Preventing Cervical Cancer in the United States: Barriers and Resolutions for HPV Vaccination

HPV and HPV Vaccine Awareness Among African Americans in the Black Belt Region of Alabama

This study aims to examine the factors associated with the level of HPV infection and HPV vaccine awareness among rural African Americans living in the Black Belt region of Alabama. A cross-sectional survey on cancer screening and health behaviors was conducted in the Black Belt region of Alabama. Adults (18 years or older) recruited through convenience sampling completed the self-administered survey. Binary logistic regressions were conducted to identify factors associated with HPV infection and HPV vaccine awareness among African American participants. Slightly more than half of the participants were aware of HPV (62.5%) and HPV vaccine (62.1%). Married or partnered participants had lower awareness of HPV or HPV vaccine. Family cancer history and self-reported health status were positively associated with both HPV and HPV vaccine awareness. In addition, employment was positively associated with HPV awareness, and participation in social groups was positively associated with HPV vaccine awareness. Tailored educational interventions that consider our findings might increase HPV and HPV vaccine awareness and contribute to better vaccine uptakes.

Extended HPV typing test performed better predict value for CIN2+ among elderly women in China

Objective

The aim of this study was to examine the cervical cancer screening practices among women residing in Lingang New District of Shanghai. Moreover, the study aimed to delve into the characteristics of HPV infection and cervical lesions in older women (≥60 years old), seeking for more effective method for cervical cancer screening.

Methods

This is a cross-sectional study enrolled women who were referred to colposcopy and cervical histological examination due to abnormal cytology or HPV tests from Shanghai Sixth People's Hospital between January 2018 and December 2022.

Results

A total of 1,931 women (mean age: 41.8 ± 12.5, range: 18-88 years old) were enrolled, 119 individuals aged ≥ 60 and 1732 aged <60. The infection rates of HPV52, 33, 35, 56, 26 and 81 were significantly higher in the elderly group. Multiple HPV infection rates were also higher in this group and were associated with cervical lesions. The probability of LSIL, HSIL and Ca in women over 60 years old was significantly higher compared to women under 60. The top three HPV genotypes in elderly women with CIN2+ were HPV16, 52, and 58. The Yoden index was higher for extended typing for HPV 31/33/45/52/58(0.41) compared to cytology(0.29), high risk HPV without specific typing(0.07), cotest(cytology and high risk HPV, 0.06 or 0.30), or the current shunt strategy(0.07).

Conclusions

Elderly women still need to continue cervical cancer screening, and extended typing test for HPV16/18/31/33/45/52/58 is a more effective method for this age group.

Barriers to cervical cancer prevention in a safety net clinic: gaps in HPV vaccine provider recommendation and series completion among Ob/Gyn patients

Objective

The primary objective of this study was to evaluate patients' knowledge regarding HPV vaccination and vaccine uptake in a diverse patient population. The secondary objective was to evaluate factors influencing the decision to vaccinate, potential barriers to vaccination, and to assess whether HPV vaccines were offered to or discussed with eligible patients in a safety net Obstetrics and Gynecology (Ob/Gyn) clinic.

Methods

A 28-item survey was developed using Likert scale survey questions to assess patient agreement with statements regarding HPV and the vaccine. The surveys were administered to patients in the Ob/Gyn outpatient clinics from May 2021 through September 2022. Additionally, pharmacy data were reviewed and chart review was performed as a quality improvement initiative to assess the impact of expanded HPV vaccine eligibility to patients with private insurance on vaccine uptake. Descriptive statistics were performed.

Results

304 patients completed surveys from May 2021 through September 2022. The median age of respondents was 32 (range 18-80). 16 (5%) were Non-Hispanic White, 124 (41%) were Hispanic White, 58 (19%) were Non-Hispanic Black, 6 (2%) were Hispanic Black, 29 (9.5%) were Haitian, 44 (14%) were Hispanic Other, 7 (2%) were Non-Hispanic Other, 20 (6.6%) did not respond. 45 (14%) patients were uninsured. Many patients (62%) reported that a physician had never discussed HPV vaccination with them. Seventy nine percent of patients reported they had never received the HPV vaccine, and 69% of patients reported that lack of a medical provider recommendation was a major barrier. Among patients to whom HPV vaccination had been recommended, 57% reported that the vaccine was not available the same day in clinic.

Conclusion

Our study demonstrated that many patients never had a provider discuss HPV vaccination with them and never received the HPV vaccine. Additionally, amongst those who did initiate HPV vaccination, completion of the series remains a key barrier. Ensuring that providers discuss HPV vaccination and that patients receive HPV vaccines, along with expanding access to and convenience of HPV vaccination are critical aspects of preventing cervical cancer.

The Association of Cervical Cancer Screening With Disability Type Among U.S. Women (Aged 25-64 Years)

INTRODUCTION

Despite a gradual decline in cervical cancer mortality because of greater use of screening, including Pap and human papillomavirus (HPV) tests, disparities in screening among adult women by disability type have not been examined. This study aims to assess the odds of cervical cancer screening using HPV tests by disability type among U.S. women aged 25-64 years.

METHODS

This study was analyzed in 2022 using pooled data from 2018 and the 2020 Behavioral Risk Factor and Surveillance System. The analytic sample included 189,795 women aged 25-64 years. Disability was defined as having any sensory disability, cognitive disability, physical disability, ≥2 disabilities, or no disability adapted from a standardized questionnaire. Descriptive analyses were used to estimate the proportion of HPV tests on the basis of 2020 American Cancer Society guidelines, which recommend testing within five years for all women aged 25-65 years. Multivariable analyses were conducted to estimate AORs of cervical cancer screening by disability type.

RESULTS

Overall, 53.8% of women met recommended 2020 American Cancer Society guidelines for cervical cancer screening using HPV tests. The proportion of HPV tests was higher in women with a cognitive disability (55.9%) and lower in those with sensory (49.7%), physical (48.2%), and ≥2 disabilities (47.8%) than in those without disabilities (54.8%). In adjusted analyses, women with any disability (AOR=0.95, 95% CI=0.88, 0.97), physical disability (AOR=0.96, 95% CI=0.80, 0.98), and ≥2 disabilities (AOR=0.88, 95% CI=0.78, 0.97) had lower odds of receiving cervical cancer screening with HPV testing than women without disabilities.

CONCLUSIONS

Disparities in screening with HPV tests among women with physical and ≥2 disabilities suggest the need for a targeted approach to improve prevention screening awareness, access, and availability in this population.

Diet-Related Risk Factors for Cervical Cancer: Data from National Health and Nutrition Examination Survey 1999-2018

Diverse dietary constituents, encompassing both macro- and micronutrient intakes, have established connections with various cancers, though their specific roles in cervical cancer remain unclear. This study explores dietary intake correlations among women aged 30 yrs and above diagnosed with cervical cancer (n = 215), contrasted with women without (n = 860). These populations were selected from the 1999-2018 cycle of the National Health and Nutrition Examination Survey. The research implemented the univariate analysis and the least absolute shrinkage and selection operator (LASSO) regression to estimate the association of 29 variables with cervical cancer, subsequently identifying the most pertinent variables linked to cervical cancer. Six covariates emerged as significantly associated with cervical cancer in univariate analyses (age, race, fiber, magnesium, caffeine, vitamin C) (p < 0.05). In LASSO regression, with the escalating penalty factor (λ), it was discerned that specific covariates, including age, race, fiber, and Vitamin C, consistently remained in the model. Univariate analysis and logistic LASSO regression findings suggested that diets deficient in fiber and vitamin C were related to cervical cancer.

Does Vaccination Protect against Human Papillomavirus-Related Cancers? Preliminary Findings from the United States National Health and Nutrition Examination Survey (2011-2018)

Most oropharyngeal and anogenital cancers are caused by human papillomavirus (HPV). Although HPV vaccines showed high efficacy against oropharyngeal and anogenital HPV infections, and cancer precursors in randomized clinical trials, there are limited data on the effectiveness of HPV vaccination against HPV-related cancers. We aimed to evaluate the association of HPV vaccination with HPV-related cancers among a nationally representative sample of United States adults, aged 20-59 years. In a cross-sectional study combining four cycles from the National Health and Nutrition Examination Survey, from 2011 through 2018, we used a survey-weighted logistic regression model, propensity score matching and multiple imputations by chained equations to explore the association of HPV vaccination with HPV-related cancers. Among 9891 participants, we did not find an association of HPV vaccination with HPV-related cancers (adjusted OR = 0.58, 95% CI 0.19; 1.75). Despite no statistically significant association between HPV vaccination and HPV-related cancers, our study findings suggest that HPV-vaccinated adults might have lower odds of developing HPV-related cancers than those who were not vaccinated. Given the importance of determining the impact of vaccination on HPV-related cancers, there is a need to conduct future research by linking cancer registry data with vaccination records, to obtain more robust results.

Awareness about Human Papillomavirus Vaccine and Its Uptake among Women from North India: Evidence from a Cross-Sectional Study

OBJECTIVE

This study aims to estimate the prevalence of human papillomavirus (HPV) vaccine usage and determine the factors for awareness about HPV vaccine among women in reproductive age group.

METHODS

This is a cross-sectional survey under a cervical cancer prevention study. The sample size was 1020 women, aged 15-49 years [550 in Delhi and 470 in Rohtak]. Bivariate analysis and Fisher exact test along with binary logistic regression analysis were used to determine the factors for awareness.

RESULT

About 18.0 % [Delhi: 24.2 % and Rohtak: 10.9 %] of the respondents had heard about the vaccine against cervical cancer. The women aged more than 30 years [AOR: 1.35; CI: 0.94, 1.94] were more likely to be aware of cervical cancer vaccine as compare to women of 30 years and less. However, the women from Rohtak [AOR: 0.90; CI: 0.48, 1.66] were less likely to be aware of vaccine against cervical cancer in reference to women aged 30 years and more [AOR: 1.61; CI: 1.01, 2.56] from Delhi. About 0.6 % [Delhi: 1.1 % and Rohtak: 0.0 %] of the respondents had received HPV vaccine.

CONCLUSION

Women tend to have limited knowledge about cervical cancer vaccine and immunisation practices. The women's demographic makeup varied significantly between the two sites, i.e , Rohtak and Delhi, which had an impact on how well they understood and utilised the cervical cancer vaccination. It is worth mentioning that none of the women from Rohtak had received the immunisation. The awareness of the cervical cancer vaccine among women from the Rohtak was lower than the Delhi women.

Association of human papillomavirus vaccination with cervical cancer screening: A systematic review and meta-analysis

INTRODUCTION

Prophylactic vaccination and routine screening are effective at preventing most cases of cervical cancer. Globally, cervical cancer is the fourth most frequently diagnosed cancer among women. The aim of this study was to investigate the association between human papillomavirus virus (HPV) vaccination (1, 2, or 3 doses) and cervical cancer screening.

METHODS

PubMed (MEDLINE), Scopus, Web of Science, and Cochrane Library electronic databases were systematically searched from July 1, 2006, up to September 30, 2021. We pooled estimates using random-effects models. Heterogeneity between studies was quantified using Cochran Q test and I2 statistics. In total, 12 studies involving 2.4 million individuals were included in the meta-analysis.

RESULTS

In the adjusted estimates, uptake of HPV vaccination was associated with increased cervical cancer screening (pooled relative risk [RR]: 1.35; 95% confidence interval [CI]: 1.21, 1.50; n = 12). Between-study heterogeneity was large (I2 = 99%). Compared to unvaccinated, those who received 3 doses of HPV vaccine had the highest uptake of cervical cancer screening (RR: 1.85; 95% CI: 1.58, 2.17), followed by those who received 2 doses (RR: 1.34; 95% CI: 1.21, 1.47). No statistically significant association with screening was found for those who received a single dose of the HPV vaccine.

CONCLUSION

In this meta-analysis, uptake of HPV vaccination was associated with higher cervical cancer screening. It is plausible that vaccinated individuals are more likely to engage in preventive health behaviors. Healthcare providers should remind patients to continue with routine screening for cervical cancer regardless of their HPV vaccine status since vaccination does not protect against all HPV types.

The Role of Healthcare Providers in Promoting Human Papillomavirus Vaccines among Men Who Have Sex with Men: A Scoping Review

BACKGROUND

The uptake of human papillomavirus vaccines (HPVV) among men who have sex with men (MSM) remains unsatisfactory. Healthcare providers play a crucial role in improving HPVV acceptability and uptake among MSM. This scoping review aims to provide an overview of (1) the perceived role of healthcare providers by MSM, and (2) the knowledge, beliefs and practices of healthcare providers themselves in promoting HPVV uptake.

METHODS

A literature search was performed with PubMed and Scopus databases using a specific search string. The relevant original research articles on this topic were identified, and the major findings were charted and discussed.

RESULTS

The literature search identified 18 studies on the perceived role of healthcare providers by MSM, and 6 studies on the knowledge, beliefs and practices of healthcare providers in promoting HPVV uptake among MSM. Recommendations by healthcare providers and disclosure of sexual orientation were important positive predictors of higher HPVV acceptability and uptake. Sexual healthcare providers were more confident in delivering HPVV to MSM clients compared to primary practitioners.

CONCLUSION

Recommendation from, and disclosure of sexual orientation to healthcare providers are important in promoting HPVV uptake among MSM. The competency of healthcare providers in delivering HPVV to MSM can be improved by having clearer guidelines, education campaigns and better incentives.

Disparities in Cervical Cancer Screening with HPV Test among Females with Diabetes in the Deep South

Simple Summary

Diabetes is linked with poorer cervical cancer prognosis, and people residing in the Southern region of the U.S. are disproportionately diagnosed with diabetes and cancer. The HPV test was recently recognized as the preferred method of cervical cancer screening by the American Cancer Society. Through our observational study, we sought to investigate the HPV testing behaviors among females with and without diabetes across the U.S. Our nationally representative estimates reveal that less than half of females reported HPV testing, and females with diabetes in the Deep South have the lowest rates of HPV testing. Various risk factors were identified to significantly lower the odds of HPV testing, including a diabetes diagnosis, older age, living in the Southern region of the U.S., and absence of certain comorbidities. The lower rates of HPV testing among females with diabetes, especially those living in the Deep South, leave these populations vulnerable to cervical cancer.

Abstract

Background: Due to diabetes being linked with poorer cervical cancer prognosis, this study aimed to evaluate HPV testing behaviors among females with and without diabetes across the U.S. by geographic area in 2016, 2018, and 2020. Methods: This cross-sectional study used the Behavioral Risk Factor Surveillance System (BRFSS) from 2016, 2018, and 2020. The study population included females aged 25–69 years old, stratified by self-reported diabetes status. The primary outcome measure was cervical cancer screening behavior, which was evaluated by self-reported HPV test uptake/receipt (yes/no). Results: A total of 361,546 females from across the U.S. were sampled. Within the study population combined from all study years, the overall likelihood of receiving an HPV test was significantly lower among females with diabetes [37.95% (95% CI: 36.87–39.04)] compared to those without diabetes [46.21% (95% CI: 45.84–46.58)] (p < 0.001). Screening rates with HPV tests were lowest among females with diabetes in the South in 2016 (29.32% (95% CI: 26.82–31.83)), 2018 (39.63% (95% CI: 36.30–42.96)), and 2020 (41.02% (95% CI: 37.60–44.45)). Conclusions: Females with diabetes are screening with HPV tests less frequently than females without diabetes, and females living in the South, particularly states in the Deep South, report the lowest rates of HPV testing.

Cervical cancer screening varies by HPV vaccination status among a National Cohort of privately insured young women in the United States 2006-2016

Human papillomavirus (HPV) vaccination in young women is low. Women aged 21 to 65 years in the United States (U.S.) have not reached the Healthy People 2020 objective of 93% for cervical cancer screening. The main aim of this study was to investigate the association between HPV vaccination status and cervical cancer screening among privately insured women aged 21 to 26 years in the U.S.This was a retrospective cohort study using the IBM MarketScan database (2006-2016). The study population included 190,982 HPV-vaccinated women and 763,928 matched unvaccinated women. Adjusted incidence rate ratio (IRR) and the 95% confidence intervals (CIs) were obtained using the generalized estimating equations models with a Poisson distribution.Among a total of 954,910 women included in the analysis, age (mean [SD]) was 23.3 [1.6] years. During 967,317 person-years of follow-up, a total of 475,702 incidents of cervical cancer screening were identified. The incidence density rates of cervical cancer screening were 461 per 1000 person-years (PY) for unvaccinated women and 787 per 1000 PY for those who received 3 doses of the HPV vaccine. After adjusting for other covariates, the IRR of cervical cancer screening was 34% higher among HPV-vaccinated women with at least one vaccine dose than unvaccinated women (adjusted IRR = 1.34, 95% CI: 1.33-1.35; P < .0001). The IRR of cervical cancer screening varied by the dose of HPV vaccination. There was evidence of a linear dose-response relationship between the number of HPV vaccine doses and cervical cancer screening (P-trend < .0001). Compared with unvaccinated women, the IRR of cervical cancer screening were 14%, 39%, and 60% higher among those who received 1, 2, and 3 doses of the HPV vaccine, respectively.In this large retrospective cohort study of privately insured women, HPV-vaccinated women were more likely to be screened for cervical cancer compared with unvaccinated women.

Diverse caregivers' HPV vaccine-related awareness and knowledge

Objectives: To assess factors associated with HPV vaccine-related awareness and knowledge among caregivers of adolescents from five ethnic community groups in Utah.Design: For this community-based participatory research study, we surveyed N = 228 caregivers of teens aged 11-17 years from African American, African refugee, American Indian/Alaskan Native, Hispanic/Latino, and Native Hawaiian/Pacific Islander community groups in Utah about their HPV vaccine awareness and knowledge.Results: Participants exhibited high awareness of cervical cancer (71.05%), moderate awareness of HPV (53.95%), and low awareness of the HPV vaccine (46.49%). HPV vaccine-related knowledge was mostly worse, with fewer than half the participants reporting knowing that HPV can cause cervical cancer (46.93%), that most people are infected with HPV at some point in their lives (28.95%), that HPV is asymptomatic in females (36.40%) and males (37.28%), that the HPV vaccine is recommended for adolescent females (41.67%) and males (36.40%), and that the HPV vaccine requires more than one dose (27.19%). HPV vaccine-related awareness and knowledge were significantly associated with race/ethnicity, educational attainment, income, occupation, birthplace, parents' birthplace, English usage, health insurance coverage, type of health insurance, and child having a primary care provider (all p < 0.05). HPV vaccine-related knowledge (p < 0.05) and awareness (p < 0.05) of caregivers were associated with a child in the household receiving the HPV vaccine.Conclusion: Our findings indicate a need to develop educational interventions in collaboration with diverse communities in Utah. We underscore the importance of promoting knowledge about the existence of the HPV vaccine, as well as deeper HPV vaccine-related issues (e.g. HPV risks, treatment, and recommendations).

Linking digital health divide to HPV awareness, HPV knowledge, and cervical cancer screening among women in the United States: A trend analysis from 2008 to 2017

The author aims to explore the trend of HPV awareness, HPV knowledge, and cervical cancer screening among American female adults, and the influence of digital health divide throughout the past decade. Data from the 2008, 2013, and 2017 iterations of the nationally representative survey of Health Information National Trends Survey (HINTS) were employed for this research. The author found that cervical cancer screening continuously increased in the past decade. Women's HPV awareness and knowledge remain low. Internet access, Internet health information seeking, and eHealth activities were significant determinants of HPV awareness and knowledge over the three iterations.

HPV vaccine acceptability and willingness-related factors among Chinese adolescents: a nation-wide study

BACKGROUND

Adolescents are the primary target population for human papillomavirus (HPV) vaccination. The objective of this study is to explore the acceptability of HPV vaccines and evaluate factors related to willingness to be vaccinated among Chinese adolescents.

METHODS

A nation-wide survey was conducted across 14 schools in mainland China. The questionnaire consisted of questions relating to socio-demographic characteristics, knowledge of adolescent sexual health, cervical cancer, HPV and HPV-related disease, and students' willingness to be vaccinated. Chi-square tests and multivariable logistic regression were conducted in the data analysis.

RESULTS

A total of 4,062 students participated in this study. Among them, only 17.1% of students reported having heard of HPV vaccines; however, 67.3% were willing to receive the HPV vaccine. Multivariable regression analysis showed that students who were from rural areas, have received sexual health education, have heard of cervical cancer or HPV vaccine, have a positive attitude toward vaccination, reported they were at the risk of developing cervical cancer, and those who value their parents' and teachers' opinions were more willing to receive HPV vaccination.

CONCLUSIONS

Awareness about the HPV vaccine is low among Chinese adolescents. The factors that most related to willingness to vaccinate among Chinese adolescents were school location, education about vaccination, HPV, and HPV vaccines. Integrating health education on HPV vaccination into existing school-based sexual health curricula may be an effective way to increase HPV vaccination coverage in mainland China.

Awareness of HPV and drivers of HPV vaccine uptake among university students: A quantitative, cross-sectional study

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision-making. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty-eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4-1.9) and family members (AOR: 1.7; 95% CI: 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07-0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.

Improving HPV Vaccination Rates: A Stepped-Wedge Randomized Trial

OBJECTIVES

To evaluate the effectiveness of a stepped-wedge randomized trial of Development of Systems and Education for Human Papillomavirus Vaccination (DOSE HPV), a multilevel intervention.

METHODS

DOSE HPV is a 7-session program that includes interprofessional provider education, communication training, data feedback, and tailored systems change. Five primary care pediatric and/or family medicine practices completed interventions between 2016 and 2018; all chose to initiate vaccination at ages 9 to 10. We compared vaccination rates in the preintervention, intervention, and postintervention periods among 9- to 17-year-olds using random-effects generalized linear regression models appropriate for stepped-wedge design, accounting for calendar time and clustering of patients by providers and clinic. Outcomes included (1) the likelihood that eligible patients would receive vaccination during clinic visits; (2) the likelihood that adolescents would complete the series by age 13; and (3) the cumulative effect on population-level vaccine initiation and completion rates. Postintervention periods ranged from 6 to 18 months.

RESULTS

In the intervention and postintervention periods, the adjusted likelihood of vaccination at an eligible visit increased by >10 percentage points for ages 9 to 10 and 11 to 12, and completion of the vaccine series by age 13 increased by 4 percentage points (P < .001 for all comparisons). Population-level vaccine initiation coverage increased from 75% (preintervention) to 84% (intervention) to 90% (postintervention), and completion increased from 60% (preintervention) to 63% (intervention) to 69% (postintervention).

CONCLUSIONS

Multilevel interventions that include provider education, data feedback, tailored systems changes, and early initiation of the human papillomavirus vaccine series may improve vaccine series initiation and completion beyond the conclusion of the intervention period.

Vaccination coverage rates and predictors of HPV vaccination among eligible and non-eligible female adolescents at the Brazilian HPV vaccination public program

Background

Since March 2014, the quadrivalent HPV vaccine has been incorporated into the Brazilian Unified Health Care System and began to be offered, without direct costs, for girls from 9 to 13 years of age. Older female adolescents would have the option to be vaccinated at private health care system being responsible for the payment of HPV vaccine. The present study aimed to evaluate the coverage rates and predictors of HPV vaccination in Brazil among two groups of female adolescents: eligible and non-eligible for the HPV vaccination public program.

Methods

We used data from the 2015 Brazilian National Adolescent School-Based Health Survey, which involved a probabilistic sample of 5404 female adolescents students at public and private schools. Using a questionnaire, we gathered information on sociodemographic characteristics, sexual behavior, and respondent perception of parental supervision and have been vaccinated for HPV. Age-specific vaccination rates were analyzed in girls aged 9 to 13 at the time of public vaccination (eligible for public policy), as well among those 14 to 17 years old not eligible by the Ministry of Health for vaccination. We used Poisson regression models to investigate associated factors.

Results

HPV vaccine coverage was 83.5 and 21.8% among eligible and non-eligible populations, respectively. In both populations, the chance of being vaccinated decreased with older age. In the eligible population there is a greater chance of being vaccinated among ethnic group “pardas” but not with other indicators of socioeconomic status. In the non-eligible population, there was a clear association between higher vaccine coverage and greater maternal education and living with the mother.

Conclusion

Our findings highlight the importance of public policies to minimize inequities in access to cancer prevention measures in vulnerable adolescents. A public policy of HPV vaccination for older female adolescents would increase coverage with possible reduction of HPV-related diseases in this group of women.

Factors influencing rates of human papillomavirus vaccination

Purpose

Failure modes and effects analysis (FMEA) was used to identify ways in which community clinic practices related to suboptimal human papillomavirus (HPV) vaccination rates could be improved.

Method

FMEA is a standardized safety method that helps determine where processes fail, the impact of failures, and needed process changes. In a quality improvement initiative conducted at an academic health center–based community clinic, a multidisciplinary team used FMEA to map HPV vaccination processes and identify areas for improvement of vaccination practices. Risk priority numbers (RPNs) were assigned to identified failure modes based on likelihood of occurrence, likelihood of detection, and ability to correct locally. Failure modes with the highest RPNs were targeted for process improvements.

Results

High RPN failure modes were related to clinic processes for follow-up, immunization status checks during well-child visits, and vaccination discussions during sick-child visits. New procedures included scheduling follow-up vaccinations and reminders during the initial vaccination appointment. HPV immunization rates improved following implementation of these procedures, indicating that clinic processes focused on patient follow-up can impact vaccination series completion.

Conclusion

FMEA processes can help health systems identify workflow barriers and locally relevant opportunities for improvement. Team-based approaches to care process improvements can also benefit from standardized problem identification and solving.

Relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.

Racial Disparities in HPV-related Knowledge, Attitudes, and Beliefs Among African American and White Women in the USA

The objective of this study was to assess the differences in HPV-related knowledge, attitudes, and beliefs among African American and non-Hispanic white women and to determine their communication preferences for cancer-related information. Data was obtained from the National Cancer Institute's (NCI) 2014 Health Interview National Trends Survey (HINTS), a cross-sectional survey of US adults 18 years of age or older. Descriptive statistics, bivariate, and multivariate logistic regression were used to identify differences in awareness and knowledge. Data was collected in 2014 and analyzed in 2016. HPV awareness (71 vs. 77%) and knowledge that HPV causes cervical cancer (64 vs. 81%) were significantly lower among blacks. Additionally, there were significant disparities in awareness of the HPV vaccine (66 vs. 79%), with only 25% of Black women indicating that they or a family member was recommended the HPV vaccine by a health care professional. There were also differences in cancer communication preferences. Blacks were more likely than Whites to trust cancer information from family (OR 2.7, confidence interval [CI] 0.725-10.048), television (OR 3.0, 95% [CI] 0.733-12.296), government health agencies (OR 5.8, [CI] 0.639-52.818), and religious organizations (OR 6.4, 95% [CI] 1.718-23.932). Study results indicate that racial/ethnic differences exist in HPV knowledge/awareness and cancer communication preferences. These results highlight the need to increase HPV prevention and education efforts using methods that are tailored to Black women. To address HPV/cervical cancer disparities, future interventions should utilize preferred communication outlets to effectively increase HPV knowledge and vaccine awareness.

The moderating role of race/ethnicity on associations between insurance status and HPV vaccination among women in the USA

OBJECTIVE

To evaluate associations between insurance status and HPV vaccination.

METHODS

The present cross-sectional study analyzed data from women aged 18-26 years who participated in the National Health and Nutritional Examination Surveys 2009-2012 in the USA.

RESULTS

The study included 621 women; 424 (68.3%) had some type of insurance and 198 (30.6%) had received the HPV vaccine. In the multivariable model, we found significant interactions between race/ethnicity and insurance status on receiving HPV vaccination. Compared with individuals with no insurance, non-Hispanic black women with any type of insurance demonstrated increased likelihood of HPV vaccination (adjusted odds ratio [aOR] 3.63, 95% confidence interval [CI] 1.60-8.21; P=0.002). Among Mexican Americans, there was a negative association between having some insurance and HPV vaccination (aOR 0.35, 95% CI 0.15-0.81; P=0.007). For non-Hispanic black women, the association remained significant across all insurance types (private [aOR 4.29, 95% CI 1.67-11.00; P=0.003], Medicaid [aOR 2.86, 95% CI 1.15-7.13; P=0.025], and other [aOR 4.74, 95% CI 1.06-21.15; P=0.042]). Non-Hispanic white women with insurance other than private or Medicaid had a higher likelihood of HPV vaccination compared with uninsured individuals (aOR 8.36, 95% CI 2.79-25.05; P<0.001).

CONCLUSION

The present findings help to identify at-risk populations less likely to receive the HPV vaccine.

Variations in reason for intention not to vaccinate across time, region, and by race/ethnicity, NIS-Teen (2008-2016)

BACKGROUND

Human papillomavirus (HPV) vaccination is expected to reduce HPV-related disease and cancer in the US. However, many parents are hesitant to obtain the vaccine for their children. The purpose of this study is to examine how the reasons for refusing the HPV vaccine vary across regions of the US, across time, and by race/ethnicity.

METHODS

This study used data on 13-17 year old adolescents collected by the National Immunization Survey - Teen (NIS-Teen) annually between 2008 and 2016. We evaluated the frequencies of parents who did not intend to vaccinate their children in the next year among unvaccinated children. Among these non-intenders, we evaluated how reasons for HPV vaccine hesitancy changed across time, by region of the US, and race/ethnicity.

RESULTS

The proportion of non-intenders among unvaccinated decreased from 72% in 2010 to 58% in 2016. The most frequent reason for vaccine hesitancy was that parents felt HPV vaccination was not necessary (22.4%), followed by lack of provider recommendation (16.2%), and lack of knowledge (15.6%). Lack of provider recommendation increased in frequency as a reason for HPV vaccine hesitancy until 2012, then decreased in frequency through 2016. Cost was one reason that was elevated in all regions compared to the Northeast. Black non-intenders were less likely to report safety, costs, or their children's fear as reasons for not intending to vaccinate their children compared to white non-intenders. Hispanic non-intenders were more likely to report lack of knowledge and that the vaccine is not a school requirement as reasons not to vaccinate their children compared to white non-intenders.

CONCLUSIONS

National advocacy for improving provider recommendation for HPV vaccination likely contributed to a sharp decline in HPV vaccine hesitancy due to lack of provider recommendation. Results indicate the need for multifaceted interventions to increase HPV vaccination.

Perceived Susceptibility to Cervical Cancer among African American Women in the Mississippi Delta: Does Adherence to Screening Matter?

BACKGROUND

Although preventive measures have greatly decreased the national burden of cervical cancer, racial/ethnic and geographic disparities remain, including the disproportionate incidence and mortality among African American women in the Mississippi Delta. Along with structural barriers, health perceptions and cultural beliefs influence participation in cervical screening. This study examined perceived susceptibility to cervical cancer among African American women in the Delta across three groups: 1) women attending screening appointments (screened), 2) women attending colposcopy clinic following an abnormal Papanicolaou test (colposcopy), and 3) women with no screening in 3 years or longer (unscreened/underscreened).

METHODS

Data were collected during a study assessing the feasibility/acceptability of self-collected sampling for human papillomavirus (HPV) testing as a cervical screening modality. A questionnaire assessed demographics, health care access, and cervical cancer knowledge and beliefs (including perceived susceptibility). Participants were asked, "Do you think you are at risk for cervical cancer?", and responses included yes, no, and I don't know. Multinomial logistic regression models compared variables associated with answers among each group.

RESULTS

Of 524 participants, one-half did not know if they were at risk of cervical cancer (50%) or HPV exposure (53%). Between the unscreened/underscreened (n = 160), screened (n = 198), and colposcopy (n = 166) groups, age (p < .001), education (p = .02), and perceived risk of HPV exposure (p < .01) differed. Older age and younger age at first intercourse (unscreened/underscreened), family history and screening recommendations (screened), and family history and perceived risk of HPV exposure (colposcopy) were associated with perceived susceptibility to cervical cancer.

CONCLUSIONS

Differences in the perceived susceptibility to cervical cancer exist between African American women in the Delta. Understanding these variations can help in developing strategies to promote screening among this population with a high burden of disease.

Legislation to Increase Uptake of HPV Vaccination and Adolescent Sexual Behaviors

BACKGROUND

Despite preventive health benefits of the human papillomavirus (HPV) vaccination, uptake in the United States remains low. Twenty-four states have enacted legislation regarding HPV vaccination and education. One reason these policies have been controversial is because of concerns that they encourage risky adolescent sexual behaviors. Our aim in this study is to determine if state HPV legislation is associated with changes in adolescent sexual behaviors.

METHODS

This is a difference-in-difference study in which we use data on adolescent sexual behaviors from the school-based state Youth Risk Behavior Surveillance System from 2001 to 2015. Sexual behaviors included ever having sexual intercourse in the last 3 months and condom use during last sexual intercourse. We compared changes in sexual behaviors among high school students before and after HPV legislation to changes among high school students in states without legislation.

RESULTS

A total of 715 338 participants reported ever having sexual intercourse in the last 3 months, and 217 077 sexually active participants reported recent condom use. We found no substantive or statistically significant associations between HPV legislation and adolescent sexual behaviors. Recent sexual intercourse decreased by 0.90 percentage points (P = .21), and recent condom use increased by 0.96 percentage points (P = .32) among adolescents in states that enacted legislation compared with states that did not. Results were robust to a number of sensitivity analyses.

CONCLUSIONS

Implementation of HPV legislation was not associated with changes in adolescent sexual behaviors in the United States. Concern that legislation will increase risky adolescent sexual behaviors should not be used when deciding to pass HPV legislation.

Clinician and Parent Perspectives on Educational Needs for Increasing Adolescent HPV Vaccination

Human papillomavirus (HPV)-related morbidity and mortality remain a significant public health burden despite the availability of HPV vaccines for cancer prevention. We engaged clinicians and parents to identify barriers and opportunities related to adolescent HPV vaccination within a focused geographic region. This mixed-method study design used an interviewer-administered semi-structured interview with clinicians (n = 52) and a written self-administered survey with similar items completed by parents (n = 54). Items focused on experiences, opinions, and ideas about HPV vaccine utilization in the clinical setting, family, and patient perceptions about HPV vaccination and potential future efforts to increase vaccine utilization. Quantitative items were analyzed using descriptive statistics, while qualitative content was analyzed thematically. Suggested solutions for achieving higher rates of HPV vaccination noted by clinicians included public health education, the removal of stigma associated with vaccines, media endorsements, and targeting parents as the primary focus of educational messages. Parents expressed the need for more information about HPV-related disease, HPV vaccines, vaccine safety, sexual concerns, and countering misinformation on social media. Results from this mixed-method study affirm that educational campaigns targeting both health care professionals and parents represent a key facilitator for promoting HPV vaccination; disease burden and cancer prevention emerged as key themes for this messaging.

Increasing Parental Knowledge Related to the Human Papillomavirus (HPV) Vaccine

INTRODUCTION

The purposes of this study were to evaluate parental attitudes toward general vaccination protocols and increase parental knowledge of the human papilloma virus (HPV) vaccine.

METHODS

A nonprobability convenience sample (N = 75) using a pre-/postintervention study design was conducted in a pediatric office in southern New Jersey. The Parental Attitudes Module measured the general disposition toward having children receive any type of vaccine. The HPV Knowledge Survey was a second tool used to specifically measures knowledge of the HPV vaccine. A self-directed computer-based learning was part of the educational intervention.

RESULTS

A paired t test showed that HPV Knowledge Survey postintervention scores were significantly higher than HPV Knowledge Survey preintervention scores (t = -10.585, p < .001). The Parental Attitudes Module and the HPV Knowledge Survey pretest showed a positive moderate relationship (r_s = .552, p < .001).

DISCUSSION

In the 10 years since the HPV vaccine has been on the market, there is a continued need to increase parental knowledge about the HPV vaccine to close the gap on vaccine nonadherence. A self-directed, computer-based learning tablet appears to be an effective tool to educate parents or legal guardians about the purpose, efficacy, and safety of the HPV vaccine.

Factors Associated with Human Papillomavirus Vaccination among Women in the United States

Background

Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) in the United States (US). HPV vaccines have the ability to prevent infection with HPV. The objective of this study was to assess the factors associated with HPV vaccination among women in the US.

Methods

Data from the 2014 Behavioral Risk Factor Surveillance System were used to assess predictors of HPV vaccination. A multivariable logistic regression analysis was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs). Analyses were conducted using SAS Version 9.4.

Results

Factors that decreased the likelihood of receiving HPV vaccination included: being between the ages of 27–50 (AOR: 0.08; 95% CI: 0.06–0.11), having some college education, and residing in the South Black Belt States (AOR: 0.49; 95% CI: 0.31–0.78), Midwest (AOR: 0.63; 95% CI: 0.44–0.90), and the West (AOR: 0.37; 95% CI: 0.15–0.95). Factors that decreased the likelihood of receiving HPV vaccination to completion included: being Non-Hispanic Black (AOR: 0.26; 95% CI: 0.11–0.64), Hispanic (AOR: 0.26; 95% CI: 0.10–0.68), between the ages of 27–50 years (AOR: 0.46; 95% CI: 0.26–0.84), and residing in the Midwest (AOR: 0.36; 95% CI: 0.18–0.73) and South Remainder (non- Black Belt) states (AOR: 0.30; 95% CI: 0.09–0.93).

Conclusion

Our results suggest that sociodemographic disparities still exist in more recent data underscoring the urgent need for additional efforts to increase HPV vaccination in populations that are least likely to receive the vaccination.

Anal Cancer Risk Among People With HIV Infection in the United States

Purpose People with HIV infection have an elevated risk of anal cancer. However, recent calendar trends are incompletely described, and which population subgroups might benefit from cancer screening is unknown. Methods We used linked data from HIV and cancer registries in nine US areas (1996 to 2012). We calculated standardized incidence ratios to compare anal cancer incidence in people with HIV infection with the general population, used Poisson regression to evaluate anal cancer incidence among subgroups of people with HIV and to assess temporal trends, and estimated the cumulative incidence of anal cancer to measure absolute risk. Results Among 447,953 people with HIV infection, anal cancer incidence was much higher than in the general population (standardized incidence ratio, 19.1; 95% CI, 18.1 to 20.0). Anal cancer incidence was highest among men who have sex with men (MSM), increased with age, and was higher in people with AIDS than in those without AIDS (ie, HIV only; adjusted incidence rate ratio, 3.82; 95% CI, 3.27 to 4.46). Incidence among people with HIV increased steeply during 1996 to 2000 (annual percentage change, 32.8%; 95% CI, -1.0% to 78.2%), reached a plateau during 2001 to 2008, and declined during 2008 to 2012 (annual percentage change, -7.2%; 95% CI, -14.4% to 0.6%). Cumulative incidence after a 5-year period was high for MSM with HIV only age 45 to 59 or ≥ 60 years (0.32% to 0.33%) and MSM with AIDS age 30 to 44, 45 to 59, or ≥ 60 years (0.29% to 0.65%). Conclusion Anal cancer incidence is markedly elevated among people with HIV infection, especially in MSM, older individuals, and people with AIDS. Recent declines may reflect delayed benefits of HIV treatment. Groups with high cumulative incidence of anal cancer may benefit from screening.

The association between diabetes/hyperglycemia and the prognosis of cervical cancer patients: A systematic review and meta-analysis

BACKGROUND

The predictive roles of diabetes in the prognosis of many types of cancer have been well studied, but its role in predicting the prognosis of cervical cancer is still controversial. The aim of the study is to evaluate the association between diabetes/hyperglycemia and the prognosis of cervical cancer.

METHODS

We conducted a systematic review for peer-reviewed studies indexed in PubMed, Embase, Web of Science, and Wanfang published before December 2016. Hazard ratios (HRs) with 95% confidence intervals (95% CIs) were pooled in the meta-analysis.

RESULTS

This systematic review identified 13 studies with a total of 11,091 cervical cancer patients, of which 11 studies were included in the meta-analysis. The study indicated that diabetes was related to poorer overall survival (HR = 1.59, 95% CI: 1.35-1.87, P < .001) and poorer recurrence-free survival (HR = 1.98, 95% CI: 1.47-2.66, P < .001) in cervical cancer patients. The meta-analysis of adjusted HRs also indicated that diabetes was independently associated with poor overall survival (HR = 1.69, 95% CI: 1.38-2.05, P < .001) and poor recurrence-free survival (HR = 1.98, 95% CI: 1.47-2.66, P < .001) in cervical cancer patients. Sensitivity analysis and subgroup analyses showed similar results. No significant heterogeneity was observed for the included studies.

CONCLUSIONS

The meta-analysis suggests that diabetes is an important predictive factor for cervical cancer prognosis, and it is linked to poorer survival of cervical cancer patients. Diabetes can serve as a useful index in the prognostic evaluation for patients with cervical cancer.

Teaching About Human Papillomavirus: Lessons Learned

Occupational and environmental health nurses play a critical role in educating the public about human papillomavirus (HPV). With HPV vaccination rates remaining low, creative educational models should be explored.

Predictors of Adults' Knowledge and Awareness of HPV, HPV-Associated Cancers, and the HPV Vaccine: Implications for Health Education

High human papillomavirus (HPV) prevalence and low HPV vaccine uptake are significant public health concerns. Disparities in HPV-associated cancers and HPV vaccine uptake rates suggest the need for additional research examining factors associated with vaccine acceptance. This study assessed HPV awareness and knowledge and identified sociodemographic characteristics associated with HPV knowledge at the population level. Data from adult men ( n = 1,197) and women ( n = 1,906) who participated in the National Cancer Institute's 2014 Health Information National Trends Survey were analyzed. Multivariable regression was used to identify predictors of four HPV knowledge categories: (1) general knowledge, (2) cervical cancer knowledge, (3) "other" cancer knowledge (i.e., anal, oral, penile), and (4) vaccine knowledge. Significant gender differences in awareness and knowledge of HPV and the HPV vaccine were revealed. Most participants (>70%) knew that HPV could cause cervical cancer, but fewer (14.9% to 31.5%) knew of the association between HPV and "other" cancers. Women were more likely to report that a health care provider recommended vaccination. Significant predictors of general HPV and HPV vaccine knowledge included gender, education, income, race, and other sociodemographic characteristics. Age and income predicted cervical cancer knowledge. Knowledge of "other" HPV-associated cancers was predicted by having a child under 18 years in the household and relationship status. HPV knowledge appears to be socially patterned. Low HPV knowledge among men and some racial minorities suggests a need for further intervention. Health education should emphasize risks of noncervical HPV-associated cancers. Patient-provider communication that includes education, counseling, and clear recommendations favoring vaccination may improve uptake.

Evolving disparities in the epidemiology of oral cavity and oropharyngeal cancers

Incidence rates of head and neck cancers (HNC) associated with human papillomavirus (HPVa) infection are increasing while non-HPV-associated (non-HPVa) HNC cancer rates are decreasing. As nearly all sexually active individuals will acquire an HPV infection, it is important to understand epidemiologic trends of HNCs associated with this sexually transmitted disease. We analyzed SEER 9 (1973-2012) and 18 data (2000-2012) for HPVa HNCs (oropharynx area; OP) and non-HPVa (oral cavity area; OC). Incidence rates were examined by gender, race, rurality, geographic location, and time. Joinpoint regression analyses assessed temporal variations. From 1973 to 2012, OC incidence decreased while OP increased, with changes largely driven by males (whose OP rate increased 106.2% vs female decrease of 10.3%). Males consistently had higher rates of both cancer groups across each registry except Alaska, OP rates among blacks changed from significantly above whites to below, and trend analysis indicated significant differences in rates over time by gender, race, and geography. Analysis of SEER 18 found that rates discordantly varied by group and gender across the 18 registries, as did the male/female rate ratio with overall means of 4.7 for OP versus 1.7 for OC (only Alaska and Georgia having overlapping ranges). Our findings indicate that much of the HPVa rate increases were driven by rate increases among males and that there were changing differences in risk between genders, race, and geographic location. The epidemiology of HNCs is complex, with locally relevant factors requiring further research for elucidation of demographic disparities in incidence.

Combining metformin and nelfinavir exhibits synergistic effects against the growth of human cervical cancer cells and xenograft in nude mice

Human cervical cancer is the fourth most common carcinoma in women worldwide. However, the emergence of drug resistance calls for continuously developing new anticancer drugs and combination chemotherapy regimens. The present study aimed to investigate the anti-cervical cancer effects of metformin, a first-line therapeutic drug for type 2 diabetes mellitus, and nelfinavir, an HIV protease inhibitor, when used alone or in combination. We found that both metformin and nelfinavir, when used alone, were moderately effective in inhibiting proliferation, inducing apoptosis and suppressing migration and invasion of human cervical cell lines HeLa, SiHa and CaSki. When used in combination, these two drugs acted synergistically to inhibit the growth of human cervical cancer cells in vitro and cervical cancer cell xenograft in vivo in nude mice, and suppress cervical cancer cell migration and invasion. The protein expression of phosphoinositide 3-kinase catalytic subunit PI3K(p110α), which can promote tumor growth, was remarkably downregulated, while the tumor suppressor proteins p53 and p21 were substantially upregulated following the combinational treatment in vitro and in vivo. These results suggest that clinical use of metformin and nelfinavir in combination is expected to have synergistic antitumor efficacy and significant potential for the treatment of human cervical cancer.

Determinants of HPV vaccine awareness and healthcare providers' discussion of HPV vaccine among females

Two human papillomavirus (HPV) vaccines are available and can prevent 98% of HPV 16 and 18 infections. This study aimed to explore determinants of 1) HPV vaccine awareness among a cohort of low-income women participating in a cancer prevention program in Central Texas and compare them to United States residents; 2) determinants of healthcare providers' discussion of HPV vaccine among female residents of the United States.

Bivariate and multivariable analysis of HPV vaccine awareness using survey data (n = 359) collected between 2014 and 2016 in Central Texas, and the Health Information and Nutrition Survey (HINTS) data which is a nationally representative dataset (unweighted n = 1214) collected in 2013 were conducted. Bivariate and multivariable regression analyses of healthcare providers' discussion of the HPV vaccine using the HINTS survey data were also conducted.

Compared to non-Hispanic Whites, there was a decreased likelihood of HPV vaccine awareness among non-Hispanic Blacks (OR = 0.50; 95% CI = 0.28–0.90) and Hispanics (OR = 0.55; 95% CI = 0.30–0.99) in the grant funded program, as well as non-Hispanic Blacks (OR = 0.28; 95% CI = 0.14–0.58) and Hispanics (OR = 0.22; 95% CI = 0.12–0.41) in the HINTS data. There was also a decreased likelihood of healthcare providers discussing the HPV vaccine with respondents who were 35–49 years (OR = 0.50; 95% CI = 0.30–0.84), 50–64 years (OR = 0.26; 95% CI = 0.14–0.49) or ≥ 65 years compared to those who were 18–34 years among the HINTS data respondents.

Interventions to increase HPV awareness among non-Hispanic Blacks and Hispanics, as well as encourage healthcare providers' discussion of the HPV vaccination during patient encounters regardless of the patient's age are needed.

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African Americans and Hispanics were less likely to be aware of the HPV vaccine.

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Residence was not associated with HPV vaccine awareness.

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Age was associated with healthcare providers' discussion of HPV vaccine.

Immunotherapy against cancer-related viruses

Approximately 12% of all cancers worldwide are associated with viral infections. To date, eight viruses have been shown to contribute to the development of human cancers, including Epstein-Barr virus (EBV), Hepatitis B and C viruses, and Human papilloma virus, among others. These DNA and RNA viruses produce oncogenic effects through distinct mechanisms. First, viruses may induce sustained disorders of host cell growth and survival through the genes they express, or may induce DNA damage response in host cells, which in turn increases host genome instability. Second, they may induce chronic inflammation and secondary tissue damage favoring the development of oncogenic processes in host cells. Viruses like HIV can create a more permissive environment for cancer development through immune inhibition, but we will focus on the previous two mechanisms in this review. Unlike traditional cancer therapies that cannot distinguish infected cells from non-infected cells, immunotherapies are uniquely equipped to target virus-associated malignancies. The targeting and functioning mechanisms associated with the immune response can be exploited to prevent viral infections by vaccination, and can also be used to treat infection before cancer establishment. Successes in using the immune system to eradicate established malignancy by selective recognition of virus-associated tumor cells are currently being reported. For example, numerous clinical trials of adoptive transfer of ex vivo generated virus-specific T cells have shown benefit even for established tumors in patients with EBV-associated malignancies. Additional studies in other virus-associated tumors have also been initiated and in this review we describe the current status of immunotherapy for virus-associated malignancies and discuss future prospects.

Human papillomavirus molecular biology

Human papillomaviruses are small DNA viruses with a tropism for squamous epithelia. A unique aspect of human papillomavirus molecular biology involves dependence on the differentiation status of the host epithelial cell to complete the viral lifecycle. A small group of these viruses are the etiologic agents of several types of human cancers, including oral and anogenital tract carcinomas. This review focuses on the basic molecular biology of human papillomaviruses.