HPV in HIV-Infected Women: Implications for Primary Prevention

Cervical Cancer Screening in Immunocompromised Women

In the context of changing recommendations for cervical cancer screening, differing recommendations in each province, and a lack of guidance for cervical screening of immunocompromised women, this article provides specific recommendations for cervical cancer screening of immunocompromised women in Canada.

Performance of careHPV, hybrid capture 2 and visual inspection with acetic acid for detection of high-grade cervical lesion in Tanzania: A cross-sectional study

Objective

To examine the test performance of careHPV, Hybrid Capture2 (HC2) and visual inspection with acetic acid (VIA) for detection of cytologically diagnosed high-grade cervical lesions or cancer (HSIL+).

Design

Cross-sectional study.

Setting

Ocean Road Cancer Institute (ORCI) and Kilimanjaro Christian Medical Center (KCMC), Tanzania.

Population

Women attending routine cervical cancer screening.

Method

We enrolled 4080 women (25–60 years) in the study. The women were interviewed on lifestyle habits, and tested for HIV. A cervical specimen for careHPV testing (performed at ORCI and KCMC), and a liquid-based cytology sample for HPV DNA detection using HC2 (performed at Tuebingen University Hospital, Germany) and for cytology assessment (performed at Vejle Hospital, Denmark) were obtained at a gynecological examination. Subsequently, VIA was performed. With cytology as gold standard, the sensitivity and specificity of careHPV, HC2, and VIA for detection of HSIL+ were calculated.

Results

Altogether, 23.6% had a positive careHPV test, 19.1% had positive HC2 test, and 6.3% had a positive VIA test. The sensitivity/specificity was 88.9%/78.9% for careHPV and 91.1%/83.7%, for HC2. VIA showed a low sensitivity of 31.1% but a high specificity (94.6%) for detection of HSIL+. The sensitivity of careHPV, HC2 and VIA was higher among younger women, and among HIV positive women. VIA triage of careHPV positive women improved specificity, but sensitivity dropped to 27%.

Conclusion

Our results confirm the low sensitivity of VIA for detection of HSIL+ and further document that careHPV test is promising as a primary screening method for cervical-cancer prevention in low-resource regions. A suitable triage test has to be identified.

Cervical Human Papillomavirus genotypes in HIV-infected women: a cross-sectional analysis of the VALHIDATE study

Introduction

Primary-prevention by prophylactic vaccination against HPV-related cancers and HPV-based screening programs are based on HPV-type distribution in immunocompetent individuals. HIV-infected women are at high risk of invasive HPV-disease sustained by a broader range of HPV-types and have higher multi-type infection rates than immunocompetent hosts.

Methods

This is a cross-sectional analysis of High Risk HPV (HR HPV) type distribution in 805 HIV+ women (HIW) compared with a control group of 1402 immunocompetent HIV- women (SPW) enrolled in the VALHIDATE study in order to define HPV type-specific distribution according to cytology.

Results

HIW had a 3.8, 3.6, and 2.7 times higher risk of atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL) and high grade squamous intraepithelial lesion (HSIL) than SPW respectively. HPV-DNA prevalence was 28.4% in HIW and 11.81% in SPW (p<0.0001). The prevalence of infection increased from normal cytology to HSIL both in HIW (from 21.45% to 90.91%) and SPW (from 9.54% to 75%). The OR for women with normal cytology of having a positive HPV-DNA test result of was 2.6 times higher in HIW than in SPW. The cumulative prevalence of HPV-16/18 in HSIL is much lower in HIW (36.4±28.4) than SPW (62.5±33.5).

Conclusions

A higher prevalence of infection and broader HPV type distribution were observed in HIV+ women compared to the general population. More than 60% of HSIL lesions of HIW patients are caused by single or multi-type infections from non-HPV16/18 HPVs. The potential 9v-HPV vaccine coverage could be even higher than that expected for the general population given the wide panel of HPV-types observed in the HSIL of HIV+ women.

Prevalence of HPV infection among HIV-positive and HIV-negative women in Central/Eastern Italy: Strategies of prevention

The present cross-sectional-study aimed to determine the prevalence of human papillomavirus (HPV)-genotypes among human immunodeficiency virus (HIV)-positive and -negative women in Central/Eastern Italy, and to identify the optimal strategies for effective HPV-prevention in each group. A representative sample of HIV-negative (150/200) and -positive (50/200) women, who underwent cervico-vaginal-swabbing. Swabs were analysed for a cytological screening and for a HPV-DNA-genotyping-test. A total of 66/200 swabs resulted HPV-positive. The overall HPV-prevalence was 33% with a higher prevalence in the HIV-positive-group (48%) compared with the HIV-negative-group (28%). The most frequent genotypes were: 16, 31, 52, 58, 66, 73 and 89. Furthermore, the prevalence of specific genotypes was different in each group. The results of the present study indicate that HIV infection appears to be an independent risk factor for HPV-infection. In addition, HPV-infection is more common and more likely to persist in HIV-positive compared with in HIV-negative women. The optimal way to counteract HPV infection is through primary prevention. The stage of immunity (cluster of differentiation 4-level) at the time of the HPV-screening is one of the most important parameters for detection of susceptibility to HPV-infection and to evaluate the response to the HPV-vaccine in HIV-positive women. It may be used to determine the sub-group of HIV-positive women that are more prone to HPV-infections or that exhibit a partial response to the HPV-vaccine. At present, a novel type of vaccine with 9-genotypes is available and in the near future, it may serve an essential role in the prevention of HPV infections.

A novel candidate HPV vaccine: MS2 phage VLP displaying a tandem HPV L2 peptide offers similar protection in mice to Gardasil-9

Human papillomaviruses (HPVs) cause approximately 5% of cancer cases worldwide. Fortunately, three prophylactic vaccines have been approved to protect against HPV infections. Gardasil-9, the most recent HPV vaccine, is predicted to offer protection against the HPV types that cause ∼90% of cervical cancer, 86% of HPV-associated penile cancers, and ∼93% of HPV-associated head & neck cancers. As an alternative to Gardasil-9, we developed and tested a novel candidate vaccine targeting conserved epitopes in the HPV minor capsid protein, L2. We displayed a tandem HPV31/16L2 peptide (amino acid 17-31) or consensus peptides from HPV L2 (amino acid 69-86 or 108-122) on the surface of bacteriophage MS2 virus-like particles (VLPs). Mice immunized with the MS2 VLPs displaying the tandem peptide or immunized with a mixture of VLPs (displaying the tandem peptide and consensus peptide 69-86) elicited high titer antibodies against individual L2 epitopes. Moreover, vaccinated mice were protected from cervicovaginal infection with HPV pseudoviruses 16, 31, 45, 58 and sera from immunized mice neutralized HPV pseudoviruses 18 and 33 at levels similar to mice immunized with Gardasil-9. These results suggest that immunization with a tandem, L2 peptide or a low valency mixture of L2 peptide-displaying VLPs can provide broad protection against multiple HPV types.

Diversity of high risk human papilloma viruses in women treated with antiretroviral and in healthy controls and discordance with cervical dysplasia in the South of Benin

Background

High risk oncologic Human Papilloma Virus (HPV) is one of the leading causes of cervical cancer worldwide. We investigated HPV genotypes among women living or not with Human Immuno-deficiency Virus (HIV) in two major hospitals in the south of the republic of BENIN in the city of Cotonou. Our objective is to investigate the association of high risk-HPV to cervical dysplasia among women under stringent anti-retroviral (ARV) treatment and in controls without HIV.

Methods

The investigation was carried out within 1 year period in two groups of adult women: one group with HIV1 infection and under ARV therapy in the National University Hospital (CNHU-HKM) designated as CH group (n = 86); and one control group without HIV infection and attending the hospital Mènontin for routine gynecologic checkup and designated as ME group (n = 86). Cells derived from cervical uterine smears (CUS) were used for this investigation. The samples in ME group were selected to have similar lamin A/C profile with CH group. HPV genotypes were assessed by polymerase chain reaction (PCR) while lamin A/C expression profile was assessed by western blotting to corroborate the risk of cervical dysplasia.

Results

HPV56 is dominant in CH group while HPV66 is dominant in ME group. 31 % of women in CH group are infected with HPV compared to 23 % in ME group. Quadruple and quintuple HPV infections are more observed among CH group but not in ME group making HPV counts of 43 in CH group and 27 in ME group. Cervical dysplasia are present in 5 % (4/86) of women in CH group and in 1 % (1/86) of women in ME group at the time of CUS collection. The adjustment of the risk to develop cervical cancer in the future related to HPV infection and the total loss of lamin A/C is not significantly different in both groups.

Conclusion

Women living with HIV are more sensitive to multiple HPV infection but not all HPV infections generated cervical dysplasia. The effectiveness of antiretroviral therapy in CH group may reduce significantly the frequency of cervical dysplasia.

Identification of novel human papillomavirus lineages and sublineages in HIV/HPV-coinfected pregnant women by next-generation sequencing

Infection by human papillomavirus (HPV) is a necessary condition for development of cervical cancer, and has also been associated with malignancies of other body anatomical sites. Specific HPV types have been associated with premalignant lesions and invasive carcinoma, but mounting evidence suggests that within-type lineages and sublineages also display distinct biological characteristics associated with persistent infections and evolution to cervical cancer. In the present study, we have assessed HPV multiple infection and variation from a cohort of highly susceptible, HIV(+) pregnant women using next-generation sequencing and an in-house pipeline for HPV full-length genome assembly. Seventy-two consensus sequences representing complete or near-complete (>97%) HPV genomes were assembled, spanning 28 different types. Genetic distance and phylogenetic analyses allowed us to propose the classification of novel HPV lineages and sublineages across nine HPV types, including two high-risk types. HPV diversity may be a hallmark of immunosuppressed patients upon HIV infection and AIDS progression.

Gardasil-9: A global survey of projected efficacy

Human papillomaviruses (HPVs) are the causative agents of human neoplasias such as warts and cancers. There are ∼19 HPV types associated with cancers, which has made it very challenging for first generation HPV vaccines to offer complete protection against all cancer-causing HPV types. Recently, a second generation HPV vaccine, Gardasil-9, has been approved to protect against more HPV types. Worldwide, Gardasil-9 will protect against HPV types associated with ∼90% of cervical cancer case in women and 80-95% of other HPV-associated anogenital cancers in both men and women. However, due to variation in HPV-type specific prevalence and distribution, the vaccine will offer different percentages of protection in different geographical regions; Gardasil-9 will offer protection against HPV types associated with ∼87.7% of cervical cancers in Asia, 91.7% in Africa, 92% in North America, 90.9% in Europe, 89.5% in Latin America & the Caribbean, and 86.5% in Australia. Because of this, Pap smear screening and testing for HPV types not included in Gardasil-9 will need to continue, especially in HIV/AIDS patients. In order to achieve complete protection against all HPV types that cause cervical cancer, a third-generation HPV vaccine is needed.

High-risk human papillomavirus and cervical lesions among women living with HIV/AIDS in Brazilian Amazon, Brazil

Objective

The goal of this study was to determine the prevalence of human papillomavirus infection infection and cervical lesions and its associated factors among HIV infected women attending an AIDS clinic in Amazonas state, Brazil.

Methods

Cross-sectional study. Women attending an AIDS clinic in the city of Manaus between March and December 2011 for gynecological examination were invited to participate. Enrolled patients answered a standardized interview including demographical, behavioral, and clinical data. Additionally, patients underwent a gynecological evaluation with collection of cervical samples for cytological analysis and high-risk human papillomavirus infection hybrid capture. A blood sample was also obtained to determine CD4 and viral load levels.

Results

A total of 310 (82.9%) women participated in the study. High-risk human papillomavirus infection was detected in 191 (61.6%) cases; 24 (13.5%) had low-grade squamous intraepithelial lesion (SIL) and 4 (2.2%) high-grade SIL. No invasive cervical cancer was diagnosed. Median age was 32 (interquartile range (IQR): 27–38) years and median of education was 8.5 (IQR 4–11) years of schooling and 56.1% had a monthly income up to US$180. In multivariate analysis, being less than 30 years old [OR = 1.7 (95% CI: 1.2–2.4, p = 0.005)], high-grade SIL [OR = 6.5 (95% CI: 1.6–23.0, p = 0.009)], and CD4 counts <200 cells/mm³ [OR = 1.6 (95% CI: 1.2–2.0, p < 0.001)] were associated with high risk human papillomavirus infection infection.

Conclusions

In the present study high-risk human papillomavirus infection was frequent and it was associated to high-SIL. These results show the importance of gynecologic examinations in routine care and follow-up required by those who present with cervical lesions.