Tissue specific HPV expression and downregulation of local immune responses in condylomas from HIV seropositive individuals

CD207 Expression Level is a New Prognostic Marker for Condyloma Acuminatum

Background

Condyloma cuminata (CA) is a sexually transmitted disease caused by human papillomavirus (HPV) infection, which is prone to recurrence and difficult to cure in the short term. CD207 is a C-type lectin receptor that is specifically expressed on the surface of Langerhans cells (LCs) and is considered as an LC-specific immunohistochemical marker. The main purpose of this study is to explore the correlation between the expression of CD207 in CA skin lesions and the duration of CA disease course and frequency of recurrence, in order to provide new prognostic markers for CA to clinicians.

Materials and Methods

A total of 40 male patients with CA and their skin lesions were collected, as well as 40 healthy male penile tissue samples. The skin lesions of CA were clinically and histologically confirmed by acetic acid test. The expression of CD207 in epidermal tissues was detected using immunohistochemistry. The difference in the number of CD207 positive cells between CA skin lesions and healthy skin controls was compared, and the association between the number of CD207 positive cells in CA skin lesions and the duration of disease course and the frequency of recurrence was determined through Spearman correlation analysis.

Conclusion

In CA skin lesions, CD207 positive cells were found to have morphological abnormalities and the number of cells was significantly reduced compared to healthy skin, suggesting that there may be antigen presentation dysfunction in CA skin lesions, which may be the reason for the prolonged and unresolved condition of the disease. The fewer CD207 positive cells in CA skin lesions, the longer the disease course and the more frequent the recurrence, therefore, the expression level of CD207 can be used as a new prognostic marker for predicting the outcome of CA.

RECCURENT GIANT CONDYLOMATA ACUMINATA CAUSED BY HUMAN PAPILLOMA VIRUS IN HIV WITH HOMOSEXUAL MALE

Perianal giant condylomata acuminate (GCA) is a rare clinical condition associated with low-risk Human papillomavirus (HPV) type 6 and 11 infections. Human Immunodeficiency Virus (HIV) infection is one of the risk factors for GCA, that can increase the condylomata acuminate incidence and spread caused by HPV. A 28-year-old man came with a cauliflower-like mass complaint in his perianal and anal since 2 months ago. The patient did not complain of pain or itching on the mass but often bled when defecating. The patient is a male who has sex with men (MSM) and often changes partners. He has been diagnosed with HIV since 11 months ago and regularly taking anti-retroviral drugs, Efavirenz 600 mg daily. He was also diagnosed having lung tuberculosis at the same time, got 6 months treatment and was declared cured. The venereological examination of the perianal and anal region revealed erythematous and grayish stem-shaped vegetation and papules, verrucous surface, multiple, well defined, with 3 x 1.5 x 2 cm in size. A positive act of white examination was obtained. Blood tests revealed CD+4 230 cells /μL. Polymerase chain reaction (PCR) examination for HPV obtained HPV types 6 and 11 infections. Histopathologic examination revealed acanthosis, papillomatosis, and hyperkeratotic epidermis and koilocytotic cells. The patient was treated with electrodesiccation three times but obtained mass in anal getting bigger with a size of 6 x 3 x 3 cm. Therefore, he agreed to be referred to the surgical department with an extensive surgical excision plan. Screening of GCA using PCR is not a routine examination but PCR has high sensitivity and specificity for determining the type of HPV, is useful for determining GCA prognosis and therapy, and is recommended for malignant and possible GCA recurrence detection

Staged resection in the management of HIV-related anogenital giant condyloma acuminatum. A case report

Introduction

Giant condyloma acuminata (GCA), also known as Bushke-Lowenstein tumour, is a rare disease which affects 0.1% of the population. Although histopathologically benign, it tends to be locally destructive. The common sites of involvement include the penis and the anorectum. Due to the rarity of the disease, there is a lack of controlled studies on the optimal management of this entity. Thus, we report a case of anogenital GCA in a 40-year-old HIV-positive man.

Case presentation

A 40-year-old man presented with progressive anogenital warts associated with foul-smelling discharge and fever. He has been diagnosed with HIV and was on HAART on presentation. A warty excrescence had infiltrated the entire external genitalia, gluteals and sacral region. Serial excision was performed along with a defunctioning colostomy. The patient recovered well, and the final histopathological showed features of GCA.

Discussion

With HIV, the HPV infection goes unchecked may develop into GCA. Malignant transformation to squamous cell carcinoma may occur in more than half of the cases. A complex interaction between HIV and HPV may lead to a higher risk of recurrence even after resection. The diagnosis is usually clinical. Imaging modalities may be used in identifying the extent and depth of invasion.

Conclusion

The optimal management of anogenital giant condyloma acuminata remains to be determined. Staged surgical excision should be conducted to achieve an optimum outcome. Radical reconstructive surgery should be reserved for patients with recurrence, malignant transformation or sphincter involvement.

Effect of Productive Human Papillomavirus 16 Infection on Global Gene Expression in Cervical Epithelium

Human papillomavirus (HPV) infection is the world's most common sexually transmitted infection and is responsible for most cases of cervical cancer. Previous studies of global gene expression changes induced by HPV infection have focused on the cancerous stages of infection, and therefore, not much is known about global gene expression changes at early preneoplastic stages of infection. We show for the first time the global gene expression changes during early-stage HPV16 infection in cervical tissue using 3-dimensional organotypic raft cultures, which produce high levels of progeny virions. cDNA microarray analysis showed that a total of 594 genes were upregulated and 651 genes were downregulated at least 1.5-fold with HPV16 infection. Gene ontology analysis showed that biological processes including cell cycle progression and DNA metabolism were upregulated, while skin development, immune response, and cell death were downregulated with HPV16 infection in cervical keratinocytes. Individual genes were selected for validation at the transcriptional and translational levels, including UBC, which was central to the protein association network of immune response genes, and top downregulated genes RPTN, SERPINB4, KRT23, and KLK8 In particular, KLK8 and SERPINB4 were shown to be upregulated in cancer, which contrasts with the gene regulation during the productive replication stage. Organotypic raft cultures, which allow full progression of the HPV life cycle, allowed us to identify novel gene modulations and potential therapeutic targets of early-stage HPV infection in cervical tissue. Additionally, our results suggest that early-stage productive infection and cancerous stages of infection are distinct disease states expressing different host transcriptomes.IMPORTANCE Persistent HPV infection is responsible for most cases of cervical cancer. The transition from precancerous to cancerous stages of HPV infection is marked by a significant reduction in virus production. Most global gene expression studies of HPV infection have focused on the cancerous stages. Therefore, little is known about global gene expression changes at precancerous stages. For the first time, we measured global gene expression changes at the precancerous stages of HPV16 infection in human cervical tissue producing high levels of virus. We identified a group of genes that are typically overexpressed in cancerous stages to be significantly downregulated at the precancerous stage. Moreover, we identified significantly modulated genes that have not yet been studied in the context of HPV infection. Studying the role of these genes in HPV infection will help us understand what drives the transition from precancerous to cancerous stages and may lead to the development of new therapeutic targets.

Papillomaviruses: Viral evolution, cancer and evolutionary medicine

Papillomaviruses (PVs) are a numerous family of small dsDNA viruses infecting virtually all mammals. PVs cause infections without triggering a strong immune response, and natural infection provides only limited protection against reinfection. Most PVs are part and parcel of the skin microbiota. In some cases, infections by certain PVs take diverse clinical presentations from highly productive self-limited warts to invasive cancers. We propose PVs as an excellent model system to study the evolutionary interactions between the immune system and pathogens causing chronic infections: genotypically, PVs are very diverse, with hundreds of different genotypes infecting skin and mucosa; phenotypically, they display extremely broad gradients and trade-offs between key phenotypic traits, namely productivity, immunogenicity, prevalence, oncogenicity and clinical presentation. Public health interventions have been launched to decrease the burden of PV-associated cancers, including massive vaccination against the most oncogenic human PVs, as well as systematic screening for PV chronic anogenital infections. Anti-PVs vaccines elicit protection against infection, induce cross-protection against closely related viruses and result in herd immunity. However, our knowledge on the ecological and intrapatient dynamics of PV infections remains fragmentary. We still need to understand how the novel anthropogenic selection pressures posed by vaccination and screening will affect viral circulation and epidemiology. We present here an overview of PV evolution and the connection between PV genotypes and the phenotypic, clinical manifestations of the diseases they cause. This differential link between viral evolution and the gradient cancer-warts-asymptomatic infections makes PVs a privileged playground for evolutionary medicine research.

Oral sampling and human papillomavirus genotyping in HIV-infected patients

BACKGROUND

Oral human papillomavirus (HPV) is associated with several health complications especially in combination with HIV infections. Screening may be useful, but methodologies and results have varied widely in previous studies. We conducted a pilot study in an HIV-positive population to evaluate HPV detection in four different oral sample types.

METHODS

Upon enrollment, an oral-rinse (OR) sample was collected in 10 ml saline. Additional samples of the buccal mucosa, tonsils, and oral lesion if present were collected with cytology brushes. DNA was extracted using LC-MagNAPure, and the Linear Array HPV genotyping Assay (Roche) was used for HPV genotyping.

RESULTS

In samples from 100 HIV-positive participants, HPV was detected in 39 (%) of the oral rinses, 13 (%) mucosal and 11 (12.9%) tonsil brushings. Of seven lesion brushings collected, four were HPV positive. All participants with HPV detected in mucosal, tonsil, or lesion brushings were also positive in the OR sample. Among the rinse samples, 27 different genotypes were detected with HPV84 (n = 6), HPV55 (n = 5), and HPV83 (n = 5) being the most common. Multiple infections were detected in 17 samples (range 2-9, mean 1.9 types). As potential cofactors, only receptive oral sex was significantly associated with HPV (P = 0.018, odds ratio 2.9, 95% CI 1.2-6.9).

CONCLUSION

Sampling is a significant factor for oral prevalence studies. Oral rinse provides the best representation for HPV in the oral cavity. To evaluate associated cofactors other than receptive oral sex, larger studies with case-control design are necessary.

FoxP3 overexpression and CD1a+ and CD3+ depletion in anal tissue as possible mechanisms for increased risk of human papillomavirus-related anal carcinoma in HIV infection

AIM

We analysed local cellular and humoral immunity factors in the anal mucosa in an attempt to explain how HIV infection increases the risk of anal cancer in HPV-infected patients.

METHOD

HIV-positive cases and matched HIV-negative controls with more than one recurrence of condylomas were included in a prospective study following treatment of the initial lesions. Patients were followed every 3 to 6 months for the development of anal intraepithelial neoplasia (AIN3) and cancer for up to 60 months. Tissue CD1a(+), CD3(+), CD4(+), CD8(+) cells and mRNAs of selected cytokines and chemokines were quantified and compared in patients with or without AIN3 or cancer using morphometric or immunohistochemistry analysis and qRT-PCR.

RESULTS

Sixty-six individuals (22 patients and 44 controls) were included. In the case group, CD1a(+) and CD3(+) cell counts were significantly lower in biopsies from AIN3 and cancer specimens compared with those from AIN 1-2 or normal biopsies (P < 0.0001). A CD1a(+) count of < 10/mm was predictive of AIN3 and cancer (Odds ratio = 9.4, 95% CI: 5.4-18.3, P < 0.0001). IL-8 and IL23 levels were significantly higher in cancer than in non-cancer tissues regardless of HIV status (P = 0.02). FoxP3 expression was significantly higher in HIV-infected cases than in controls with AIN3/cancer (P < 0.04).

CONCLUSION

Depletion of CD1a(+) and CD3(+) cells and overexpression of FoxP3 in the anal mucosa appear likely to contribute to the risk of HPV-related anal cancer in HIV-infected patients. Furthermore, overexpression of IL-8 and IL-23 in the anal mucosa might be responsible for the development of this cancer regardless of HIV status.

Women with HIV are more commonly infected with non-16 and -18 high-risk HPV types

OBJECTIVE

To review and summarize evidence from clinical, translational and epidemiologic studies which have examined the clinically relevant aspects of HPV type prevalence and cervical dysplasia in HIV-infected women.

METHODS

Relevant studies were identified through a MEDLINE search. References of identified reports were also used to identify additional published articles for review.

RESULTS

HIV-infected women in different geographic regions (such as Zambia, Brazil, Rochester NY) appear to be infected with less prevalent types of HR-HPV as compared to the general population who, across all continents, are more commonly infected with types 16 and 18. Secondly, integration of HPV DNA into the host genome is no longer thought to be a necessary cause of malignant transformation of cervical cells. However, rate of integration appears to differ by the type of HPV. In fact, the types of HPV which appear to be more common in cervical dysplasia of HIV-infected women are the same types which are more likely to require integration for malignant transformation. Finally, HPV types found in HIV-infected women are relatively common and likely to persist. The most common among these types belong to the alpha-9 and -7 species which are the most carcinogenic species.

CONCLUSION

Given that current vaccines target HR-HPV-16/18, the findings from the above mentioned studies may have important implications for the design of HPV vaccines that target the types of HPV associated with disease risk in HIV-infected women. HPV typing and assessment of the physical state (whether it is integrated or episomal) appear to be two valuable parameters for the prognostic evaluation of dysplastic lesions of the uterine cervix. This, however, has not yet been assessed in HIV-infected women. Recent data about the immune response in HPV/HIV co-infection may lead to understanding potential mechanisms for less virulent HPV causing malignant transformation in HIV-infected women.

Human papillomavirus (HPV) viral load and HPV type in the clinical outcome of HIV-positive patients treated with imiquimod for anogenital warts and anal intraepithelial neoplasia

OBJECTIVE

To evaluate the efficacy of 5% imiquimod in HIV-positive male patients with anogenital warts or anal intraepithelial neoplasia (AIN), and to elucidate whether human papillomavirus (HPV) type and viral load were important for clinical outcome and recurrences.

METHODS

Thirty-seven patients with histologically proven anogenital warts or AIN were enrolled. Topical 5% imiquimod was applied three times per week for more than 8 h overnight for 16 weeks, although patients were allowed to continue therapy for 4 more weeks if they did not have complete clearance of lesions.

RESULTS

Mean age was 34 years. The perianal area was the main lesion location. Thirty-three patients had CD4 counts of < 500 cells/mm(3). Eighteen patients had a histopathological diagnosis of AIN-1. Main HPV types detected corresponded to low-risk HPV types. At 20 weeks of therapy, 46% patients achieved total clearance whereas 14 patients had > 50% clearance. Recurrence was observed in 5 of 17 patients who cleared. Clearance was not influenced by patients' CD4 counts, wart location, HIV viral load or HPV viral load.

CONCLUSIONS

The assumption that visible perianal warts are benign lesions in HIV-positive patients has to be reevaluated since an important number of such lesions could correspond to low-grade anal disease, which in turn could progress to high-grade anal disease or cancer. In addition, our results in this preliminary study indicate that imiquimod appears to be effective in treating AIN in HIV-positive patients. Further studies are needed to document its utility to prevent high-grade dysplasia and/or anal cancer.

The oncogenic potential of human papillomaviruses: a review on the role of host genetics and environmental cofactors

Human papillomaviruses (HPVs), with over 100 genotypes, are a very complex group of human pathogenic viruses. In most cases, HPV infection results in benign epithelial proliferations (verrucae). However, oncogenic types of HPV may induce malignant transformation in the presence of cofactors. For example, over 99% of all cervical cancers and a majority of vulval, vaginal, anal and penile cancers are the result of oncogenic HPV types. Such HPV types have been increasingly linked to other epithelial cancers involving the skin, larynx and oesophagus. Although viral infection is necessary for neoplastic transformation, evidence suggests that host and environmental cofactors are also required. Research investigating HPV oncogenesis is complex and quite extensive. The inability to produce mature HPV virions in animal models has been a major limitation in fully elucidating the oncogenic potential and role of associated cofactors in promoting malignant transformation in HPV-infected cells. We have reviewed the literature and provide a brief account of the current understanding of HPV oncogenesis, emphasizing the role of genetic susceptibility, immune response, and environmental and infectious cofactors.

Effect of imiquimod in anogenital warts from HIV-positive men

BACKGROUND

HIV-positive patients have unpredictable local immune responses even with severe systemic immunosuppression and data reported to date is insufficient to predict the effect of imiquimod in HIV-positive patients.

OBJECTIVE

To evaluate the efficacy of 5% topical imiquimod in HIV-positive male patients with anogenital warts (AGW) and to elucidate its effect on recurrence.

STUDY DESIGN

Open-label clinical trial.

RESULTS

Of the 43 patients enrolled, 86% completed treatment. Patients' mean age was 34 years (range: 19-50). Thirty-one patients were receiving highly active antiretroviral therapy (HAART) therapy. At week 16, 10 patients completely cleared lesions and 21 patients had a wart size reduction > or =50%. At 20 weeks of therapy, 17 patients achieved total clearance whereas 14 patients had a >50% wart reduction. Clearance was not influenced by CD4-counts, HIV-viral load, previous therapy, or wart localization. Of the patients who experienced a complete clearance, five (29%) had a recurrence. Mean time of recurrence was 14.4 weeks. Erythema, pruritus, and burning sensation were the most frequent local skin reactions.

CONCLUSIONS

Topical 5% imiquimod is safe and may benefit HIV-positive patients with anogenital warts particularly when it is used for up to 20 weeks. It is also useful to decrease wart recurrence.

Cutaneous malignancy and human immunodeficiency virus disease

Certain skin cancers occur with increased frequency or altered course in patients infected with HIV. Malignant melanoma and squamous cell carcinoma are examples of cutaneous malignancies that have a more aggressive course in patients with HIV. Others, such as basal cell carcinoma, appear more frequently in this population but do not appear to be more aggressive. The incidence of HIV-associated Kapsosi's sarcoma has markedly decreased since the advent of HIV antiretroviral therapy. Our understanding of the pathogenesis of this malignancy and its unique management issues are fully reviewed. Cutaneous T-cell lymphoma (CTCL) is rare in this population. Other types of cutaneous lymphoma and HIV-associated pseudo-CTCL are discussed. This article addresses prevention, treatment, and follow-up strategies for this at-risk population.

LEARNING OBJECTIVE

At the completion of this learning activity, participants should be familiar with the unique epidemiology, clinical course, and management of cutaneous malignancy in patients infected with HIV.

HPV infection in adolescents: natural history, complications, and indicators for viral typing

Human papillomavirus (HPV) is the most common sexually transmitted disease in both men and women. Prevalence rates are the highest for adolescents. Despite the high prevalence rates, sequelae of genital warts, dysplasia, and cancer are rare developments. Knowledge about the natural history, virology, and cancerous transformation has lead to improved viral detection, including the use of HPV DNA detection tests, screening efforts for HPV-related precancerous and cancerous lesions, and clinical interventions and treatments, including both therapeutic and prophylactic vaccinations.

Anal carcinoma: incidence and effect of cumulative infections

INTRODUCTION

Human papilloma virus (HPV) causes anal condyloma that is a risk factor for anal carcinoma. The incidence and mechanism of invasive anal carcinoma in patients with anal condyloma are prospectively determined.

PATIENTS AND METHODS

From 1993 to 2002, 228 consecutive patients (164 HIV positive) with anal canal condylomas were included in the study, after curing of their lesions. They were asked to attend follow-up visits at 3- or 6-month intervals. We checked for anal co-infection with syphilis, gonococci, viruses (Epstein-Barr virus, cytomegalovirus, herpes simplex, HPV types), and quantified Langerhans' cells (LC) in anal mucosa at baseline and during follow up. We cured and analysed relapsed condylomas during follow up (3-112 months; median 26). Serum HIV loads and CD4 T-lymphocyte counts were determined at each visit and the densities of LC in consecutive specimens from patients with cancers were compared with that for a matched control group (n = 23).

RESULTS

Analysis of 199 patients showed high-grade dysplasia (HGD) in 13.6% of patients, more in HIV-positive (16%) than in HIV-negative (6%) patients at baseline. During follow up, 3.5% (7/199; six HIV positive) patients developed invasive carcinoma after 13-108 months and 112 (56%) patients relapsed condylomas. HIV and anal co-infection were identified as independent risk factors (P < 0.01) for HGD and cancer: odd ratio (95% confidence interval) of 9.4 (2.4-37.4) and 3.67 (0.95-14.2), respectively. LC densities in anal mucosa were lower in patients with invasive carcinoma than in controls.

CONCLUSION

The risk of invasive carcinoma in HPV-infected patients is increased by HIV and anal co-infection. Decreases in LC numbers in anal mucosa may favour this outcome.

Genital and perianal warts: new treatment opportunities for human papillomavirus infection

Human papillomaviruses are among the most common sexually transmitted diseases in the United States. Genital warts are a common phenotypic expression of human papillomaviruses, affecting 1% of the population; therefore, the obstetrician/gynecologist will invariably be required to advise and treat patients with this clinical manifestation. Issues essential in the diagnosis, counseling, and management of patients with genital warts will be examined, including epidemiology, transmission, molecular biology, and host immune response. This review will also provide the health care professional with a thorough examination of the new patient-applied treatment opportunities for anogenital condyloma, in addition to an overview of current provider-administered therapies, to assist in patient management.

External genital warts: diagnosis, treatment, and prevention

External genital warts (EGWs) are visible warts that occur in the perigenital and perianal regions. They are due primarily to non-oncogenic human papillomavirus (HPV) types, usually types 6 and 11. Physical examination assisted by bright light and magnification is the recommended approach for primary diagnosis. Biopsy is indicated when EGWs are fixed to underlying structures or discolored or when standard therapies are not effective. Recurrences are common, and there is no single treatment that is superior to others. Among women with atypical squamous cells, molecular HPV testing may be useful in determining who should be referred for colposcopy. Condoms may provide some protection against HPV-related diseases and thus are recommended in new sexual relationships and when partnerships are not mutually monogamous. Because the efficacy of cesarean section in preventing vertical transmission of HPV infection from women with EGWs to their progeny has not been proved, it is not recommended.

Human papillomavirus molecular biology and pathogenesis

Human papillomavirus (HPV) infection is the most common sexually transmitted disease in the world and accounts for an estimated 11% of the global cancer incidence in women. HPV-16 is the most prevalent type detected in cervical cancer and along with types 18, 31, 33 and 45 has been classified as a class I carcinogen. In addition to cervical cancer, HPVs are also associated with the malignant transformation of other mucosal and skin cancers. Thus, the combination of the malignant potential of HPV and its high prevalence of infection confers to it an importance of generalized clinical and virological significance. The natural history of HPV infection with or without treatment varies from spontaneous regression to persistence. The most important mechanism for wart regression appears to be cell-mediated immunity. Cytokines released by keratinocytes or cells of the immune system may play a part in the induction of an effective immune response against HPV infection and the subsequent regression of lesions. This review discusses the molecular biology, pathogenesis and immunology of HPV infections.

Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection

Oral warts are a manifestation of human papillomavirus infection that have been noted infrequently in persons with human immunodeficiency virus (HIV). A nested case-control study was conducted to assess rates of and risk factors for oral warts among a cohort of HIV-seropositive patients. From 1997 through 1999, 56 patients with oral warts were identified among 2194 HIV-positive patients attending an urban oral health center (prevalence, 2.6%). Incident cases of oral warts were significantly more likely to have been diagnosed in 1999 than they were in 1997-1998 (P=.001). Multivariate analysis indicated that the risk of oral warts was associated with a >/=1-log(10) decrease in HIV RNA level in the 6 months before diagnosis of oral warts (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.08-5.11) and with serologic evidence of chronic or previous infection with hepatitis B virus (OR, 2.66; 95% CI, 1.31-5.41). The incidence of oral warts in HIV-seropositive patients appears to be increasing in the era of highly active antiretroviral therapy. Oral warts were associated with reductions in virus load, which suggests that this may in part be related to immune reconstitution.

The interrelation of HIV, cervical human papillomavirus, and neoplasia among antenatal clinic attenders in Tanzania

OBJECTIVES

To determine the prevalence and interrelation of cervical human papillomavirus (HPV) genotypes, squamous intraepithelial lesions (SIL), HIV, and other reproductive tract infections (RTIs) among urban antenatal clinic attenders in Mwanza, Tanzania.

METHODS

Genital swabs were collected from 660 pregnant women and tested for a range of RTIs and for cervical cytology. Cervical HPV-DNA was detected by PCR and genotyped. HIV and syphilis serologies were performed.

RESULTS

HPV prevalence was 34% (209/612 women). Of the 144 typeable samples, 83% were high risk (HR-HPV) oncogenic strains (56% HPV 16 related types). SIL was detected in 43 women (7%), with high grade SIL in 3%. There was a high prevalence of HIV (15%), and of any RTI (83%). Genital warts were detected in 20 women (3%). HPV infection was associated with some behavioural factors (short duration of relationship, single status, not using condoms) and gonorrhoea. There was no overall association between HPV and HIV (OR=1.02, 95% CI 0.6-1.6), but a non-significant trend towards a stronger association with HR-HPV in women aged 15-19 (OR=2.79, 95% CI 0.8-9.5) and women aged > or =30 (OR=3.20, 95% CI 0.7-15). SIL was associated with HPV (OR=3.66, 95% CI 1.9-7.0), but not significantly with HIV (OR=1.54, 95% CI 0.7-3.4). Prevalence of SIL was higher among women dually positive for HPV/HIV compared to HPV infection only (21% v 12%), although this difference was not statistically significant (p=0.17).

CONCLUSIONS

HPV infection was highly prevalent in this young antenatal population. The association of HIV with HR-HPV types in older women may suggest that the principal HIV/HPV interaction in this population is for HIV to upregulate HPV persistence, leading to subsequent development of SIL.

Prevalence of high-grade dysplasia and cancer in the anal canal in human papillomavirus-infected individuals

BACKGROUND & AIMS

The incidence of anal cancer is higher in patients with anal canal condyloma, a sexually transmitted disease, than in the general population. We determined the prevalence of anal dysplasia and cancer in patients with anal canal condyloma with respect to human immunodeficiency virus (HIV) status, immunity status, and human papillomavirus types.

METHODS

In 174 consecutive patients (114 HIV positive, 60 HIV negative) with anal canal condyloma, lesions were cured, and the patients were then followed up prospectively. Langerhans cells (LCs) in normal anal mucosa were quantified, and viruses (Epstein-Barr virus, cytomegalovirus, human simplex virus 1, and various human papillomavirus [HPV] types) were characterized on inclusion. During follow-up (median 26 months), relapsed condylomas were resected and examined histologically. HIV load and CD4 T-lymphocyte counts in serum were determined at each visit.

RESULTS

Several factors differed significantly between HIV-positive and HIV-negative patients: LCs/mm anal tissue (15 vs. 30), oncogenic HPV (27% vs. 13%), other current anal infections (44% vs. 0%), and sex ratio (93% vs. 73% male). During follow-up, condylomas relapsed in 75% of the HIV-positive patients, with 19 high-grade dysplasias (HGDs) and 1 invasive carcinoma, but in only 6% of HIV-negative patients, with 1 HGD. Male sex, HIV positivity, and <15 LCs/mm tissue were independent risk factors for condyloma relapse. HIV positivity, HGD before inclusion, and condyloma relapse were independent risk factors for HGD and cancer. Serum HIV load was associated with relapse, whereas CD4 T-lymphocyte counts were not.

CONCLUSIONS

The prevalence of HGD and carcinoma is higher in HIV-positive than in HIV-negative patients, probably because of HPV activity. HIV-positive patients with high serum HIV load and/or a history of anal dysplasia should be examined by anoscopy, and condylomas should be analyzed histologically.

An overview of sexually transmitted diseases. Part III. Sexually transmitted diseases in HIV-infected patients

The HIV epidemic has dramatically altered the field of sexually transmitted diseases (STDs). HIV infection is unique among sexually transmitted diseases because it can modify the clinical presentation and features of other STDs. Conversely, other STDs can affect the transmission of HIV. This review is the third part of a series that has provided a general overview of STDs. In this article, genital ulcer diseases (genital herpes, syphilis, chancroid, lymphogranuloma venereum, and granuloma inguinale), human papillomavirus infection (anogenital warts and subclinical infections), molluscum contagiosum, human herpesvirus 8 infection, viral hepatitis, and ectoparasitic infestations (scabies and pediculosis pubis) are discussed as they occur in HIV-infected hosts. Additional features as they relate to HIV-infected patients, such as epidemiology and transmission, are discussed when applicable.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should improve their understanding of sexually transmitted diseases in the HIV-infected host.