18-3.85) increased the risk of HR-HPV infection. In the multivariate analysis, HIV positivity remained strongly associated with HR-HPV infection (OR 1.94, 95% CI 1.17-3.22).

CONCLUSIONS

Risk factors related to sexual behaviors play a significant role in HR-HPV infection in this population. This report will inform health policymakers on HPV prevalence and contribute to discussions on the use of HPV testing as the primary cervical cancer screening test in South Africa.

Mathematical analysis of a two-sex Human Papillomavirus (HPV) model

A two-sex deterministic model for Human Papillomavirus (HPV) that assesses the impact of treatment and vaccination on its transmission dynamics is designed and rigorously analyzed. The model is shown to exhibit the phenomenon of backward bifurcation, caused by the imperfect vaccine as well as the re-infection of individuals who recover from a previous infection, when the associated reproduction number is less than unity. Analysis of the reproduction number reveals that the impact of treatment on effective control of the disease is conditional, and depends on the sign of a certain threshold unlike when preventive measures are implemented (i.e. condom use and vaccination of both males and females). Numerical simulations of the model showed that, based on the parameter values used therein, a vaccine (with 75% efficacy) for male population with about 40% condom compliance by females will result in a significant reduction in the disease burden in the population. Also, the numerical simulations of the model reveal that with 70% condom compliance by the male population, administering female vaccine (with 45% efficacy) is sufficient for effective control of the disease.

Dendritic cell-expressed common gamma-chain recruits IL-15 for trans-presentation at the murine immunological synapse

Background: Mutations of the common cytokine receptor gamma chain (γc) cause Severe Combined Immunodeficiency characterized by absent T and NK cell development. Although stem cell therapy restores these lineages, residual immune defects are observed that may result from selective persistence of γc-deficiency in myeloid lineages. However, little is known about the contribution of myeloid-expressed γc to protective immune responses.  Here we examine the importance of γc for myeloid dendritic cell (DC) function. Methods: We utilize a combination of in vitro DC/T-cell co-culture assays and a novel lipid bilayer system mimicking the T cell surface to delineate the role of DC-expressed γc during DC/T-cell interaction. Results: We observed that γc in DC was recruited to the contact interface following MHCII ligation, and promoted IL-15Rα colocalization with engaged MHCII. Unexpectedly, trans-presentation of IL-15 was required for optimal CD4+T cell activation by DC and depended on DC γc expression. Neither recruitment of IL-15Rα nor IL-15 trans-signaling at the DC immune synapse (IS), required γc signaling in DC, suggesting that γc facilitates IL-15 transpresentation through induced intermolecular cis associations or cytoskeletal reorganization following MHCII ligation. Conclusions: These findings show that DC-expressed γc is required for effective antigen-induced CD4+ T cell activation. We reveal a novel mechanism for recruitment of DC IL-15/IL-15Rα complexes to the IS, leading to CD4+ T cell costimulation through localized IL-15 transpresentation that is coordinated with antigen-recognition.

Dendritic cell-expressed common gamma-chain recruits IL-15 for trans-presentation at the murine immunological synapse

Background: Mutations of the common cytokine receptor gamma chain (γc) cause Severe Combined Immunodeficiency characterized by absent T and NK cell development. Although stem cell therapy restores these lineages, residual immune defects are observed that may result from selective persistence of γc-deficiency in myeloid lineages. However, little is known about the contribution of myeloid-expressed γc to protective immune responses.  Here we examine the importance of γc for myeloid dendritic cell (DC) function. Methods: We utilize a combination of in vitro DC/T-cell co-culture assays and a novel lipid bilayer system mimicking the T cell surface to delineate the role of DC-expressed γc during DC/T-cell interaction. Results: We observed that γc in DC was recruited to the contact interface following MHCII ligation, and promoted IL-15Rα colocalization with engaged MHCII. Unexpectedly, trans-presentation of IL-15 was required for optimal CD4+T cell activation by DC and depended on DC γc expression. Neither recruitment of IL-15Rα nor IL-15 trans-signaling at the DC immune synapse (IS), required γc signaling in DC, suggesting that γc facilitates IL-15 transpresentation through induced intermolecular cis associations or cytoskeletal reorganization following MHCII ligation. Conclusions: These findings show that DC-expressed γc is required for effective antigen-induced CD4+ T cell activation. We reveal a novel mechanism for recruitment of DC IL-15/IL-15Rα complexes to the IS, leading to CD4+ T cell costimulation through localized IL-15 transpresentation that is coordinated with antigen-recognition.

Prevalence, incidence and correlates of low risk HPV infection and anogenital warts in a cohort of women living with HIV in Burkina Faso and South Africa

OBJECTIVE

To report the prevalence and incidence of low-risk human papillomavirus infection (LR-HPV) and anogenital warts (AGW) among women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA), and to explore HIV-related factors associated with these outcomes.

METHODS

We enrolled 1238 WLHIV (BF = 615; SA = 623) aged 25-50 years and followed them at three time points (6, 12 and 16 months) after enrolment. Presence of AGW was assessed during gynaecological examination. Cervico-vaginal swabs for enrolment and month 16 follow-up visits were tested for HPV infection by Inno-LiPA® genotyping. Logistic regression was used to assess risk factors for prevalent infection or AGW. Cox regression was used to assess risk factors for incident AGW.

RESULTS

Women in SA were more likely than those in BF to have prevalent LR-HPV infection (BF: 27.1% vs. SA: 40.9%; p<0.001) and incident LR-HPV infection (BF: 25.8% vs. SA: 31.6%, p = 0.05). Prevalence of persistent LR-HPV was similar in the two countries (BF: 33.3% vs. SA: 30.4%; p = 0.54), as were prevalence and incidence of AGW (Prevalence: BF: 7.5% vs. SA: 5.7%; p = 0.21; Incidence: BF: 2.47 vs. SA: 2.33 per 100 person-years; p = 0.41). HPV6 was associated with incident AGW (BF: adjusted Hazard Ratio (aHR) = 4.88; 95%CI: 1.36-17.45; SA: aHR = 5.02; 95%CI: 1.40-17.99). Prevalent LR-HPV (BF: adjusted Odds Ratio [aOR = 1.86]; 95%CI: 1.01-3.41; SA: aOR = 1.75; 95%CI: 0.88-3.48); persistent LR-HPV (BF: aOR = 1.92; 95%CI: 0.44-8.44; SA: aOR = 2.81; 95%CI: 1.07-7.41) and prevalent AGW (BF: aOR = 1.53; 95%CI: 0.61-3.87; SA: aOR = 4.11; 95%CI: 1.20-14.10) were each associated with low CD4+ counts (i.e. <200 vs. >500 cells/μL). Duration of ART and HIV plasma viral load were not associated with any LR-HPV infection or AGW outcomes.

CONCLUSION

LR-HPV infection and AGW are common in WLHIV in sub-Saharan Africa. Type-specific HPV vaccines and effective ART with immunological reconstitution could reduce the burden of AGW in this population.

A case of oropharyngeal Ureaplasma urealyticum infection in a human immunodeficiency virus positive bisexual male co-infected with human papilloma virus and Treponema pallidum

Introduction

Management strategies for sexually transmitted infections (STIs) in their extragenital forms address Neisseria gonorrhoeae and Chlamydia trachomatis alone; whereas increased rates of isolation of other STI agents have been reported from various parts of the world. Their extragenital presence as a reservoir of infection emphasizes the need to screen and treat them at these sites.

Case presentation

A 35-year-old human immunodeficiency virus 1 infected bisexual male presented with urethral discharge and multiple ano-genital warts. He was reactive for the venereal disease research laboratory (VDRL) test. He tested positive for Ureaplasma spp. both by culture and PCR at urethral and oropharyngeal sites, but was negative at the rectal site. The patient was successfully treated with doxycycline and penicillin, and was followed up with a test of cure at 6 weeks.

Conclusion

In view of the disseminating infections that can be caused by Ureaplasma spp., it makes it important to screen for these infections even at non-genital sites, especially in the immunocompromised. STIs may be asymptomatic and can serve as a reservoir of infection in a population. This report should promote all efforts to formulate guidelines for extragenital screening of all STI pathogens.

Clinical implications of the interaction between HPV and HIV infections

HIV-related immunodeficiency has complex effects on female genital HPV, which include increased risks of infection, multiple types, persistence, reactivation and the risk to develop pre-invasive and invasive disease. Reconstitution of immunity with anti-viral drugs improves cellular immunity, but the risk of HPV-related malignancy remains higher than background incidences and presents at younger ages. Early initiation of antiretroviral therapy (ART) allows improved retention of immune memory through existing antibodies and T-cell clones and improves long-term outcomes. Suggestions of a higher risk to contract HIV if there is existing genital HPV infection are supported and explained by pathophysiological cervical changes, including inflammation. HIV-HPV interactions should influence public health decisions towards prioritising large-scale prepubertal HPV-vaccine roll-out, secondary cervical cancer prevention and early detection programmes for HIV-infected women and early initiation of ART. This chapter will also focus on special considerations for the management of women with co-infection with these two viruses and genital HPV-related diseases.

High diversity of alpha, beta and gamma human papillomaviruses in genital samples from HIV-negative and HIV-positive heterosexual South African men

BACKGROUND

This study investigated the prevalence of HPVs in heterosexual South African men and the impact of HIV co-infection.

METHODS

HPV was detected in penile swabs from 195 HIV-infected and 140 HIV-uninfected men using PCR with FAP59/64 primers and Roche Linear Array HPV genotyping (LA). Genotyping of FAP positive specimens was achieved by high-throughput sequencing of amplicons.

RESULTS

HPV was detected by FAP PCR and LA in 79% (266/335) of the men. Men with HIV co-infection and men with HIV infected sexual partners had a significantly (p<0.0001) higher HPV infection risk (adjusted odds ratio 4.0 (2.1-8.2) and 3.7 (2.1-6.7), respectively). LA genotyping and 454 sequencing of 218 FAP positive specimens detected 45 known α-HPV types, 45 β-HPV types (34 known, 10 putative and 1 novel putative), and 91 γ-HPV types (26 known, 51 putative and 14 novel putative). Alpha, beta and gamma types were detected in 89.8%, 51.4% and 62.4% of the 218 men with HPV-62, HPV-5 and HPV-121 most common in each genus, respectively.

CONCLUSION

A great diversity of known and novel alpha, beta and gamma HPV types were detected with higher prevalence in HIV co-infected men and unknown associations, if any, with genital lesions and cancers.

Risk factors for genital human papillomavirus among men in Tanzania

The objective of the study was to assess risk factors for Human Papillomavirus (HPV) among men in Tanzania, both overall and in relation to HIV status. In a cross-sectional study conducted among 1,813 men in Tanzania, penile swabs were tested for HPV using Hybrid Capture 2 (HC2). Study participants were offered HIV testing. Risk factors for HPV (HC2 high-risk and/or low-risk positivity) were assessed using logistic regression with adjustment for age, lifetime number of sexual partners, and HIV status. Altogether, 372 men (20.5%) were HPV-positive. Among men tested for HIV (n = 1,483), the HIV prevalence was 9.4%. The odds ratio (OR) of HPV increased with increasing age. HIV-positivity was associated with an increased odds ratio of HPV (OR = 1.91; 95%CI: 1.30-2.82), whereas the odds of HPV tended to be lower in circumcised men than in uncircumcised men (OR = 0.77; 95%CI: 0.54-1.09). When stratifying by HIV status, we found lower odds of HPV in overweight HIV-positive men (BMI > 25) than in normal weight HIV-positive men (OR = 0.25; 95%CI: 0.08-0.78). This did not apply to HIV-negative men. Circumcision tended to decrease the odds of HPV both in HIV-positive men and in HIV-negative men, although not being statistically significant. In conclusion, HIV is a strong risk factor for HPV among men in Tanzania. Additionally, in HIV-positive men a high BMI seems to be associated with a lower risk of HPV. Finally, we observed a tendency toward a lower risk of HPV both among HIV-positive and HIV-negative circumcised men compared to their uncircumcised counterparts. J. Med. Virol. 89:345-351, 2017. © 2016 Wiley Periodicals, Inc.

Female genital tract inflammation, HIV co-infection and persistent mucosal Human Papillomavirus (HPV) infections

BACKGROUND

Persistent genital infections with high-risk HPV types increase risk of cervical disease and cancer. Since genital inflammation increases HIV acquisition risk and cancer progression, we evaluated whether HPV infection induces cytokine expression in the reproductive tract.

METHODS

Genital cytokines concentrations were measured in 93 HIV-infected and 72 uninfected women. HPV typing was done by Roche Linear array. Persistence and clearance of HPV were evaluated using longitudinal data.

RESULTS

Infection with HPV did not influence genital cytokine concentrations. In contrast, HIV-infected women had higher IL-1α, IL-6, IL-8, IP-10, MCP-1 and G-CSF concentrations compared to HIV-uninfected women, and HPV-infections that were more prevalent, persistent and multi-type.

CONCLUSION

HPV did not influence inflammatory cytokine levels in the genital tract, although immune suppression may favor persistence.

Prevalence of IgG Antibodies against Human Papillomavirus (HPV) type 6, 11, 16, and 18 Virus-Like Particles in Women of Childbearing Age in Port Harcourt, Nigeria

Most HPV prevalence studies have been carried out in high-resource countries with few studies focused on low-resource regions where highest HPV prevalence in the world occurs. This study reports on prevalence of IgG antibodies against HPVs among women of childbearing age in Port Harcourt, Nigeria. One hundred and eighty-two consented women (age-range 19-45 years) were consecutively recruited. Demographic/behavioral data and 5 mL blood samples were collected from each woman. Plasma of each sample was assayed for HPV-6/11/16/18 virus-like particles using a HPV IgG ELISA kit. The overall anti-HPV prevalence was 4.9% while 7.7% with itching/wound in the private part tested positive. Most (88.9%) of the seropositive women were sexually active. Group-specific seropositivity was low (0.0-10.0%). It also showed that all the 9(100.0%) who tested positive to the HPV responded "yes" to no information on the source of HPV information. Being younger, married, high educational level, religion, and lack of information on HPV were the main correlates of HPV positivity among these women. None was vaccinated and would have been naturally exposed to at least one of HPV-6/11/16/18. With 4.9% seropositivity and lack of information regarding HPV among these women, this study recommends a statewide enlightenment campaign and vaccination.

Human papillomavirus prevalence in South African women and men according to age and human immunodeficiency virus status

BACKGROUND

Both cervical cancer and human immunodeficiency virus (HIV) are major public health problems in Sub-Saharan Africa. The objectives of the study were to investigate human papillomavirus (HPV) prevalence according to age, HIV status and gender.

METHODS

Participants were 208 HIV-negative women, 278 HIV-positive women, 325 HIV-negative men and 161 HIV-positive men between the ages of 18-66 years. HPV types were determined in cervical and penile cells by Roche Linear Array HPV genotyping assay.

RESULTS

HPV prevalence was 36.7 % (76/207; 95 % confidence intervals (CI): 30.4-43.4 %) in HIV-negative women, with the highest prevalence of 61.0 % (25/41; 95 % CI: 45.7-74.4 %) in women aged 18-25 years. HPV prevalence was 74.0 % (205/277; 95 % CI: 68.5-78.8 %) in HIV-positive women, with the highest prevalence of 86.4 % (38/44; 95 % CI: 72.9-94.0 %) in women aged 18-25 years. HPV prevalence was found to decrease with increasing age in HIV-negative women (P = 0.0007), but not in HIV-positive women (P = 0.898). HPV prevalence was 50.8 % (159/313; 95 % CI: 45.3-56.3 %) in HIV-negative men, with the highest prevalence of 77.0 % (27/35; 95 % CI: 60.7-88.2 %) in men aged 18-25 years. HPV prevalence was 76.6 % (121/158; 95 % CI: 69.2-82.9 %) in HIV-positive men, with the highest prevalence of 87.5 % (7/8; 95 % CI: 50.8-99.9 %) in men 18-25 years of age. HPV prevalence was found to decrease with increasing age in HIV-negative men (P = 0.004), but not in HIV-positive men (P = 0.385). HIV-positive women had a significantly higher prevalence of one or more HPV type(s) in the bivalent (HPV-16/18: 20 % 55/277, 9 % 12/207; P <0.001), quadrivalent (HPV-6/11/16/18: 26 % 71/277, 12 % 24/207; P = 0.001) and nonavalent vaccine (HPV-6/11/16/18/31/33/52/56/58: 65 % 181/277, 24 % 50/207; P <0.001) compared to HIV-negative women. Similar observation were observed in men for bivalent (20 % 32/158, 10 % 30/313; P = 0.001), quadrivalent (35 % 56/158, 13 % 41/313; P <0.001) and nonavalent vaccine (75 % 119/158, 28 % 87/313; P <0.001).

CONCLUSIONS

This study demonstrated high HPV prevalence among HIV-positive women and men in all age groups. The high prevalence of HPV types found in bivalent, quadrivalent and nonavalent vaccines in South African HIV-positive and HIV-negative women and men demonstrate that this population will greatly benefit from current HPV vaccines.

The Interaction between Human Immunodeficiency Virus and Human Papillomaviruses in Heterosexuals in Africa

Sub-Saharan Africa has the highest incidence of human papillomavirus (HPV) and cervical cancer in the world, which is further aggravated by the burden of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) disease with invasive cervical cancer being an AIDS-defining cancer. The prevalence of HPV infection and associated disease is very high in HIV-infected people and continues to be a problem even after anti-retroviral therapy. In the genital tract, the interaction between HPV and HIV is complex, with infection with multiple HPV types reported to make both women and men more susceptible to HIV infection. Besides the national programmes to vaccinate girls against HPV and screen women for cervical cancer, there should be targeted cervical cancer screening, treatment and prevention programmes introduced into HIV treatment centres. There is evidence that in high HIV prevalence areas, HIV-positive women could cause increases in the prevalence of genital HPV infection in HIV-negative men and so increase the HPV circulating in the community. Condom use and circumcision reduce the acquisition of HIV-1, and also to some extent of HPV. This review will highlight what is known about the interaction of HIV and HPV, with an emphasis on research in Africa.

Cost evaluation of reproductive and primary health care mobile service delivery for women in two rural districts in South Africa

Background

Cervical cancer screening is a critical health service that is often unavailable to women in under-resourced settings. In order to expand access to this and other reproductive and primary health care services, a South African non-governmental organization established a van-based mobile clinic in two rural districts in South Africa. To inform policy and budgeting, we conducted a cost evaluation of this service delivery model.

Methods

The evaluation was retrospective (October 2012–September 2013 for one district and April–September 2013 for the second district) and conducted from a provider cost perspective. Services evaluated included cervical cancer screening, HIV counselling and testing, syndromic management of sexually transmitted infections (STIs), breast exams, provision of condoms, contraceptives, and general health education. Fixed costs, including vehicle purchase and conversion, equipment, operating costs and mobile clinic staffing, were collected from program records and public sector pricing information. The number of women accessing different services was multiplied by ingredients-based variable costs, reflecting the consumables required. All costs are reported in 2013 USD.

Results

Fixed costs accounted for most of the total annual costs of the mobile clinics (85% and 94% for the two districts); the largest contributor to annual fixed costs was staff salaries. Average costs per patient were driven by the total number of patients seen, at $46.09 and $76.03 for the two districts. Variable costs for Pap smears were higher than for other services provided, and some services, such as breast exams and STI and tuberculosis symptoms screening, had no marginal cost.

Conclusions

Staffing costs are the largest component of providing mobile health services to rural communities. Yet, in remote areas where patient volumes do not exceed nursing staff capacity, incorporating multiple services within a cervical cancer screening program is an approach to potentially expand access to health care without added costs.

Human papillomavirus prevalence among men in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

We performed a systematic review and meta-analysis to summarise the available data on the prevalence of human papillomavirus (HPV) among men in sub-Saharan Africa.

METHODS

PubMed and Embase were searched up to 10 March 2014. Random effects meta-analyses were used to calculate a pooled prevalence of any HPV and high-risk (HR) HPV.

RESULTS

A total of 11 studies comprising 9342 men were identified. We found that HPV is very common among men in sub-Saharan Africa, the prevalence of any HPV ranging between 19.1% and 100%. Using random effects meta-analysis, the pooled prevalence of any HPV was 78.2% (95% CI 54.2 to 91.6) among HIV-positive and 49.4% (95% CI 30.4 to 68.6) among HIV-negative men (p=0.0632). When restricting the analyses to PCR-based studies, the pooled prevalence of any HPV was 84.5% (95% CI 74.2 to 91.2) among HIV-positive and 56.4% (95% CI 49.7 to 62.9) among HIV-negative men (p<0.0001). Of the HPV types included in the nine-valent HPV vaccine, the most common HR HPV types were HPV16 and HPV52, and HPV6 was the most common low-risk HPV type. When examining the prevalence of HPV in relation to age no clear trend was observed.

CONCLUSIONS

The prevalence of HPV is high among men in sub-Saharan Africa, which could contribute to the high rates of penile and cervical cancer in this part of the world. Implementation of the prophylactic HPV vaccines could potentially help prevent this large burden of HPV and HPV-associated disease in sub-Saharan Africa. CLINICALTRIALS.GOV IDENTIFIER: NCT00932009.

Comprehensive profiling of the vaginal microbiome in HIV positive women using massive parallel semiconductor sequencing

Infections by HIV increase the risk of acquiring secondary viral and bacterial infections and methods are needed to determine the spectrum of co-infections for proper treatment. We used rolling circle amplification (RCA) and Ion Proton sequencing to investigate the vaginal microbiome of 20 HIV positive women from South Africa. A total of 46 different human papillomavirus (HPV) types were found, many of which are not detected by existing genotyping assays. Moreover, the complete genomes of two novel HPV types were determined. Abundance of HPV infections was highly correlated with real-time PCR estimates, indicating that the RCA-Proton method can be used for quantification of individual pathogens. We also identified a large number of other viral, bacterial and parasitic co-infections and the spectrum of these co-infections varied widely between individuals. Our method provides rapid detection of a broad range of pathogens and the ability to reconstruct complete genomes of novel infectious agents.

Risk factors for oral human papillomavirus in heterosexual couples in an African setting

OBJECTIVE

Oral human papillomavirus (HPV) prevalence and factors associated with oral HPV infection were investigated.

METHODS

Cervical, penile and oral HPV types were determined in 221 heterosexual couples by Roche Linear Array HPV genotyping assay.

RESULTS

Oral HPV prevalence was found to be 6.8% in women and 13.5% in men (P = 0.23). The risk of oral infection with a specific HPV type in women was increased when the same type was detected in their genital tract (odd ratio (OR): 3.65, 95% confidence interval (CI): 1.62-8.25, P = 0.002), the genital tract of their male partner (OR: 6.08, 95% CI: 2.90-12.73, P < 0.001) or the mouth of their male partner (OR: 8.30, 95% CI: 1.58-43.50, P = 0.012). In men, the risk of oral infection with a specific HPV type was increased when the same type was detected in the genital tract of their female partner (OR: 7.28, 95% CI: 1.45-36.58, P = 0.016) or the mouth of their female partner (OR: 5.43, 95% CI: 0.79-37.06, P = 0.084) but not when the same type was present in their own genital tract.

CONCLUSIONS

These findings suggest that in African settings oral HPV infection is acquired from sexual partners, and that in women may also be the result of self-inoculation.

Influence of HIV-1 and/or HIV-2 infection and CD4 count on cervical HPV DNA detection in women from Senegal, West Africa

BACKGROUND

HIV infection is associated with greater risk of precancerous lesions and cervical cancer in women. However, several factors remain unclarified regarding the association between HIV infection and HPV detection, especially among those with HIV type 2 versus type 1 infection and severely immunocompromised persons.

OBJECTIVES

To evaluate HPV overall and type-specific detection among HIV-infected and uninfected women in Senegal.

STUDY DESIGN

Detection of HPV DNA for 38 genotypes in cervical swabs using PCR-based methods was evaluated in HIV-positive (n=467) and HIV-negative (n=2139) women participating in studies in Senegal. Among HIV-1 and/or HIV-2 positive women, CD4 counts were assessed. Adjusted multivariable prevalence ratios (PR) were calculated.

RESULTS

The prevalence of any HPV DNA and multiple HPV types was greater among HIV-infected individuals (78.2% and 62.3%, respectively) compared with HIV-negative women (27.1% and 11.6%). This trend was also seen for HPV types 16 and 18 (13.1% and 10.9%) compared to HIV-negative women (2.2% and 1.7%). HIV-infected women with CD4 cell counts less than 200 cells/μl had a higher likelihood of any HPV detection (PRa 1.30; 95% CI 1.07-1.59), multiple HPV types (PRa 1.52; 95% CI 1.14-2.01), and HPV-16 (PRa 9.00; 95% CI 1.66-48.67), but not HPV-18 (PRa 1.20, 95% CI 0.45-3.24) compared to those with CD4 counts 500 cells/μl or above.

CONCLUSION

HIV-infected women, especially those most severely immunocompromised, are more likely to harbor HPV. Measures to prevent initial HPV infection and subsequent development of cervical cancer through focused screening efforts should be implemented in these high risk populations.

Progress on human papillomavirus (HPV) infection and cervical cancer prevention in sub-Saharan Africa: highlights of the 27th International Papillomavirus Conference in Berlin, 17-22 September 2011

Highlights of the International Papillomavirus Conference in Berlin, 17-22 September 2011.

The impact of human immunodeficiency virus on human papillomavirus transmission in heterosexually active couples

OBJECTIVES

This study investigated HPV transmission and the factors influencing it in heterosexually active couples in South Africa.

METHODS

A total of 486 heterosexual couples were recruited at a health facility and returned at 6-monthly intervals. Cervical and penile HPV types were determined by Roche Linear Array HPV genotyping assay. HPV transmission was defined as the detection of a new HPV type in an individual whose partner was infected with the same type at the date of acquisition.

RESULTS

The female-to-male HPV transmission rate was 2.80/100 person-months (95% confidence interval (CI): 2.03-3.86) while the male-to-female HPV transmission rate was 1.17/100 person-months (95% CI: 0.82-1.67). HIV-positive women were found to be at higher risk of HPV infection transmitted from their male partners compared to HIV-negative women (RR (relative risk): 2.31, 95% CI: 1.08-4.92, P = 0.03). HIV-positive men with CD4 counts <350/mL had a higher risk of HPV infection transmitted from their female partners compared to HIV-positive men with CD4 counts ≥350/mL (RR: 3.17, 95% CI: 1.05-9.55, P = 0.04).

CONCLUSIONS

HIV infection and low CD4 counts increase the rate of HPV acquisition from sexual partner.

Prevalence and risk factors for cervical intraepithelial neoplasia among HIV-infected women

OBJECTIVES

To evaluate the prevalence and the risk factors for cervical intraepithelial neoplasia (CIN) among HIV-infected women.

METHODS

Cross-sectional study of 494 HIV-infected women in Brazil, between 1998 and 2008. Gynecologic exam was performed, and samples were collected for cervical cytology and for HPV DNA detection. Cervical biopsy was carried out when indicated. HPV infection, CD4 T-lymphocyte count and HIV viral load were compared with cervical histopathology. Univariate and multivariate statistical analyses were performed to evaluate the statistical association of several risk factors.

RESULTS

CIN prevalence detected by histopathology was 23.4% (6% of CIN2/3 and 17.4% cases of CIN1). Multivariate analysis confirmed an independent association of CIN with CD4 T-lymphocyte count below 200 cells/mm³ (OR 5.0, 95% CI 2.5-10.1), with a positive detection of HPV DNA (OR 2.0, 95% CI 1.2-3.5), and with age < 34 years old (OR 1.5, 95% CI 1.0-2.4). HIV viral load and antiretroviral use were not independent risk factors for CIN.

CONCLUSIONS

Severity of immunosuppression, presence of HPV infection and younger age are strong predictors of CIN among HIV-infected women.

Human papillomavirus vaccines: where do they fit in HIV-infected individuals?

Human papillomavirus (HPV) is the etiological agent for cervical cancer and a large majority of anal cancers worldwide. In 2006 two preventive vaccines against the HPV were approved by the US Food and Drug Administration and have since been approved in over 100 countries. HIV-infected populations are at an increased risk for HPV-related cancers. None of the efficacy trials for these vaccines included HIV-infected populations. However, studies in HIV-infected children and adult men show that the vaccine is safe and highly immunogenic. Studies evaluating the vaccine in HIV-infected women are in progress. Based on these studies, the American Council on Immunization Practices recommends HPV vaccination for all HIV-infected children and young adults up to age 26 years. HPV vaccine policies in resource-limited countries, many of which have a high prevalence of HIV infection, are still being developed. Future studies should examine the role of HPV vaccination for older HIV-infected adults who likely have ongoing HPV infection.

Multiply-primed rolling circle amplification of human papillomavirus using sequence-specific primers

Multiply-primed rolling circle amplification (RCA) is a suitable technique for amplification of circular templates and has been used to identify novel human papillomaviruses (HPV). In this study we develop an efficient RCA for whole genome amplification of HPV using HPV-specific primers in clinical samples and establish a protocol for whole genome sequencing using the Sanger method. Amplification of cloned HPV-genomes by RCA was compared using specific primers against random hexamers. Using HPV-specific primers increased the effectiveness on average 15.2 times and the enrichment of HPV relative to human gDNA on average 62.2 times, as compared to using random hexamer. RCA products were sequenced without need for cloning, even when using low-input amounts. The technique was successfully used on 4 patient samples from FTA cards, to generate whole HPV-genome sequences. Degenerated HPV-specific primers for RCA produce DNA of sufficient quality and quantity suitable for sequencing and other potential downstream analyses.

Genital human papillomavirus (HPV) concordance in heterosexual couples

BACKGROUND

Few studies have assessed genital human papillomavirus (HPV) concordance and factors associated with concordance among asymptomatic heterosexual couples.

METHODS

Genotyping for HPV was conducted with male and female sex partners aged 18-70 years from Tampa, Florida. Eligibility included no history of HPV-associated disease. Type-specific positive concordance (partners with ≥ 1 genotype in common) and negative concordance (neither partner had HPV) were assessed for 88 couples. Factors associated with concordance were assessed with Fisher exact tests and tests for trend.

RESULTS

Couples reported engaging in sexual intercourse for a median of 1.7 years (range, 0.1-49 years), and 75% reported being in the same monogamous relationship for the past 6 months. Almost 1 in 4 couples had type-specific positive concordance, and 35% had negative concordance for all types tested, for a total concordance of 59%. Concordance was not associated with monogamy. Type-specific positive concordance was associated with an increasing difference in partners' lifetime number of sex partners and inversely associated with an increasing difference in age. Negative concordance was inversely associated with both the couple's sum of lifetime number of sex partners and the difference in the partners' lifetime number of sex partners.

CONCLUSIONS

Genital HPV concordance was common. Viral infectiousness and number of sex partners may help explain concordance among heterosexual partners.

Impact of human immunodeficiency virus on the natural history of human papillomavirus genital infection in South African men and women

BACKGROUND

This study investigated genital human papillomavirus (HPV) incidence and clearance in 278 human immunodeficiency virus (HIV)-seropositive (HIV-positive) women, 208 HIV-negative women, 161 HIV-positive men, and 325 HIV-negative men, followed at 6-month intervals for up to 24 months.

METHODS

HPV types were determined by the Roche Reverse Linear Array HPV genotyping assay.

RESULTS

The rate of new HPV detection at the cervix and penis were 33.83 events/1000 person-months (95% confidence interval [CI], 26.39-43.46) and 55.68 events/1000 person-months (95% CI, 43.59-69.19), respectively. HIV infection was associated with increased risk of new HPV detection in women (relative risk [RR], 2.98; 95% CI, 2.07-4.29) and men (RR, 2.00; 95% CI, 1.49-2.69). The risk of new HPV detection increased in women (RR, 5.25; 95% CI, 3.52-7.81) and men (RR, 8.71; 95% CI, 6.19-12.24) when the sexual partner was infected with the same HPV type. The rate of clearing any HPV infection was 95.1 events/1000 person-months (95% CI, 83.3-108.1) in men and 66.9 events/1000 person-months (95% CI, 57.0-78.5) in women. HIV infection reduced the rate of HPV clearance in women (RR, 0.46; 95% CI, .34-.62) and men (RR, 0.71; 95% CI, .55-.93).

CONCLUSIONS

HIV infection increases the risk of new HPV detection and decreases the rate of HPV clearance in both women and men.

Prevalence and concordance of HPV, HIV, and HSV-2 in heterosexual couples in Kigali, Rwanda

BACKGROUND

In the absence of prospectively collected transmission data, the transmission potential of a sexually transmissible infection (STI) can be estimated by its proxy of concordance in sexual partners. Here we report concordance data of 3 viral STIs: human papillomavirus (HPV), HIV, and herpes simplex virus type 2 (HSV-2) among heterosexual couples in Kigali, Rwanda.

METHODS

Cervical and penile HPV typing was performed among 166 community-sampled fertile couples in Kigali, Rwanda (median sampling interval 10 days (interquartile range: 5-36). HIV and HSV-2 serostatus, curable STIs, and sociobehavioral and clinical characteristics were also assessed.

RESULTS

Concordance rates for all 3 viral STIs were higher than expected by chance alone. Positive concordance among couples was 25% for HSV-2, 15.7% for any HPV, 8.4% for high-risk (HR)-HPV, and 6% for HIV. HR-HPV prevalence among women and men was 19.9% and 26.5%, respectively. Partner's HIV status was more strongly associated with HR-HPV detection in men (OR: 8.5; confidence interval: 2.9-24.6) than in women (OR: 1.9; confidence interval 0.5-6.7).

CONCLUSION

More than half of the couples were discordant for HIV, HPV, and/or HSV-2, indicating that prevention strategies directed to infected cases are important to protect their uninfected sexual partners.

Induction of human β-defensins and psoriasin in vulvovaginal human papillomavirus-associated lesions

BACKGROUND

Infections with a low-risk type of human papillomavirus (HPV) may lead to genital warts. HPV targets the basal cell layer of epithelial cells. The first line of defense is the innate immune system, which provides nonspecific protection against a variety of pathogens. The antimicrobial peptides (AMPs) α- and β-defensins, cathelicidins, psoriasin, and RNase7 are central mediators.

METHODS

The expression of various α- and β-defensins, cathelicidin LL-37, psoriasin, and RNase7 was studied in biopsy samples from 35 patients with genital warts and 25 healthy women using quantitative real-time polymerase chain reaction and immunohistochemical analysis.

RESULTS

We found a significantly higher expression of the β-defensins hBD-1 (P = .03), hBD-2 (P < 0.01), and hBD-3 (P < .001), and psoriasin (P = .001) in condylomata acuminata, compared with normal controls. The RNA and protein levels of RNase7 did not differ between infected and uninfected samples (P = .55). The α-defensins HNP 1-3, HD5, and HD6 and the cathelicidin LL-37 were scarcely detectable in normal and infected tissue.

CONCLUSIONS

The differing expression of AMPs in HPV-infected, compared with noninfected, vulvovaginal biopsy samples suggests that these peptides are important in the local immune response. Curiously, hBD-1 shows a significant induction whereas RNase7 does not, which suggests differing regulation of AMPs over the course of bacterial and viral infections.