Cervical HPV Infection in Female Sex Workers: A Global Perspective

Human Papillomavirus Genotype Detection and Cytology Using a New Self-Sampling Method

OBJECTIVE

High-risk human papillomavirus (hrHPV) testing using dry-type self-sampled vaginal specimens is becoming more widespread worldwide due to increased screening uptake. However, for the triage of hrHPV-positive women, a visit to a general practitioner is required for reflex cytology. This study aimed to evaluate the hrHPV detection capability of CellSoft®, a wet-type self-sampling method that also allows for cytology.

METHODS

Thirty-eight women aged 20 years and older were included in the study. The women self-sampled using CellSoft® after using an Evalyn® Brush. PCR-based HPV genotyping was performed on both specimens and hrHPV detection results of both devices were compared. Additionally, cytological exam was performed on CellSoft® samples.

RESULTS

Overall agreement between self-sampling devices for the detection of hrHPV in CellSoft® and Evalyn Brush was observed in 97.4% (37/38) of participants. More hrHPV genotypes were detected with Evalyn Brush than with CellSoft®. Among the 22 CellSoft® hrHPV-positive cases, 11 (47.6%) were atypical squamous cells of undetermined significance or worse.

CONCLUSION

CellSoft® hrHPV genotype detection results were in good agreement with those of Evalyn Brush. CellSoft® provided a sufficient cell volume for HPV testing and cytological evaluation.

Prevalence and Genotypic Diversity of Human Papillomavirus Infection Among Male and Female Sex Workers in Thailand

BACKGROUND

Human papillomavirus (HPV) is associated with cancer. Female sex workers (FSWs) are known to be at risk for HPV, but little is known about male sex workers (MSWs).

METHODS

We examined HPV prevalence and associated risk factors in both populations. During 2022, HPV testing using vaginal or penile samples, HIV testing, and interviews were performed among 100 MSWs and 100 FSWs in Chiang Mai, Thailand.

RESULTS

The prevalence of all HPV types was 63.5% (66% in MSW, 61% in FSW), HPV-16 prevalence was 14%, HPV-52 was 13%, and HPV-18 was 4%. There was no difference between MSW and FSW for these subtypes. The prevalence of HPV-16 or HPV-18 was 17%, and for HPV-16, HPV-18, or HPV-52, it was 26%. HIV-positive participants had a higher prevalence of all HPV types (94% vs. 60%, P = 0.004), HPV-16 or HPV-18 (39% vs. 15%, P = 0.018), and HPV-16, HPV-18, or HPV-52 (50% vs. 23%, P = 0.017).

CONCLUSIONS

We demonstrated an equally high HPV prevalence across the sexes. Further studies are needed to determine if this indicates an equal risk for cancer. Increased HPV awareness, screening, and vaccination should be considered, regardless of gender.

Cervical cancer screening programs for female sex workers: a scoping review

Background

Cervical cancer (CC) is the fourth most common neoplasia affecting women worldwide. Female sex workers (FSWs) are among those at highest risk of developing and succumbing to CC. Yet, they are often overlooked in CC screening programs and have limited access to CC healthcare globally. The development of CC screening programs for this high-risk target population is necessary to reduce the global burden of this disease and to reach the World Health Organization's objective of accelerating the elimination of CC.

Objective

This review summarizes findings on CC screening programs for FSWs that have been implemented worldwide, and assesses their effectiveness and sustainability.

Methods

A scoping review was conducted using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). A literature search was performed on PubMed, Swisscovery, and Google Scholar for studies describing and assessing CC screening programs for FSWs. In addition, targeted searching online Non-Governmental and International Organizations websites identified grey literature. A single reviewer screened titles and abstracts, and extracted data from the research findings.

Results

The search identified 13 articles published from 1989 to 2021. All implemented programs successfully reached FSWs and provided them with CC screening during the study period. The most effective and sustainable strategies were the Screen and Treat approach, introducing CC screening into existing STI services in drop-in or outreach clinics, HPV-DNA self-sampling, and integrating sex-workers-specific services in public health facilities. Follow-up was deemed the main challenge in providing and enhancing CC healthcare to FSWs with rates of loss to follow-up ranging from 35 to 60%.

Conclusion

FSWs are often omitted in national CC screening programs. The further development and improvement of CC healthcare, including follow-up systems, for this high-priority target population are imperative.

Exploring the Molecular Pathogenesis, Pathogen Association, and Therapeutic Strategies against HPV Infection

The human papillomavirus (HPV), commonly documented as the cause of warts, has gained much interest recently due to its possible links to several types of cancer. HPV infection is discussed in this review from multiple angles, including its virology, epidemiology, etiology, immunology, clinical symptoms, and treatment. Recent breakthroughs in molecular biology have led to the development of new methods for detecting and treating HPV in tissue. There is no cure for HPV, and although vaccines are available to prevent infection with the most common HPV viruses, their utilization is limited. Destruction and excision are the primary treatment modalities. This review sheds light on the epidemiology, molecular pathogenesis, the association of several other pathogens with HPV, the latest treatment strategies available to treat the same, and an overview of the progress made and the obstacles still to be overcome in the fight against HPV infection.

Health vulnerabilities in female sex workers in Brazil, 2016

Female sex workers (FSW) suffer stigma and discrimination that negatively impact their physical and mental health and affect access to health care services. This paper aims to describe selected health indicators among FSW in 12 Brazilian cities in 2016. Brazilian cross-sectional Biological Behavioral Surveillance Survey was conducted in 2016 among 4328 FSW recruited by respondent-driven sampling. The sample weighing was inversely proportional to participant's network sizes and the seeds were excluded from the analysis. Health indicators were estimated with 95% confidence interval and included indicators of health status, symptoms of depression, antenatal care, pap smear coverage, signs and symptoms of sexually transmitted infection, contraception and regular condom use, number of births and children alive per women, human immunodeficiency virus and syphilis testing, usual source of care, and perception of discrimination. Most participants self-rated their health as very good/good (65.8%) and 27.7% were positively screened for major depressive disorder episode on Patient Health Questionnaire-2. Antenatal coverage was 85.8% and 62.3% of FSW had access to pap smear exam in the past 3 years. A total of 67.0% of FSW were using some contraceptive method at the time of the study. Male condom was the most common method (37.1%), followed by oral pill (28.9%). A total of 22.5% FSW had never been tested for HIV and the main reasons were "not feeling at risk" (40.4%) and "being afraid or ashamed" (34.0%). The vast majority of FSW used Brazilian National Health System as their usual source of health care (90.2%). Approximately one-fifth of the participants felt discriminated against or were treated worse for being FSW (21.4%) and only 24.3% disclose their sex work status in health services. The vulnerability of FSW is expressed in all health indicators. Indicators of health status, antenatal care, pap smear coverage, and contraception were worse than in the Brazilian population, and point out to the importance of increase FSW's access to health care services. Also, stigma and discrimination emerged as an important barrier to FSW's health care in all dimensions and need to be struggled.

Oral, genital and anal human papillomavirus infections among female sex workers in Ibadan, Nigeria

BACKGROUND

There are limited data on the epidemiology of HPV in different anatomical sites of female sex workers (FSW). We investigated the prevalence and concordance of cervical, vulval, oral and anal HPV among FSW in Ibadan, Nigeria.

METHODS

FSWs aged 18-45 years were enrolled in a cross-sectional survey. After interview and clinical examination, samples were collected from mouth, cervix, vulva and anus. HPV genotyping was done with Anyplex II 28HPV assay. Multivariable analyses were performed to explore associated risk factors and concordance of HPV infections across sites.

RESULTS

In total, 315 FSWs participated in the study with a mean age of 30-6.5 years. The prevalence of any HPV infection was 88% in the vulva, 84% in the cervix, 75% in the anus and 24% in the oral cavity. HPV 35 was the most prevalent and concordant high-risk type in the four sites. The risk factors for HPV infection by anatomic site varied.

CONCLUSION

This large study showed a high prevalence and concordance of HPV infections of cervical, vulval, oral and anal HPV among FSWs in Nigeria. The potential to acquire and transmit HPV is high in this population, and we highlighted the urgency to protect young women through HPV vaccination.

Oncogenic human papillomavirus DNA in female sex workers of Bihar, India

Objective

Human papillomavirus (HPV) is a sexually transmitted virus which play a vital role to developing Cervical cancer. It is presumed and accepted that sexually exposed women will have occurred HPV infection at least once in their whole life. Hence, determined the actual cause of transmission of HPV infection in sexually active women with single sex partner that is married women and sexually active women with multiple sex partners that is female sex works (FSWs).

Methods

A total 197 urine sample of FSWs and MW has been utilized through RT-PCR technique for HR-HPV detection. DNA extracted from urine samples and estimation and purification of DNA, used RT-PCR technique for HPV-16 and HPV-18 detection.

Results

The overall prevalence of HR-HPV was detected to be 16.75% (33/197) and 83.25% (164 out 197) negative results reported in both studied subjects. The results analysis of HPV-16 and HPV-18 reveals in which prevalence of HPV-16 was 14.21% (28/197) and HPV-18 was detected 2.53% (5/197) in studied subjects in both study groups. The prevalence of HPV-16 and HPV-18 among MW was high (18.75%) and HPV-16 and HPV-18 was low (14.85%) in FSWs. It did not differ significantly of HR-HPV prevalence in MW who has single sex partner and FSWs who has multiple sex partners.

Conclusion

The study indicates that oncogenic HPV prevalence did not different significantly in multiple sex partners, that is, FSWs and single sex partner, that is, MW. The probability of genital hygiene rather than multiple sexual partners stands more apt as a cause of HPV infection. This study advises to develop more awareness program about genital hygiene in women to reduce the HPV infection and can be prevented from cervical cancer. Hence, genital hygiene may be reducing the burden of HPV infection in women.

The pattern of human papillomavirus infection and genotypes among Nigerian women from 1999 to 2019: a systematic review

BACKGROUND

There are no robust national prevalence of Human Papillomavirus (HPV) genotypes in Nigerian women despite the high burden of cervical cancer morbidity and mortality.

THE OBJECTIVE OF STUDY

This study aims to determine the pooled prevalence and risk factors of genital HPV infection in Nigeria through a systemic review protocol.

METHODS

Databases including PubMed, Scopus, Google Scholar and AJOL were searched between 10 April to 28 July 2020. HPV studies on Nigerian females and published from April 1999 to March 2019 were included. GRADE was used to assess the quality of evidence.

RESULTS

The pooled prevalence of cervical HPV was 20.65% (95%CI: 19.7-21.7). Genotypes 31 (70.8%), 35 (69.9%) and 16 (52.9%) were the most predominant HPV in circulation. Of the six geopolitical zones in Nigeria, northeast had the highest pooled prevalence of HPV infection (48.1%), while the least was in the north-west (6.8%). After multivariate logistic regression, duration (years) of sexual exposure (OR = 3.24, 95%CI: 1.78-9.23]), history of other malignancies (OR = 1.93, 95%CI: 1.03-2.97]), history of sexually transmitted infection (OR = 2.45, 95% CI: 1.31-3.55]), coital frequency per week (OR = 5.11, 95%CI: 3.86-14.29), the status of circumcision of the sexual partner (OR = 2.71, 95%CI: 1.62-9.05), and marital status (OR = 1.72, 95%CI: 1.16-4.72), were significant risk factors of HPV infection (p < 0.05). Irregular menstruation, post-coital bleeding and abdominal vaginal discharge were significantly associated with HPV infection (p < 0.05).

CONCLUSION

HPV prevalence is high in Nigeria and was significantly associated with several associated risk factors. Rapid screening for high-risk HPV genotypes is recommended and multivalent HPV vaccines should be considered for women.

Human Papilloma Virus infection and cervical cancer among women who sell sex in Eastern and Southern Africa: A scoping review

OBJECTIVES

Women who sell sex have a high prevalence of human papilloma virus, which may cause cervical cancer. The objective of this review was to collate findings on prevalence, associated factors, screening, service provision and utilization of services in relation to human papilloma virus and cervical cancer among women who sell sex in Eastern and Southern Africa.

METHODS

A scoping review methodology was employed. Inclusion criteria were as follows: (1) empirical papers, (2) of studies conducted in Eastern and Southern Africa, (3) published in the last 10 years, and (4) addressing women who sell sex in relation to (5) human papilloma virus and cervical cancer. A thorough search of a range of databases surfaced 66 papers. Both authors applied inclusion and exclusion criteria, resulting in 14 papers being reviewed.

RESULTS

The reported prevalence of high-risk human papillomavirus virus varied between 23.6% and 70.5%. HIV sero-positivity, other sexually transmitted infections and Epstein-Barr virus were associated with human papilloma virus and high-grade cervical lesions. High-risk human papilloma virus was associated with women who reported younger age at first intercourse, non-barrier contraceptive use, and no history of condom use. For screening, there was overall agreement between physician- and self-collected samples. Contradictory results were found for visual inspection with acetic acid. Screening services utilization was associated with provider's recommendation, history of sexually transmitted infections, frequency of facility visit and history of vaginal examination. A diagonal programme led to an increase in screening, attributed to the targeted services.

CONCLUSIONS

Context is important in planning cervical cancer services. There is a need for enhanced sexually transmitted infections and viral management within cervical cancer prevention. Women who sell sex should be empowered in self-collection of stored-dry specimens, especially in resource-constrained regions. Cervical cancer screening services should be honed to the needs of women who sell sex.

Australia's Role in Pneumococcal and Human Papillomavirus Vaccine Evaluation in Asia-Pacific

Australian researchers have made substantial contributions to the field of vaccinology over many decades. Two examples of this contribution relate to pneumococcal vaccines and the human papillomavirus (HPV) vaccine, with a focus on improving access to these vaccines in low- and lower-middle-income countries (LLMICs). Many LLMICs considering introducing one or both of these vaccines into their National Immunisation Programs face significant barriers such as cost, logistics associated with vaccine delivery. These countries also often lack the resources and expertise to undertake the necessary studies to evaluate vaccine performance. This review summarizes the role of Australia in the development and/or evaluation of pneumococcal vaccines and the HPV vaccine, including the use of alternative vaccine strategies among countries situated in the Asia-Pacific region. The outcomes of these research programs have had significant global health impacts, highlighting the importance of these vaccines in preventing pneumococcal disease as well as HPV-associated diseases.

Worldwide burden of genital human papillomavirus infection in female sex workers: a systematic review and meta-analysis

BACKGROUND

Although female sex workers (FSWs) have long been identified as a key human papillomavirus (HPV)-affected population, the burden and scope of their disproportionate risk for HPV infection have not been systematically estimated. We therefore aimed to estimate the prevalence of HPV and the distribution of HPV types in FSWs at the country, regional and global levels.

METHODS

We searched the PubMed, Embase, SCOPUS, EBSCO, ProQuest, Cochrane Library and Web of Science databases for articles published between 1 January 1990 and 31 June 2019. Studies of genital HPV prevalence in FSWs, or with sufficient data (e.g. adequate number of HPV-positive cases and sample size) to compute prevalence rates in FSWs, were included in this systematic review. The meta-analysis was completed using the random effects model.

RESULTS

We ultimately identified 107 studies in 45 countries or regions with sufficient data to calculate HPV prevalence in FSWs. The pooled global HPV prevalence among FSWs was 39.5% (95% CI 35.3, 43.9%), with notable variations by WHO region and country. Globally, the five most common HPV types in FSWs were HPV16 (9.0%), HPV 52 (8.3%), HPV89 (7.0%), HPV58 (6.2%), and HPV53 (5.3%).

CONCLUSIONS

Our findings suggest that FSWs are disproportionately affected by HPV, which is more pronounced in the Western Pacific and African regions, and are therefore in need of prevention, treatment and care services.

Comparison of cervical cancer screening by self-sampling papillomavirus test versus pap-smear in underprivileged women in France

BACKGROUND

The purpose of this study was to compare cervical cancer screening by pap smear (PS) versus preliminary HPV testing based on self-collected samples (SC-HPV).

METHODS

Interventional study among underprivileged women from 25 to 65 years old in four French cities. The control group (CG) was referred for a PS. The experimental group (EG) conducted a SC-HPV test followed by a PS in case of positivity. Differences on screening completion and cytological abnormalities were analysed by logistic and Cox regression.

RESULTS

383 women were assigned to the EG and 304 to the CG. The screening completion proportion was 39.5% in the CG compared to 71.3% in the EG (HR = 2.48 (CI 95% [1.99-3.08]; p < 0.001). The proportion of cytological abnormalities was 2.0% in the CG and 2.3% in the EG (OR = 1.20 (CI 95% [0.42-3.40]; p = 0.7). The proportion of participants lost to follow-up was 60.5% in the CG and 63.2% in the EG HPV positive (p = 0.18).

CONCLUSION

Providing an SC-HPV-test increased the participation of underprivileged women in CCS. Nevertheless, the significant number of lost to follow-up in both groups can undermine the initial benefits of the strategy for HPV positive women. Registration: Clinicaltrials.gov: NCT03118258.

Visual inspection with acetic acid (VIA) positivity among female sex workers: a cross-sectional study highlighting one-year experiences in early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda

BACKGROUND

Although cervical cancer is preventable, most women in sub-Saharan Africa (SSA) do not receive routine screening and few treatment options exist. Female Sex Workers (FSWs) are among the Ugandan female population at highest risk of acquiring sexually transmitted infections (STIs) including HIV and human papilloma viruses (HPV), the cause of cervical cancer. We report one-year experiences of visual inspection with acetic acid (VIA) positivity among FSWs in the early detection of pre-cancerous and cancerous cervical lesions in Kampala, Uganda.

METHODS

Between June 2014 and July 2015, we enrolled FSWs into a cross-sectional study at a research clinic. The women were screened using the VIA method (application of 3-5 % acetic acid to the cervix). All VIA positive women were referred to a tertiary hospital for colposcopy, biopsy, and immediate treatment (if indicated) at the same visit according to national guidelines. Data on socio-demographic, sexual behaviour, sexual reproductive health and clinical characteristics were collected. We used logistic regression to identify factors associated with VIA positivity.

RESULTS

Of 842 women assessed for eligibility, 719 (85 %) of median age 30 (IQR 26, 35) were screened, and 40 (6 %) women were VIA positive. Of the 24 histology specimens analysed, 6 showed inflammation, only 1 showed cervical intraepithelial neoplasia (CIN) 1, 13 women showed CIN2/3, while 4 women already had invasive cervical cancer. The overall prevalence of HIV was 43 %, of whom only 35 % were receiving ART. In the age-adjusted analysis, VIA positivity was more likely among women who reported having > 100 life-time partners (aOR = 3.34, 95 %CI: 1.38-8.12), and HIV positive women (aOR = 4.55; 95 %CI: 2.12-9.84).

CONCLUSIONS

We found a relatively low proportion of VIA positivity in this population. The experience from our program implies that the VIA results are poorly reproducible even among a category of trained professional health workers. VIA positivity was more likely among women with a high number of sexual partners and HIV infection. Interventions for improving cervical cancer screening should be recommended as part of HIV care for FSWs to reduce the disease burden in this population.

Type-specific incidence, persistence and factors associated with human papillomavirus infection among female sex workers in Benin and Mali, West Africa

OBJECTIVES

This study in female sex workers (FSWs) aimed to: (1) estimate type-specific incidence and persistence of human papillomavirus (HPV) infection in Cotonou (Benin) and Bamako (Mali); and (2) identify the factors associated with type-specific incidence and persistence of high-risk HPV (HR-HPV) infection.

METHODS

A 1-year prospective cohort study on cervical cancer screening, and HPV and human immunodeficiency virus (HIV) infections was conducted among FSWs in Cotonou and Bamako from 2017 to 2019. Poisson regression models assessed factors associated with the incidence of HR-HPV infection, while log-binomial regression was performed to identify factors associated with the persistence of HR-HPV infection. Adjusted relative risks (ARR) and 95% confidence intervals (95% CI) were estimated.

RESULTS

The incidence of HR-HPV infection was 46.98 per 1000 women-months (predominant types HPV16, HPV35 and HPV59). Factors associated with the incidence of HR-HPV infection were age <20 years (ARR 15.10; 95% CI 3.29-69.19), age at sexual debut <18 years (ARR 6.92; 95% CI 1.97-24.27) and sex work duration ≤1 year (ARR 7.40; 95% CI 1.84-29.69). The persistence of HR-HPV infection at 12 months was 38.7% (most persistent types HPV59, HPV52 and HPV51). Persistence of HR-HPV infection was higher in women with chlamydia (P = 0.031), HIV infection (P < 0.001) and multiple-type HPV infections (P < 0.001).

CONCLUSION

FSWs in West Africa are at high risk of incident and persistent HR-HPV infection, suggesting an urgent need for cervical cancer screening in this population.

Human papillomavirus genotype distribution and factors associated among female sex workers in West Africa

OBJECTIVES

This study aimed to: (1) Estimate HPV prevalence and genotype distribution among female sex workers (FSWs) in Mali and Benin as well as the prevalence of multiple HPV type infections in this group, and (2) Identify potential risk factors associated with high-risk (HR) HPV infections.

METHODS

We analyzed baseline data of 665 FSWs aged ≥ 18 years recruited during a prospective cohort of cervical cancer screening in Cotonou (Benin) and Bamako (Mali) from 2017 to 2018. The Linear Array HPV genotyping test was used to identify HPV genotypes. Descriptive statistics and multivariate log-binomial regression were used. Adjusted prevalence ratios (APR) with 95% confidence intervals (95%CI) were estimated to identify risk factors associated with HR-HPV infections.

RESULTS

HPV data were available for 659 FSWs (Benin: 309; Mali: 350). The mean age was 35.0 years (± 10.7) in Benin and 26.8 years (± 7.6) in Mali. The overall HPV prevalence rates were 95.5% in Benin and 81.4% in Mali. About 87.7% and 63.4% of FSWs harbored ≥ 2 HPV types in Benin and Mali, respectively. The top three prevalent HR-HPV among FSWs in Benin were: HPV58 (37.5%), HPV16 (36.6%) and HPV52 (28.8%). Corresponding patterns in Mali were HPV16 (15.7%), HPV51 (14.3%) and HPV52 (12.9%). In Benin, the main factors associated with HR-HPV were vaginal douching (APR = 1.17; 95%CI:1.02-1.34) and gonococcal infection (APR = 1.16; 95%CI:1.04-1.28), while in Mali they were sex work duration ≤ 1 year (APR = 1.35; 95%CI:1.10-1.65) and HIV infection (APR = 1.26; 95%CI: 1.06-1.51).

CONCLUSION

Our study found a very high prevalence of HPV infection as well as high frequency of multiple HPV type infections in FSWs in two countries in West Africa. These findings suggest the necessity to emphasize cervical cancer prevention in this high-risk group.

Prevalence and genotype distribution of genital human papillomavirus infection in female sex workers in the world: a systematic review and meta-analysis

BACKGROUND

Female sex workers (FSWs) are amongst the most susceptible groups to acquire human papillomavirus (HPV) infection and consequently, to develop cervical intraepithelial neoplasia and cervical cancer. This is the first systematic review and meta-analysis to provide estimates of the pooled prevalence of HPV infection and the distribution of HPV types among FSWs across the world.

METHODS

Five computerized databases were searched for relevant studies published since the inception date of databases to September 2019. The pooled HPV prevalence was calculated by the random effect model described by DerSimonian-Laird. Subgroup analysis was performed to identify the probable sources of heterogeneity. The meta-analysis was performed using the "Metaprop" function in the R package Meta.

RESULTS

Sixty-two studies involving 21,402 FSWs from 33 countries were included in this meta-analysis, and the pooled HPV prevalence was 42.6% (95% confidence interval (CI): 38.5-46.7%). HPV-16 (10.1, 95% CI: 8.2-12.5%), HPV-52 (7.9, 95% CI: 5.9-10.7%), and HPV-53 (6.0, 95% CI: 4.4-8.1%) were the most common high-risk HPV types identified among FSWs. The pooled estimated prevalence of HPV infection among FSWs before and after 2010 were slightly different, 43.6% (95% CI: 36.1-51.4%) and 41.9% (95% CI: 37.2-46.8%), respectively.

CONCLUSION

Due to the high prevalence of HPV infection, particularly with high-risk types, FSWs have a great susceptibility to the development of cervical and vaginal cancers. Furthermore, they can transmit their infection to their clients, which may result in a high prevalence of HPV and the incidence of HPV-associated malignancies among the general population.

Evaluating sexual health in sex workers and men who have sex with men: the SMESH cross-sectional protocol study

INTRODUCTION

Human papillomavirus (HPV) infection is transmitted through skin-to-skin contact, and vaginal and anal sex are the most common transmission routes. Sex workers and men who have sex with men (MSM) are more exposed to the virus, and therefore, a higher frequency of this infection would be expected. The prevalence of HPV infection types and the forms and factors of transmission must be investigated to control infection-related outcomes. This protocol study will be the first nationwide study with a uniform methodology to evaluate HPV prevalence of and infection types among sex workers and MSM in Brazil.

METHODS AND ANALYSIS

This multicentre cross-sectional study will be conducted with a respondent-driven sampling method to recruit 1174 sex workers and 1198 MSM from all regions of Brazil. The study will consist of preliminary interviews to verify the eligibility criteria and characterise the network size as well as a second questionnaire to obtain sociodemographic, behavioural and sexual information. Specimens from the oral cavity and anal and cervical or penile/scrotal sites will be collected. All HPV samples will be processed in a certified central laboratory. Other sexually transmitted infections will be evaluated by interview and by rapid testing for HIV and syphilis. Strict quality control will be conducted using different procedures, including the training and certification of the health professionals responsible for acquiring data and monitoring visits.

ETHICS AND DISSEMINATION

The project was approved by the research ethics committee of the main institution and the corresponding ethics committees of the recruitment sites. Due to the literature gap on the sexual health of sex workers and MSM and the intense stigma surrounding these populations, a critical analysis of the study results will contribute to epidemiological knowledge and will be useful for the development of strategies against virus morbidities.

Cervical Human Papillomavirus Prevalence, Genotypes, and Associated Risk Factors among Female Sex Workers in Greater Accra, Ghana

Cervical cancer is a largely preventable disease mediated by persistent infection with high-risk Human Papillomaviruses (Hr-HPV). There are now three approved vaccines against the most common HPV genotypes. In Ghana, mortality due to cervical cancer is on the rise, due to the absence of an organized and effective cervical cancer prevention and control program. Data on circulating HPV genotypes is important for studying the likely impact of mass introduction of HPV vaccination of the female population before sexual debut. High HPV prevalence has been reported in Female Sex Workers (FSWs), who constitute an important active group for maintenance of HPV in the population. This study was conducted to determine the size of HPV prevalence in this group and to provide information for future assessment of the impact of vaccine introduction in the country. We conducted a cross-sectional study where the snowballing technique was used to identify and select FSW's ≥18 years, operating within suburbs of Greater Accra Region (GAR). A risk factor assessment interview was conducted and cervical swabs were collected for HPV-DNA detection and genotyping by Nested Multiplex PCR. Hundred participants, age ranging from 18 to 45 years, median 24 years, were studied. The prevalence of Cervical HPV was 26%. Eleven genotypes were detected comprising 9 high-risk in order of decreasing prevalence HPV-16 (8%), HPV-35 (5%), HPV-33/39/-68 (3%), HPV-52/51/59 (2%) and HPV-18 (1%) and 2 Low-risk types, HPV-42(3%), and HPV-43 (1%). Three women had HPV types that could not be genotyped by our method. Oral contraceptives use was associated with a reduced chance of HPV infection (P=0.002; OR=0.19, 95% CI 0.07-0.54). This study found a high HPV prevalence among FSWs in the GAR. A high number of Hr-HPV genotypes seen are vaccine preventable, providing additional compelling argument for implementing a national cervical cancer prevention plan including vaccination.

Human Papillomavirus infection in senegalese female sex workers

OBJECTIVES

Several studies have documented the HPV genotypes in the Senegalese general population. The objective was to explore the HPV genotype distribution in Senegalese FSWs in order to assess the potential relevance of currently-available vaccines.

METHODS

Vaginal swabs samples collected as part of the National Integrated Biological and Behavioral Survey in 14 regions throughout the country were randomly selected for HPV testing using bead-based multiplex genotyping (TS-MPG).

RESULTS

Among the 436 FSW samples analyzed, the overall HPV prevalence was 79.8% (N = 348), with 70.1% (N = 244) cases presenting as multiple infections. High Risk HPV genotypes affecting at least 10% of FSWs included in order of decreasing frequency: 52, 16, 35, 51, 33, 31, 18, and 45. Sixty-seven (15.4%) FSWs were HIV positive and they were significantly more affected by HPV (94% vs 77%; p < 0.01) than seronegative FSWs as well as infections with multiple genotype.

CONCLUSION

The present study indicates that FSW in Senegal experience a high burden of HPV infection with a high frequency of coinfection with HIV and multiple HPV genotypes. Public health interventions for this key population should include an earlier cervical dysplasia/cancer detection and preventative measures such as vaccination programs that must consider the HPV genotype distribution.

Should female sex workers be offered HPV vaccination?

Prophylactic vaccines are efficacious in preventing Human Papillomavirus (HPV) infection and subsequent cervical intraepithelial neoplasia (CIN), cervical cancer, other anogenital cancers, and anogenital warts. Female sex workers (SW) are at increased risk of acquiring sexually transmitted infections, including HPV. There are several reasons to offer HPV vaccination to SW: they are at high risk for HPV and often unvaccinated, and the immunogenicity of the vaccine is also excellent in previously HPV exposed women. Furthermore, women with disease caused by HPV may still benefit from vaccination. The efficacy of vaccinating mid-adult women (26-44 years old) against persistent HPV infection and CIN2+ is good. Although an SW may have been infected or exposed to HPV, she may not have been exposed to all vaccine-included hrHPV types. Vaccination induces mucosal immunity via the production of neutralizing antibodies on the surface of the female genital tract, thus preventing potential transmission to clients. Nevertheless, some considerations argue against offering vaccination to SWs. Current vaccines are only prophylactic and as such, do not affect current HPV infections. Women who have previously cleared HPV infections, may do so again and thus not need vaccination. Fewer SW might be naïve to HPV-types than currently thought. HPV vaccination has probably no effect on latent infections. Vaccinating sometime after sexual debut could be too late, as infections have already occurred. Taken together, some data suggest that vaccination of SW may offer health benefits, also for the community, but sufficient evidence is lacking. In certain cases, HPV vaccination of SW may be recommended. Evidence-based, public health decisions concerning vaccination of SW are challenging and could be facilitated with more research in this high-risk group.

Analysis of Nucleotide Alterations in the E6 Genomic Region of Human Papillomavirus Types 6 and 11 in Condyloma Acuminatum Samples from Brazil

Condyloma acuminata (CA), or genital warts, are benign proliferative epidermal or mucous lesions that are caused by infection with human papillomavirus (HPV), mainly the low-risk types 6 and 11. HPV variants are defined as viral sequences that share identity in the nucleotide sequence of the L1 gene greater than 98%. Based on this criterion, HPV6 and 11 variant lineages have been studied, and there are ongoing attempts to correlate these genetic variants with different clinical findings of infection. Therefore, the aims of this study were to detect variants and nucleotide alterations present in the E6 regions of HPV types 6 and 11 found in CA samples, to correlate the HPV presence with the clinical-pathological data of the patients, and to determine phylogenetic relationships with variants from other places in the world. The E6 regions of 25 HPV6 samples and 7 HPV11 samples from CA were amplified using PCR with specific primers. The products were ligated to a cloning vector and five colonies of each sample were sequenced to observe the nucleotide alterations. Twelve samples were identified as the HPV6B3 variant, presenting the mutation (guanine) G474A (adenine), and one of them also showed the mutation (thymine) T369G. The other 13 patients were positive for HPV6B1 without nucleotide alterations. In the analysis of the HPV11 samples, all patients showed the mutations T137C and (cytosine) C380T. One patient also presented the nucleotide alteration T410C. None of the mutations found in the 32 analyzed samples resulted in amino acid changes. Patient age, local occurrence, and HIV infection did not show significant association with HPV infection. Besides, the data found in this study did not show a relationship with the geographical region of isolation when compared to other data from different regions of the world. In this way, despite the nucleotide alterations found, it was not possible to observe amino acid changes and variants grouping according to geographical region.

Prevalence of human papillomavirus, human immunodeficiency virus and other sexually transmitted infections among female sex workers in Togo: a national cross-sectional survey

OBJECTIVES

Sub-Saharan Africa is a region with high incidence of both human immunodeficiency virus (HIV) and cervical cancer. We conducted the first national study in Togo to assess prevalence of human papillomavirus (HPV), HIV and other sexually transmitted infections (STIs) among female sex workers (FSW).

METHODS

A multicentric cross-sectional study was conducted among FSW recruited in hot spots (clubs, streets) in four Togolese cities. HPV and STIs were tested from cervical and anal swabs. HIV and syphilis were screened with rapid tests.

RESULTS

In all, 310 FSW were recruited; HIV and cervical high-risk HPV (hrHPV) prevalence were 10.6% (33/310) and 32.9% (102/310), respectively. The most frequent hrHPV types were HPV58 (13.6%, 19/140), HPV35 (12.9%, 18/140), HPV31 (12.1%, 17/140) and HPV16 (10.7%, 15/140). Prevalence of hrHPV and multiple hrHPV infections showed higher rates in HIV-positive than in HIV-negative FSW (48.5% versus 31.0%, p 0.04 and 21.2% versus 9.0%, p 0.03; respectively). Prevalence of hrHPV was higher in cervical than anal swabs (34.1% versus 20.7%, p 0.0004). High-risk HPV anal infections were more frequent among HIV-positive than HIV-negative FSW (51.9% versus 17.3%, p 2 × 10^-5). Concomitant anal and cervical hrHPV infections were present in 43.2% (41/95) of hrHPV-positive FSW. Overall prevalence in the cervix of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis were 4.2%, 6.1%, 5.5% and 6.5%, respectively.

CONCLUSIONS

This first African study on paired cervical and anal samples showed a high prevalence of genital HPV infections with a rather high rate of concomitant HPV infections but low type concordance. We report an unusual distribution of hrHPV types. These findings highlight the critical need for implementation of a national HPV vaccination strategy.

Human Papillomavirus Infection in Female Sex Workers: A Case Control Study

Background

To determine the association of infection with human papillomavirus (HPV) and the occupation of female sex worker; and the correlation of infection with HPV with sociodemographic, clinical and behavioral characteristics of female sex workers.

Methods

We performed a case-control study of 217 female sex workers and 354 women without sex work in Durango City, Mexico. We determined the prevalence of infection with HPV in cervical samples of women using polymerase chain reaction, and HPV genotypes were determined using line probe assay. Bivariate and multivariate analyses were used to assess the association between the characteristics of women and infection.

Results

Twelve (5.5%) of the 217 sex workers, and 10 (2.8%) of the 354 control women were positive for HPV DNA (age-adjusted OR = 1.51; 95% CI: 0.62 - 3.68; P = 0.36). Six (50.0%) of the 12 HPV DNA positive sex workers had infections with high-risk genotypes (16, 31, 33, 35, 51, 58). Seven (70%) of the 10 HPV DNA positive control women had infections with high-risk genotypes (16, 18, 56, 58, and 66). The frequency of high risk genotypes in the control women was equal with that found in the female sex workers (P = 0.41). Logistic regression analysis showed that the variable alcohol consumption was associated with HPV infection (OR = 4.0; 95% CI: 1.0 - 16.0; P = 0.04).

Conclusions

No association between HPV infection and female sex work was found in our setting. High risk HPV genotypes were prevalent among the women studied. Results can be used for the design of preventive measures against HPV infection.

Pattern of Utilization of Cervical Cancer Screening Services among Female Sex Workers in Some Selected Brothels in Abuja, Nigeria

Objective

The utilization of cervical cancer screening services remains low among Female Sex Workers (FSWs) in Sub-Saharan Africa, with few or no studies conducted in Nigeria. However, the prevalence of human papillomavirus in this population is reportedly high because of associated risk factors. This study examined the pattern of cervical cancer screening service utilizations among FSWs in the Abuja metropolis.

Methods

This descriptive cross-sectional survey used a purposive sampling technique to select 406 respondents via a structured questionnaire including questions regarding whether they had been screened for cervical cancer, the frequency of screening and type of screening method. Data were analyzed using SPSS version 22 and presented using frequency tables and percentages.

Results

The response rate among the participants was 97.6%. The mean age of the FSWs was 32 ± 5.1 years. Regarding the pattern of screening age, the mean age at the first screening was 28 ± 4.3 years. Only 81 (20%) participants had been screened annually, and visual inspection with acetic acid was most frequently used (20.9%). Respondents preferred to undergo screening in their brothels. The awareness of screening services was high (n = 290, 71.4%); however, the utilization of cervical cancer screening services remained low, as 246 (60.6%) FSWs had never been screened. The nonutilization of screening services was related to poor accessibility and a lack of awareness and interest.

Conclusions

Although a high level of awareness that would be expected to influence uptake, cervical cancer screening services were rather underutilized by the study respondents. Therefore, a concerted effort is needed to ensure that FSWs understand cervical cancer and its consequences. Hopefully, this effort will improve the uptake.

Cervical cancer screening among transactional female sex workers in the Dominican Republic

Cervical cancer is the third leading cause of cancer-related death and the second most diagnosed cancer among women in developing countries. We determined the prevalence of abnormal Papanicolaou (Pap), high-risk HPV (hrHPV), and colposcopy among transactional female sex workers (FSWs) in La Romana, Dominican Republic. The results of 144 FSWs of ages 18-54 years who completed a demographic interview and Pap testing with hrHPV detection between June 2015 and April 2016 were analyzed. Women with abnormal results were referred for colposcopy. Risk factors for abnormal Pap were assessed through bivariate and multivariate analyses. Overall, 36.1% (52/144) of Paps were abnormal and 43.4% (62/143) had hrHPV. Of all women with hrHPV and/or abnormal Pap (68/144; 47.2%), 61 (89.7%) were referred and 16 (26.2) underwent colposcopy. HPV16 and/or 18/45 was detected in 33.3% (15/45) of low-grade Paps. Binge drinking, weekly (AOR 5.1, 95% CI: 1.8-14.5) or daily (AOR 4.9, 95% CI: 1.5-16.6), and age at first sexual relation (AOR 1.2, 95% CI: 1.0-1.5) were significantly associated ( p < 0.05) with abnormal Pap. Although almost half of participants had abnormal Pap or hrHPV, few underwent colposcopy. Improving access to cervical cancer screening and follow-up for FSWs is imperative.

Are vaginal swabs comparable to cervical smears for human papillomavirus DNA testing?

Objective

Human papillomavirus (HPV) testing is widely incorporated into cervical cancer screening strategies. Current screening requires pelvic examination for cervical sampling, which may compromise participation. The acceptance could be raised by introducing testing on vaginal swabs. We explored the interchangeability of vaginal swabs and cervical smears for HPV testing, by means of a prospective study conducted in female sex workers (FSWs). Besides, we report on the occurrence of 32 different HPV genotypes in FSW with low-grade squamous intraepithelial lesion (LSIL) or high-grade squamous intraepithelial lesion (HSIL).

Methods

Paired physician-collected vaginal swabs and cervical smears from 303 FSW were tested for HPV using the Abbott RealTime High-Risk HPV assay. Cervical cytology was examined on cervical smears. In case of HSIL/LSIL cytological classification (n=52), both samples were genotyped using INNO-LiPa HPV Genotyping Extra II.

Results

The overall prevalence of high-risk (HR)-HPV was 51%. In FSW with HSIL/LSIL cervical cytology, the sensitivity and specificity of vaginal samples for the detection of HR-HPV was 100% and 70% and for probable HR-HPV 100% and 91%. The mean number of genotypes identified in vaginal samples (mean=3.5; 95% confidence interval [CI]=2.8–4.2) was significantly higher than in cervical smear samples (mean=2.6; 95% CI=2.1–3.0) (p=0.001). The most frequently encountered HR-HPV genotypes were HPV16, 31, 51, and 52.

Conclusion

As our study shows that vaginal swabs are equivalent to cervical smears for the detection of (probable) HR-HPV, vaginal swabs can be used for HPV testing in cervical cancer screening strategies. Given the acceptance of vaginal sampling, this finding offers an opportunity to boost screening coverage.

Human papillomavirus (HPV) types prevalence in cervical samples of female sex-workers on Curaçao

Sex-workers have an increased risk for high-risk HPV(hrHPV) cervical cancer. On Curaçao, legal and illegal prostitution practice is high and the promiscuous lifestyle is common. We aimed to gain insight in HPV-genotype prevalence in cervical scrapes of female sex workers (FSW) and related risk factors in comparison with women not working in the sex industry. Cervical samples were taken from 76 FSW and 228 non-FSW (NFSW) age matched controls in the period between 2013 and 2015. HPV was detected by GP5+/6+ PCR-EIA followed by genotyping via reverse line-blot. HPV prevalence in FSWs was 25.0% and in NFSWs 29.4% (p = 0.14). NFSW had more often untypable HPV-genotypes (HPV-X:5.3% vs 0.0%; p = 0.042). A trend for statistical difference was observed in HPV prevalence between FSWs from Dominican Republic (42.1%) and FSWs from Colombia (19.2%; p = 0.067). Young age was the only risk factor related to HPV prevalence in FSWs. (Mean age FSW 29.2 y ±7.8 and NFSW 33 y ±6.2) Smoking and drugs consumption were significantly higher among FSW. A significant higher number of women with history of any STD was reported by NFSWs. In addition, >90% of FSW had their previous Pap smear <3 years ago, while >35% NFSW never had a previous Pap smear (p < 0.001).

IN CONCLUSION

no significant difference in HPV prevalence is observed between FSW and NFSW. HPV prevalence in FSW was associated with a lower age. During interviews, FSW seemed more aware about prevention strategies, reported less history of STD's and were more updated with cervical cancer screening, compared to NFSWs.

Vaginal and anal human papillomavirus infection and seropositivity among female sex workers in Amsterdam, the Netherlands: Prevalence, concordance and risk factors

BACKGROUND

We studied prevalence, risk factors and concordance of vaginal and anal HPV infection and L1 seropositivity among female sex workers (FSW) in Amsterdam.

METHODS

In 2016, FSW aged ≥18 years having a sexually transmitted infections (STI) consultation were invited to participate. Participation entailed taking vaginal and anal self-swabs. Demographics and sexual behaviour data were collected. HPV DNA was analysed using the SPF10-PCR-DEIA-LiPA25-system-v1. Serum was tested for HPV L1 antibodies using multiplex serology assays. Determinants of vaginal and anal high risk HPV (hrHPV) infection and L1 seropositivity were assessed with logistic regression analyses.

RESULTS

We included 304 FSW; median age was 29 years (IQR 25-37). Vaginal and anal hrHPV prevalence were 46% and 55%, respectively. HrHPV L1 seropositivity was 37%. Vaginal-anal hrHPV concordance was strong, but no significant association between vaginal or anal hrHPV infection and seropositivity was found. Having had anal sexual contact was not associated with anal hrHPV infection (P = 0.119).

DISCUSSION

Vaginal and anal hrHPV prevalence is high among FSW in Amsterdam, the Netherlands. Promotion of HPV vaccination, preferably at the beginning of the sex (work) career, may be a useful prevention method against hrHPV infection and disease.

Attitudes towards Human Papilloma Virus Vaccination in the Latin American Andean Region

This commentary explores the distribution of human papilloma virus (HPV) and HPV-related diseases, and factors affecting attitudes towards HPV, HPV-related diseases, and HPV vaccination in the Latin American Andean region. Lack of knowledge of HPV, known negative attitudes or incorrect assumptions about HPV, HPV-related diseases, and HPV vaccination provide a basis upon which to develop targeted HPV awareness and preventive health media campaigns. For maximal effect, media campaigns should use the internet, radio, and television to address health care providers, parents, and students. Additional programming can be developed for clinics to use in-house with their clients. Ministries of Education, Finance, and Health all have roles to play to increase national HPV, HPV-related diseases, and HPV vaccination awareness.

Sexual and reproductive health outcomes among female sex workers in Johannesburg and Pretoria, South Africa: Recommendations for public health programmes

BACKGROUND

The sexual and reproductive health (SRH) status of female sex workers is influenced by a wide range of demographic, behavioural and structural factors. These factors vary considerably across and even within settings. Adopting an overly standardised approach to sex worker programmes may compromise its impact on some sub-groups in local areas.

METHODS

Records of female sex workers attending clinic-, community-, or hotel-based health services in Johannesburg (n = 1422 women) and Pretoria (n = 408 women), South Africa were analysed. We describe the population's characteristics and identified factors associated with sexual and reproductive health outcomes, namely HIV status; previous symptomatic sexually transmitted infection (STI); modern contraceptive use and number of child dependents.

RESULTS

The women in Johannesburg were less likely than those in Pretoria to have HIV (42.2% vs 52.9%), or previous symptomatic STIs (44.3% vs. 8.3%), and were 1.4 fold less likely to have child dependents (20.1% vs. 15.3%). About 43% of women in Johannesburg were Zimbabwean and 40% in Pretoria. Of concern, only about 15% of women in both sites were using modern contraceptives. Johannesburg women were also more likely to access health services at a hotel (85.0% vs. 80.6%) or clinic (5.7% vs. 0.5%), to have completed secondary education (57.1% vs. 36.0%), and moved house more than twice during the past year (19.6 vs. 2.0%). In both cities, risk of HIV rose rapidly with age (23.8%-58.2% vs. 22.0%-64.8%). Of interest, HIV prevalence was considerably higher in those with consistent condom use with one's main partner than inconsistent users.

CONCLUSIONS

Sex worker populations are heterogeneous. Local health programmes must prioritise services that reflect the variety and complexity of sex worker needs and behaviours, and should be designed in consultation with sex workers. Segmenting sex worker populations according to age, country of origin and place of service delivery, and training healthcare providers accordingly, could help prevent new HIV infections, improve adherence to antiretroviral treatment and increase uptake of SRH services.

Prevalence of high-risk human papilloma virus types and cervical smear abnormalities in female sex workers in Chandigarh, India

PURPOSE

Cervical cancer is the most common cancer among women in developing nations. Nearly 90% of the cases have been linked to the presence of high-risk human papillomavirus (hrHPV) types 16 and 18. The risk of cervical cancer may be high in female sex workers (FSWs) due to multiple sexual partners. This study aimed to determine the prevalence of cytological abnormalities and hrHPV types 16 and 18 in FSWs in Chandigarh, North India using the liquid-based cytology (LBC) approach.

MATERIALS AND METHODS

The cervical brush samples were collected from 120 FSW and 98 age-matched healthy controls (HCs). These were subjected to pap smear using conventional method, LBC and the detection of hrHPV types 16 and 18 was carried out using polymerase chain reaction.

RESULTS

The LBC samples showed better cytological details and also reduced the number of unsatisfactory smears from 11% in Pap to 1.5% in the LBC. A significantly higher number of inflammatory smears were reported in FSWs (51.7% vs. 34.7%, P = 0.01). The hrHPV types 16/18 were detected in 33/120 (27.5%) FSW versus 23/98 (23.5%) HCs. The risk of acquiring hrHPV was higher in FSWs, who had age at first sex ≤25 years, higher income and the habit of smoking.

CONCLUSION

The high prevalence of hrHPV among FSWs and HCs suggests the need for the implementation of effective National Screening Programme for early detection of hrHPV types to decrease the burden of cervical cancer, especially in high-risk population.

Cervical cancer screening in rural South Africa among HIV-infected migrant farm workers and sex workers

At an HIV clinic in the Limpopo province of South Africa, chart reviews revealed long delays in addressing abnormal Pap smears, difficulty in referrals, poor quality and lost results, and increasing cases of cervical cancer. To address these barriers, a “see and treat” approach to screening was proposed. The objective was to integrate this method into current HIV care offered by local providers and to obtain demographic and risk factor data for use in future educational and intervention programs in the region.

A cross sectional study of HIV farm workers and at-risk sex workers attending an HIV clinic was performed with visual inspection with acetic acid (VIA). Those with positive screens were offered cryotherapy. Clinic charts were reviewed retrospectively for Pap smear results for the previous year at the time of program initiation and at 12 and 18 months post-program.

A total of 403 participants consented and underwent screening with VIA (306 Farm workers and 97 sex workers participated). 83.9% of participants (32.9% sex workers and 100% farm workers) were HIV +. VIA was positive in 30.5% of participants, necessitating cryotherapy. There was no significant difference in VIA positivity between HIV + farm workers and sex workers. There was a positive correlation between Pap smears and VIAs results.

We demonstrate successful integration of cervical cancer screening using VIA for HIV + farm workers and sex workers into an existing HIV treatment and prevention clinic in rural South Africa, addressing and treating abnormal results promptly.

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Integration of cervical cancer screening into HIV care is beneficial for sustainable programming.

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VIA is an effective method of cervical cancer screening in low-resource settings.

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Global health cancer care faces many challenges including screening and prevention.

Sexual and reproductive health services utilization by female sex workers is context-specific: results from a cross-sectional survey in India, Kenya, Mozambique and South Africa

BACKGROUND

Female sex workers (FSWs) are extremely vulnerable to adverse sexual and reproductive health (SRH) outcomes. To mitigate these risks, they require access to services covering not only HIV prevention but also contraception, cervical cancer screening and sexual violence. To develop context-specific intervention packages to improve uptake, we identified gaps in service utilization in four different cities.

METHODS

A cross-sectional survey was conducted, as part of the baseline assessment of an implementation research project. FWSs were recruited in Durban, South Africa (n = 400), Mombasa, Kenya (n = 400), Mysore, India (n = 458) and Tete, Mozambique (n = 308), using respondent-driven sampling (RDS) and starting with 8-16 'seeds' identified by the peer educators. FSWs responded to a standardised interviewer-administered questionnaire about the use of contraceptive methods and services for cervical cancer screening, sexual violence and unwanted pregnancies. RDS-adjusted proportions and surrounding 95% confidence intervals were estimated by non-parametric bootstrapping, and compared across cities using post-hoc pairwise comparison tests with Dunn-Šidák correction.

RESULTS

Current use of any modern contraception ranged from 86.2% in Tete to 98.4% in Mombasa (p = 0.001), while non-barrier contraception (hormonal, IUD or sterilisation) varied from 33.4% in Durban to 85.1% in Mysore (p < 0.001). Ever having used emergency contraception ranged from 2.4% in Mysore to 38.1% in Mombasa (p < 0.001), ever having been screened for cervical cancer from 0.0% in Tete to 29.0% in Durban (p < 0.001), and having gone to a health facility for a termination of an unwanted pregnancy from 15.0% in Durban to 93.7% in Mysore (p < 0.001). Having sought medical care after forced sex varied from 34.4% in Mombasa to 51.9% in Mysore (p = 0.860). Many of the differences between cities remained statistically significant after adjusting for variations in FSWs' sociodemographic characteristics.

CONCLUSION

The use of SRH commodities and services by FSWs is often low and is highly context-specific. Reasons for variation across cities need to be further explored. The differences are unlikely caused by differences in socio-demographic characteristics and more probably stem from differences in the availability and accessibility of SRH services. Intervention packages to improve use of contraceptives and SRH services should be tailored to the particular gaps in each city.

Barriers to HIV and sexual and reproductive health care for female sex workers in Tete, Mozambique: results from a cross-sectional survey and focus group discussions

Background

In the context of an operational research project in Tete, Mozambique, use of, and barriers to, HIV and sexual and reproductive health (HIV/SRH) commodities and services for female sex workers (FSWs) were assessed as part of a baseline situational analysis.

Methods

In a cross-sectional survey 311 FSWs were recruited using respondent driven sampling and interviewed face-to-face, and three focus group discussions were held with respectively 6 full-time Mozambican, 7 occasional Mozambican and 9 full-time Zimbabwean FSWs, to investigate use of, and barriers to, HIV/SRH care.

Results

The cross-sectional survey showed that 71 % of FSWs used non-barrier contraception, 78 % sought care for their last sexually transmitted infection episode, 51 % of HIV-negative FSWs was tested for HIV in the last 6 months, 83 % of HIV-positive FSWs were in HIV care, 55 % sought help at a health facility for their last unwanted pregnancy and 48 % after sexual assault, and none was ever screened for cervical cancer. Local public health facilities were by far the most common place where care was sought, followed by an NGO-operated clinic targeting FSWs, and places outside the Tete area. In the focus group discussions, FSWs expressed dissatisfaction with the public health services, as a result of being asked for bribes, being badly attended by some care providers, stigmatisation and breaches of confidentiality. The service most lacking was said to be termination of unwanted pregnancies.

Conclusions

The use of most HIV and SRH services is insufficient in this FSW population. The public health sector is the main provider, but access is hampered by several barriers. The reach of a FSW-specific NGO clinic is limited. Access to, and use of, HIV and SRH services should be improved by reducing barriers at public health facilities, broadening the range of services and expanding the reach of the targeted NGO clinic.

Prevalence of high-risk human papillomavirus and abnormal pap smears in female sex workers compared to the general population in Antwerp, Belgium

Background

Although female sex workers (FSWs) are a well-known high-risk group for Human Papillomavirus (HPV) infections, few tailored intervention programmes for HPV have been established worldwide. The lack of reliable data on the prevalence of HPV and related cervical lesions hampers the establishment of evidence-based intervention programmes.

The objectives of this study were to describe the prevalence of high-risk Human Papillomavirus (hrHPV) infections and abnormal pap smears in FSWs compared to a control group in Antwerp, Belgium.

Methods

HPV genotyping and cytology data were analysed from routine Pap smear tests that were collected from both FSWs and the general population (1334 samples for each group) between June 2006 and June 2010. Within the laboratory database, all FSWs were matched 1:1 for age and testing date to determine the ORs of hrHPV genotypes, DNA and cytology outcome.

Results

The prevalence of hrHPV DNA in FSWs was 41.7 % compared to 19.8 % in the age-matched controls with an overall OR of 2.8 (95 % CI: 2.3–3.4). Significant differences were observed in all age groups, and the most significant differences were observed in the cohort under 21 years of age (prevalence of 64.4 % in FSWs versus 14.8 % in controls; OR 10.3 (95 % CI: 5.0–21.2). Significantly more cervical lesions were observed in FSWs, particularly in the 17- to 21-year old age group (OR for LSIL or HSIL: 10.3 (95 % CI: 3.2–33.8). In both groups, HPV 16 was the most prevalent at 12.1 and 6.6 % in the FSW and control groups, respectively. HPV 18 was the 8^th and 7^th most frequent genotype at 5.0 and 2.5 % in the FSW and control groups, respectively.

Conclusions

FSWs have a significantly higher prevalence of hrHPV and more abnormal Pap smears than does the general population in Antwerp, Belgium. The hrHPV prevalence in FSWs is similar to that reported in the literature. The need for tailored intervention programmes should be investigated further.

Barriers to Cervical Screening Among Sex Workers in Vancouver

OBJECTIVES

We longitudinally examined the social, structural, and geographic correlates of cervical screening among sex workers in Metropolitan Vancouver, British Columbia, to determine the roles that physical and social geography play in routine reproductive health care access.

METHODS

Analysis drew on (2010-2013) data from an open prospective cohort of sex workers (An Evaluation of Sex Workers' Health Access). We used multivariable logistic regression with generalized estimating equations (GEE) to model correlates of regular cervical screening.

RESULTS

At baseline, 236 (38.6%) of 611 sex workers in our sample had received cervical screening, and 63 (10.3%) were HIV-seropositive. In multivariable GEE analysis, HIV-seropositivity (adjusted odds ratio [AOR] = 1.65; 95% confidence interval [CI] = 1.06, 2.58) and accessing outreach services (AOR = 1.35; 95% CI = 1.09, 1.66) were correlated with regular cervical screening. Experiencing barriers to health care access (e.g., poor treatment by health care staff, limited hours of operation, and language barriers) reduced odds of regular Papanicolaou testing (AOR = 0.81; 95% CI = 0.65, 1.00).

CONCLUSIONS

Sex workers in Metropolitan Vancouver had suboptimal levels of cervical screening. Innovative mobile outreach service delivery models offering cervical screening as one component of sex worker-targeted comprehensive sexual and reproductive health services may hold promise.

Human papillomavirus infection and cervical dysplasia in female sex workers in Northeast China: an observational study

Background

Women having multiple sex partners are reportedly at an increased risk of HPV infection. However, the prevalence and risk factors of HPV infection in female sex workers (FSWs) vary considerably across racial/ethnic, socioeconomic, and geographic groups. This study aimed to determine the prevalence and risk factors of HPV infection in FSWs in Northeast China.

Methods

A total of 309 FSWs identified and approached through a local police office and 1000 healthy subjects from a single factor undergoing annual gynecological examinations in Shenyang were recruited. A liquid-based ThinPrep Pap test and the Hybrid Capture II-based high-risk HPV DNA test, with or without a colposcopic examination, were performed on both FSWs and control subjects. Data on HPV infection and histological and cytological lesions of the cervix were obtained and analyzed. A questionnaire survey was administered to all 309 FSWs with their socio-demographic and behavioral information collected. The association of various socio-demographic and behavioral variables with HPV infection was assessed.

Results

HPV was significantly more prevalent in FSWs (61.90 %) than in healthy control subjects (21.00 %) (P < 0.01), so were cervical lesions (P < 0.01). HPV prevalence in our sample of FSWs fell in the upper range of reported values in FSWs across different countries, and was similar to that for FSWs in the southeast Chinese city of Huzhou but higher than that for FSWs in southwest China, Guangxi, as compared with data from other studies within China. HPV infection in FSWs was significantly associated with the age at first sexual intercourse (OR 0.699, 95 % CI 0.492–0.992) and post-menopause (OR 2.928, 95 % CI 1.099–7.800) (P < 0.05).

Conclusions

FSWs are at a substantially high risk of HPV infection and cervical dysplasia development as compared with healthy control subjects in Shenyang, China. Age of first sexual intercourse and post-menopause are two independent risk factors for HPV infection in this special group of population. Intensified and coordinated efforts from government, public health sector, communities and families are needed to reduce the risk of HPV infection in this specific group of population.

HPV Carcinomas in Immunocompromised Patients

Human papillomavirus (HPV) infection is the most common sexually transmitted disease worldwide and can result in pre-malignancies or overt malignancies of the skin and mucosal surfaces. HPV-related illnesses are an important personal and public health problem causing physical, mental, sexual and financial detriments. Moreover, this set of malignancies severely affects the immunosuppressed population, particularly HIV-positive patients and organ-transplant recipients. There is growing incidence of HPV-associated anogenital malignancies as well as a decrease in the average age of affected patients, likely related to the rising number of high-risk individuals. Squamous cell carcinoma is the most common type of HPV-related malignancy. Current treatment options for HPV infection and subsequent disease manifestations include imiquimod, retinoids, intralesional bleomycin, and cidofovir; however, primary prevention with HPV vaccination remains the most effective strategy. This review will discuss anogenital lesions in immunocompromised patients, cutaneous warts at nongenital sites, the association of HPV with skin cancer in immunocompromised patients, warts and carcinomas in organ-transplant patients, HIV-positive patients with HPV infections, and the management of cutaneous disease in the immunocompromised patient.