After adjusting for other risk factors, HPV-positive subjects had 24.9  folds of risk of developing HSIL or above cervical neoplasia as compared to HPV-negative subjects, whereas risk for low-grade intraepithelial lesion and atypical squamous cytology was not increased. The study showed that women with a prevalent infection of high-risk HPV had a 4% cumulative risk for CC in 6 years, whereas those tested negative had little risk. The result supports an HPV test-orientated CC screening programme with intervals of at least 5 years.Knowing that infection of high-risk human papillomavirus (HPV) causes virtually all cervical cancer (CC), the long-term outcomes of HPV infection, especially the absolute risk and time lapse of developing CC, are beyond the scope of ordinary follow-up study owing to ethical concerns. The present study followed the natural history and long-term outcomes of HPV infection in a cohort of women by national health insurance care and data linkage without additional disturbance. The status of cervical HPV infection was determined in 1708 healthy women, aged 20–90 (median 43), enrolled from 10 hospitals in seven cities around the island country of Taiwan. Records of consecutive Pap smear results and cancer reports of 108 cytology-negative, HPV-positive and 1202 cytology- and HPV-negative women with no prior record of CC or abnormal cervical cytology were retrospectively analysed for a duration of up to 75 months (median 61 months). The cumulative incidences of high-grade squamous intraepithelial lesion (HSIL) and  The aetiological and universal roles of high-risk human papillomavirus (HPV) infection in cervical carcinogenesis have been well established. Primary and secondary preventive measures targeting on the vaccination and detection of HPV have emerged as effective public health strategies . Before Given the long and heterogeneous natural history of HPV infection and the lack of a robust animal model or culture system, studying the natural history of HPV infection typically requires a cohort of long-term follow-up that is both labour intensive and expensive. Following subjects beyond the precancer stage is ethically not allowed. An alternative way is to utilize the registry of medical records to follow subjects passively. Previous studies of passive follow-up tested HPV infection serologically and retrospectively (On Mother's Day (May 13) in 2000, a campaign of CC screening including a single-visit Pap test and Hybrid Capture 2  HPV DNA testing was implemented for mothers who had not been screened for at least 1 year at 10 general hospitals from seven major cities around Taiwan: two in Taipei metropolitan area, three in the north, one in the central west, three in the southern west and one in the east of the island . At the A schematic overview of the study design and case outcomes was shown in in situ (CIS)) and CIS/adenocarcinoma in situ (AIS)/CC. The most severe cytology results occurring during the follow-up period were counted, and the lag time was counted between the date of enrolment and the date of occurrence of the most severe abnormal cytology.The National Health Insurance of Taiwan provides annual Pap smear screening for women aged 30 or above since 1995 . The cytThe Taiwan Cancer Registry was established in 1970. The data were input from the medical delivery system consisting of one cancer hospital, 18 medical centres and hundreds of regional and district general hospitals. In 1995, 81% of the reported cancers were confirmed by pathological examinations, 13% by imaging diagnosis and 6% by other methods  and 2007n=3) were less than 5%, respectively, and the ratio of positive mean to negative mean was more than 3.0.Hybrid Capture 2 high-risk HPV DNA test was conducted. Cervical scrapings were collected by using the cytobrush and transfer medium provided by the manufacturer. The same cytobrush was used for Pap smear before dipping into the transfer medium for HPV test. Hybrid Capture 2 used RNA probes specific for 13 cancer-associated HPV types. The DNA–RNA hybrids were captured and detected by reporter molecule-labelled antibodies as described before  Atypia, (2) LSIL and (3) HSIL or above neoplasia. For all statistical tests, the level of significance was set at 0.05.STATA version 8 was used for data analysis. vs 59.52±1.21 months) (mean±s.e.m.). As expected, HPV-positive subjects had a slightly shorter follow-up interval (24.47±1.45 months) than the HPV-negative (27.38±0.43 months) subjects (P=0.06). The average number of follow-up was slightly higher in HPV-positive groups than in HPV-negative groups (3.15±0.23 vs 2.79±0.04). When stratified by follow-up outcomes, the follow-up intervals did not differ between the two groups , the prevalence of HPV infection was 8.24% (108/1310). The rate tended to increase with age, from 8.08% in age 30–40 years to 10.0% in age over 60 years, but without statistical significance. Among different geographic regions, participants living in Taoyan and Hsinchu had a slightly but insignificantly higher HPV prevalence (9.64%) as compared to other regions (6.37–8.66%) .n=108), 12% developed cervical neoplasia, whereas only 3.8% of HPV-negative subjects (n=1202) did so. The major difference was the occurrence rate of HSIL or above neoplasia, which was 9.25% in the HPV-positive group and 0.14% in the HPV-negative group. All the four subjects with follow-up outcomes of CIS (n=2), AIS or CC were HPV-positive on enrolment . vs 0.0007), but this was not true in the Atypia and LSIL groups.The records of consecutive Pap smear results and cancer reports of 108 cytology-negative, HPV-positive and 1202 cytology- and HPV-negative women were followed for a median duration of 61 months. In the meanwhile, there were five prevalent cases of CC, who were all HPV-positive, being excluded from the follow-up. The status of HPV infection on enrolment mattered greatly to the outcomes of follow-up. In HPV-positive subjects (nrolment . When covs HPV-negative subjects was 24.9 (7.01–108.27) (P<0.0001). The cumulative risk for HSIL or above cervical neoplasia in HPV-positive subjects was 3.88% in 4 years, 4.88% in 5 years and 10.0% in 6 years. For HPV-negative subjects, the cumulative risks were 0.086, 0.26 and 0.34% in 4, 5 and 6 years, respectively.A nonintervention, passive follow-up of HPV-infected subjects was conducted in this study as a way to explore the natural history of the infection in the real world of a universal health insurance care system. The absolute risks of the occurrence of cervical neoplasia were obtained in infected and noninfected subjects. The prevalence of high-risk HPV infection determined by HC2 (8.2%) was similar to that in other reports from the same population , indicatvs 27.4 months, P=0.06). However, after exclusion of subjects with neoplastic outcomes, those with Normal outcome had similar follow-up intervals in the HPV-positive and HPV-negative groups .Passive follow-up of cervical neoplasia requires a well-established public or private health-care system with long-term and consistent coverage of the target population (vs 5%) was noted in the Brazil cohort (vs Chinese) to cervical carcinogenesis can be different among cohorts, the accessibility and extent of medical interventions, such as Pap smear, cervical biopsy and local treatments, may be the key differences among the settings. The subjects in this cohort were completely undisturbed after a single visit for Pap smear and HPV testing. The results thus figure the real natural history of HPV infection in the population in Taiwan.Previous long-term follow-up studies of the outcomes of HPV infection were limited (In contrast to the occurrence of HSIL and cancer, which was highly associated with HPV infection at enrolment, in this study and that of the Manchester cohort (


SIRT1 deacetylates several downstream effector                        proteins including KU70, NBS1, the FOXO transcription factor family, and p53,                        several of which are in response to DNA damage events occurring within the cell                        [The                        sirtuin protein SIRT1 is a well studied and highly complex NADAging,                        Allison et al. show that HPV E7 upregulates cellular SIRT1 and induces global                        histone modifications within the cell as an additional mechanism for promoting                        cell survival and inhibiting apoptosis.                                The transformative properties of the                        Human Papilloma Virus (HPV) were originally exploited well over 40 years ago as                        tools for elicudating mechanisms of cell growth control and cancerous                        transformation . Indeed,bona fide tumor suppressor as                        it does not induce cell growth arrest when overexpressed in cell culture and                        has no documented cases of deleterious point mutations in any type of human                        tumor [in vivo, therefore, could                        be attributed to the genetic context of p53 [ Significant                        research intensity has been placed on understanding the role SIRT1 has in                        cellular transformation and cancer with studies showing both growth-promoting                        and grow-inhibiting effects of the protein. It has been suggested that SIRT1                        does not fit the classical definition of a    tumor . The grot of p53 . In cellt of p53 ,8. The nAging, Allison, Jiang, and Milner have shown for                        the first time that a DNA tumor virus targets the anti-aging protein SIRT1 and                        exploits protein function as a mechanism for promoting uncontrolled cell                        growth. It is well known that specific genotypes of HPV (HPV 16 and HPV 18) are                        causative agents of cervical cancer with nearly 500,000 new diagnoses each year                        [                         In this issue of          . Previou         . AllisonHPV E6 and E7 proteins are coded for by a                        bicistronic mRNA, which makes it difficult to assess the individual                        contributions of HPV E6 and E7 on cellular transformation. In this study, it                        was found that HPV E6 and E7 could be selectively silenced by siRNA in HPV                        16-positive SiHa cells allowing for functional assessment of each protein                        separately. Interestingly, selective silencing of HPV E6 was not sufficient for                        apoptosis induction, whereas silencing of HPV E7 induced apoptosis despite HPV                        E6-mediated p53 suppression. These data suggest that selective targeting of                        both p53 and SIRT1 by HPV is required to block apoptosis and cell growth arrest                        as part of the transformation process. HPV E7 was also shown to upregulate                        global histone H3 S10 phosphorylation, presumably through upregulation or                        stabilization of survivin. Global chromatin modifications during transformation                        are thought to lead to chromatin instability         The                        malignant transformation of cervical cells by HPV from a latent state is not                        well understood. The virus exists as an episomal chromosome for an                        indeterminate amount of time within a cell until cellular transformation occurs                        and the virus integrates into the host genome . Stable HPV                        E6 has received intense focus in small molecule drug discovery for disrupting                        E6-mediated E6-AP protein induction and subsequent p53 degradation. However,                        these data would suggest that focus on HPV E7 is warranted as a more suitable                        target since siRNA-mediated reduction of HPV E7 in SiHa cells induces                        apoptosis. Conversely, reduction of HPV E6 leads to p53-mediated cell growth                        arrest, but a full apoptotic response requires inhibition of both viral                        proteins. These data could have profound implications on the focus of drug                        discovery for HPV therapeutics and suggests a re-analysis of current target                        strategies. Though p53 is a major factor for controlling cell growth and is                        targeted by HPV E6, the current study has shown that HPV E7 and the                        upregulation of cellular SIRT1 has significant effects on the tumorigenic                        growth of HPV infected cervical cancer cells. Importantly, downregulation of                        HPV E7 is sufficient for inducing apoptosis in these cells, indicating that                        selective targeting of this protein may be an effective strategy for reversing                        cervical cancer tumor growth.                                The                        current study also provides insight into general regulation of SIRT1 and                        specific roles it may have in tumorigenesis and cancer. The downstream effect                        of SIRT1 overexpression and p53 degradation mediated by HPV E6 and E7 is                        reminiscent of other tumor types that lack functional p53 and overexpress                        SIRT1, a condition seen in several non-cervical cancer cell lines . Under Identification                        of SIRT1 as a downstream target of HPV E7 has broad implications in understanding                        HPV and cellular transformation. HPV E6 has long been known for targeting p53,                        but HPV E7 has now been shown to be involved with p53 regulation as well                        through targeting SIRT1. As small DNA viruses were originally used as tools to                        understand and elucidate cancerous growth, they have once again provided                        invaluable insight into cellular factors involved in cellular transformation.                        This is not only important for developing novel therapeutics for treating HPV                        infection, but is crucial for understanding the physiologic function of SIRT1                        in cancer and aging. Is SIRT1 a critical component in the viral latency to                        malignancy transition? Is SIRT1 an important anti-apoptotic factor in                        transformed cells that have lost functional p53? Is overexpression of SIRT1 a                        general mechanism for maintaining global de-acetylation in tumor cells?                        Answering these questions will undoubtedly provide new insight into the                        molecular mechanisms of cellular transformation and tumorigenesis for both                        cervical cancer and other tumor cell types overexpressing SIRT1.


Despite intensive study of high-risk mucosal human papillomaviruses (HPV), little is known of the epidemiology of cutaneous HPV. As part of a study of cutaneous squamous cell carcinoma and HPV among organ transplant recipients (OTR) from London and Oxford, we investigated the seroprevalence and risk factors for 34 HPV types (detected using Luminex technology) among 425 Caucasian OTR without skin cancer.Overall, 86% of participants were seropositive to at least one HPV: 41% to mucosal alpha types, 33% to cutaneous alpha types, 57% to alpha types, 56% to beta, 47% to gamma types and 45% to other types . In both centres, the most common types were HPV6 (33% and 26% for London and Oxford respectively), HPV8 (24% and 18%), HPV15 (26% and 29%), HPV17 (25% and 21%), HPV38 (23% and 21%), HPV49 (19% and 21%), HPV4 (27% and 23%), HPV65 (30% and 25%), HPV95 (22% and 20%), HPV1 (33% and 24%) and HPV63 (28% and 17%). The seroprevalence of 8 HPV types differed significantly (P < 0.05) between London and Oxford. Those individuals seropositive to multiple types of one genus were more likely to be seroreactive to multiple types of another genus. As expected, antibodies against mucosal alphaHPV types were more frequent in younger patients and among women. Sunbed use and sunbathing was associated with seropositivity to multiple gammaHPV (P-trend = 0.007) and self-history of abnormal smear was related to seroactivity to multiple betaHPV (P = 0.01). Skin type and other self reported markers of exposure to ultraviolet radiation were not consistently associated with any HPV types. No other distinguishing epidemiological features of transplant recipients with antibodies against single or multiple HPV types were identified.Findings for mucosal HPV types were in line with results from previous studies. We observed differences in HPV seroprevalence between organ transplant recipients from two geographically close centres but no clear risk factor was found associated with cutaneous HPV seropositivity among organ transplant recipients. These findings have implications for interpretation of future seroepidemiology studies addressing the association between HPV and cutaneous SCC in OTR populations. Papillomaviruses are small circular double-stranded DNA viruses of around 8 kb. To date, at least one hundred and eighteen papillomaviruses have been completely described of which approximately 100 are human and the remainder are animal types. Based on DNA analysis, the HPV phylogenetic tree is composed of 5 genera  which, in turn, are grouped into species and subdivided into types  from London with a solid organ graft other than kidney) with a blood sample and a completed questionnaire, but without skin cancer were available for analyses. Table Table Additional file Regarding the other risk factors, patients who were seropositive to HPV6 were more likely to be ex- or current smokers, to have had more children (P-trend < 0.001) and to have had a history of genital warts and/or abnormal cervical smear. A self-reported history of psoriasis (n = 23 patients) was not associated with any of the 34 HPV types examined. Among women, an association was found between history of abnormal cervical smear and presence of antibodies against many betaHPV types . However, across the 2 centres, only 28 women had such histories and results could not be examined by individual centre (data not shown). No other distinguishing epidemiological features of transplant recipients with antibodies against any of the 34 HPV types examined were identified (data not shown).Figure Little is known of the seroepidemiology of HPV, with the exception of those mucosal types associated with cancer of the uterine cervix . Organ tet al., this issue) suggesting that the association was not due to higher susceptibility to multiple HPV seropositivity of OTR patients following immunosuppressive treatments. Multiple HPV seropositivity could reflect infections with more types due to higher environmental exposure to these viruses, similar modes of transmission or cross-reactivity of the antibodies. Alternatively, it could reflect higher viral load that induced stronger and more frequent antibody responses. Viral load for beta HPV types could be regulated by genetic or other host factors. EV patients, who cannot appropriately control beta HPV replication have high viral loads and strong antibody responses to a broad variety of beta HPV types [Eighty six percent of transplant recipients without skin cancers in this study were seroreactive to at least one HPV type, identical to previous results from a UK study among immunocompetent people , illustrPV types . MutatioPV types ,20. In tPV types . If betaFindings for mucosal HPV types were in line with results from previous studies  and provet al (2004) reported no association in 313 controls patients between seropositivity to any of 6 beta HPV types  and age, sex, skin type, lifetime sun exposure and painful sunburns at different age periods [The largest previous study of HPV seroprevalence in the immunocompetent population reported on age and sex distributions of alpha, beta, gamma, nu and mu HPV types among 1797 German adults and children . Overall periods . Karagas periods . AnderssIn summary, findings on the association between various risk factors and mucosal HPV types were an internal validation of the methodological approach used in this study. Significant differences in HPV seroprevalence were identified between study centres. Sunbed use and sunbathing was associated with seropositivity to multiple gammaHPV and, among women, self-history of abnormal smear was related to seroactivity to multiple betaHPV. No other distinguishing epidemiological feature of transplant patients with antibodies against any of the 34 individuals or multiple HPV types examined were identified. Interpretation of future HPV and cancer association studies will require a better understanding of HPV seroepidemiology and further research is now needed to clarify the risk factors and the natural history of these viruses.HPV: human papilloma virus; OTR: organ transplant recipients; OR: odds ratio; CR: count ratio; CI: confidence interval.The authors declare that they have no competing interests.RN, CP, CH and FW conceived the study. LM, AL, BIW and DC participated in acquisition of all the biological material and data. MP, TW and KM developed the HPV assays and KM analysed the samples. DC analysed the data and drafted the manuscript. All authors read, contributed to and approved the manuscript.Human papillomavirus seroprevalence by centre, sex, age at recruitment, time since transplantation and skin type by each HPV type, among Caucasian transplant patients without skin cancer from London and Oxford (N = 425). This file shows seroprevalence of the 34 HPV types by centre, sex, age at recruitment, time since transplantation and skin type.Click here for file


Our case illustrates the first report of an HIV-infected patient with a nasopharyngeal squamous cell carcinoma with viremia by one Epstein-Barr virus (EBV) and seropositivity by two high risk oncogenic human papilloma viruses (HPV)-types (HPV-16 and HPV-33), previous to his death. This patient presented a fatal fast-evolution. He reported having an oppressive headache in the last week. The exploration only showed hypoesthesia in the right side of the face. A small ulcer in the cavum and an exophytic polypoid lesion in the back and upper area of the right nostril were observed by nasopharyngoscopy. Computed tomography visualized a mass in the cavum. A biopsy diagnosed a moderately differentiated squamous cell cancer. P.E.T. showed a hypermetabolic mass from the skull base to the right jawbone . In addition, P.E.T. also showed infiltration in the latero-cervical, supra clavicular and para-oesophagus nodes, in C3 and C6 , and in the liver (not shown). The patient restarted HAART on May 9th and was discharged. The patient was readmitted to the hospital on June 6th and he died one week later because of liver failure. The patient signed the informed consent to study HPV (June 6th) and his family authorized to publish this event.A 38 year-old man diagnosed with HIV in 1987 (disseminated tuberculosis) and HCV, who was an ex-IDU, smoker (30 cigarettes per day), and alcohol consumer (30 g/day), with poor HAART adherence, and a CD4 nadir of 6 cells/mmth) by PCR real time and multiplex PCR kit, respectively. Furthermore, HPV was analyzed in samples from the oral cavity, anus, and penis. EBV was positive in the biopsy and in serum (63000 copies/mL) and HPV was positive in serum for two high risk oncogenic types: HPV-16 and HPV-33. HPV was also detected in the anus (HPV-16 and HPV-51) and in the penis (HPV-51).Epstein-Barr Virus (EBV) and Human Papilloma Virus (HPV) were studied in biopsy and in blood serum sample  can be detected in blood which could be associated with a worse and rapid outcome.S.V. has received honoraria for collaborating with Laboratorios Dr Esteve. B. Clotet has received honoraria for speaking and participating in advisory boards from Abbott, Bristol-Myers Squibb, Boehringer-Ingelheim, Gilead Sciences, GlaxoSmithKline, Pfizer.


Introducing human papillomavirus (HPV) testing into cervical cancer screening has the potential to change the way that women understand cervical cancer, the psychological impact of abnormal screening results and the likelihood of future participation in screening. The study used in-depth interviews to examine how women make sense of information about HPV in the context of cervical cancer screening. A total of 74 women were recruited following participation in HPV testing. Women varied widely in their beliefs about the aetiology of cervical cancer and its relationship with sexual activity, as well as in their understanding of the sexually transmitted nature of HPV. While some women who understood that HPV is sexually transmitted were able to integrate this into their existing model of cervical cancer, others were shocked by the link between cervical cancer and sex, of which they had been previously unaware. Women were generally reassured to know that HPV is common, has no symptoms, can lie dormant for many years, can clear up on its own and need not raise concerns about transmission to sexual partners. Women's understanding of HPV varied considerably, even after participation in testing. The way in which information is presented to women will be crucial in minimising the negative psychological impact of testing positive and ensuring that participation in screening remains high. With the establishment of the role of high-risk types of human papillomavirus (HPV) in the aetiology of the majority of cervical cancers . In addiSuch major changes to the way that cervical cancer is prevented will inevitably be accompanied by a shift in public understanding of the disease. Linking cervical cancer to a potentially stigmatising sexually transmitted infection (STI) could affect uptake of cervical screening, the impact of abnormal results  and publAligning public understanding of cervical cancer with the medical model of a viral aetiology raises questions about how people will make sense of information about the virus. In this paper, we examine the responses of women participating in HPV testing to information about the virus, to assess their understanding of HPV and the impact on beliefs about cervical cancer.A total of 74 women were recruited in two UK cities, from clinical trials of HPV testing and a colposcopy clinic where HPV testing is carried out as part of routine care. Most participants had an HPV test at the same time as their routine smear, but for some, testing was offered alongside colposcopy following abnormal cytology results.We used nonrandom, purposive sampling  to ensurWithin each centre, all women had been given standardised information about HPV, although there was some variation in the detail between centres. They were all given a leaflet informing them about the sexually transmitted nature of the virus, its high prevalence, its tendency to lie dormant and its link with cervical abnormalities as well as warts. The wording describing sexual transmission was often open to a degree of interpretation; for example one leaflet said ‘Although there may be occasional exceptions, it is thought that Human Papillomavirus is sexually transmitted’. Some women also called help-lines or consulted health professionals for additional information.In-depth interviews were carried out with women, usually in their own homes. These were structured around a topic guide covering general background, screening history, beliefs about cervical cancer, understanding of HPV, experience of participation in HPV testing, and understanding and impact of results. Interviews were carried out by the first and second authors and by trained, freelance interviewers, using a mixture of ethnic matching and mismatching, and were translated where necessary. They were transcribed verbatim.Analysis used the Framework method to identify emerging themes and organise the data . I don't think I've ever thought of it in that sense. SA/N1When asked why she thought some people might get HPV, she said ‘I don't know’. Having always had clear smear results in the past, she seemed never to have thought about what might cause an abnormality, and had not read about HPV as her result was negative.Women in this group had some awareness that HPV is linked to sexual activity. Although most knew that it could be an STI, other causal explanations were given, and there was widespread belief that HPV was somehow different from other STIs. This group was also characterised by a lack of awareness of the link between cervical cancer and sexual activity. Other models of cancer were put forward, with causes including bad luck, chance, family history and smoking. The link between HPV and cervical abnormalities or cancer was generally poorly understood, so women in this group were able to retain their model of cancer as something that could not be linked to sex.A clear example is a white woman who did not link attendance at cervical screening with being sexually active, and when asked directly whether she believed that sex could affect cervical cancer risk, she said no; she thought it ‘just appeared’. She was uncertain about the sexually transmitted nature of HPV, and did not think that the link between HPV and cervical cancer had been established. This quote illustrates the contrast between the information about HPV and her existing model of cervical cancer:I have never thought that you catch cervical cancer through having too much sex. I don't know, that seems laughable because cancer is such a big word and sex is quite pleasurable so you wouldn't expect to get something like that from it. W/P13 HPV+ smear normalAlthough she was aware of the idea that HPV might be sexually transmitted, by doubting the connection she was able not only to manage her own response to her positive result , but also to maintain her current model of cancer as something that does not have easily identifiable causes.Beliefs in this group were sometimes very complex. Another woman  knew that attending for cervical screening was associated with the onset of sexual activity, but had a very clear model of cancer: ‘I think everyone's got cancer in them and it takes … something to set it off, to wake it up’. Although she had been told that HPV is sexually transmitted, she did not conceptualise it as being similar to other STIs. She understood that HPV was linked to cancer, which she did not see as being something you catch and this led her to believe that you could get HPV in other ways: ‘I think it wasn't like a specific thing to, to sex. … I don’t know, I suppose, with it being cancer … I wouldn't … associate it with [being caught from] anyone else’.In some cases, women were clearly aware that HPV is an STI, but they did not conceptualise it as causally related to cervical cancer, so, again, were able to maintain their model of cervical cancer separate from sexual transmission.All the women in this group mentioned the link between cervical cancer and some aspect of sexual activity, be it having many partners, having sex when young or nuns having low rates of the disease. However, they did not see it as inevitably linked to sex, and held other concurrent causal beliefs. Human papillomavirus was also linked with sex to some extent, but the causal relationship between HPV and cervical cancer was not recognised, or had not been thought through sufficiently to lead the women to reassess their beliefs about cervical cancer. Many of the women in this group, and in the group below, believed that the research in which they were taking part was designed to investigate a possible link between cervical cancer and HPV.A nurse in this group cited having many sexual partners as an established risk factor for cervical cancer, but seemed unable to reconcile her model of cancer with her beliefs about sexually transmitted diseases. She knew that HPV is an STI, but regarded HPV as very different from cervical cancer:Well, cervical cancer … that's not just caused by a sexually transmitted disease. Anyone can, except that, well, no, you're not going to, you're not likely to get cervical cancer if you've never been sexually active, so it is, it is only in, in sexually active people but [Sighs] Well, I don't know, it is, it's just different. Because that's, I mean cervical cancer … is a killer. The HPV is a, a nuisance. W/P6 HPV+ CIN1In this quote, she seems to be struggling to bring together her medical knowledge about the risk factors for cervical cancer with her lay belief that cancer and STIs are unrelated.Other women talked about sexual activity not being the ‘sole cause’ of cervical cancer, or about knowing people who had had the disease, and it not being related to sex in their case. This woman talked about a friend who was diagnosed with cervical cancer:The doctors used to say ‘Oh if you have more than a certain amount of sexual partners’ blah blah blah but … I know that she was a virgin when she went with [boyfriend's name], so I know she wasn't one of those promiscuous women so then I thought that's a load of crap. AC/P7 HPV+ CIN2-3These women did not conceptualise the relationship between HPV and cervical cancer clearly enough to necessitate a reassessment of their beliefs.This group was similar to the previous group, except that they held firmer beliefs about the causal relationship between sex and cervical cancer, often providing explanations for the mechanism through which this might operate: ‘something to do with the sperm that can damage the cervix’ ; ‘some infection that you could pick up at that young age which may start that off’ (W/P33 HPV+ CIN2-3); ‘young boys … can be quite rough [during sex]’ (W/P27 HPV+ CIN2-3). They were aware of the possibility that HPV could be sexually transmitted, although not all believed it. This, together with uncertainties about the relationship between HPV and cervical cancer, prevented them from fully integrating their models of HPV and cervical cancer.A Caribbean participant held a variety of beliefs about how the relationship between cervical cancer and sex might operate: through ‘unprotected sex’, ‘infections’ and ‘lots of bashing’. She was aware that HPV could be transmitted by sexual partners, but had not fully understood the causal link between HPV and cervical cancer. She said she knew there was a connection between the two, but she did not know what it was. Despite knowing that both cervical cancer and HPV are related to sex, she did not apply this to her own abnormal smear and HPV-positive result:Did I think the whole thing was sex? (Pause) Not necessarily. I don't know. I just thought cancer. (Pause) Yeah because you can get HPV it doesn't necessarily affect guys as it does women in the same way and it can actually be transmitted through … sexual partners and stuff. Hence the reason they ask about sexual partners [when you go for a smear] and blah-di-blah and protection and all that kind of stuff. … I didn't feel ‘Oh my God I feel dirty and unclean’ ‘cause I didn't associate the HPV as much to the sexual thing. I was thinking more of the cancer thing. AC/P4 HPV+ CIN2-3Throughout the interview, she expressed a series of slightly contradictory beliefs, clearly trying to make sense of the information about HPV in the context of her pre-existing beliefs about cervical cancer.Women in this group described a variety of beliefs about the relationship between cervical cancer and sexual activity – some held sophisticated causal models while others doubted the relationship was true. The group was characterised by a lack of understanding of HPV, and particularly by a lack of awareness that it is sexually transmitted. One reason for the lack of awareness of HPV was that many of these women had tested negative for the virus, or had not received their results at the time of the interview. This meant that they had not received detailed information about HPV, or had not felt the need to read it as their result was normal. Other women received the HPV result at the same time as a smear result and interpreted it as being another test for the same thing.An example was a woman who tested positive for HPV but had a normal smear result . She had heard of a link between cervical cancer and number of sexual partners, but did not think that it could be true, believing that cancer ‘can hit anyone’. She believed that HPV was ‘something connected with the smear’ and so thought that ‘it's like cervical cancer; it can hit you at a certain point in life’. In the absence of any other knowledge about HPV, she seemed to extrapolate from her beliefs about cervical cancer to construct causal attributions for the virus.This group was characterised by a lack of previous understanding of the link between sexual activity and cervical cancer. Information about HPV had therefore forced a change in women's model of cancer, which was often associated with feelings of shock. Women in this group were different from those in previous groups, in that they had read and understood the information about HPV and had often sought additional information, frequently leading to a sophisticated understanding of the virus and its link with cervical cancer. A white woman described her reaction when she realised that cervical cancer was caused by a sexually transmitted virus:When I got the HPV I was horrified to discover that sex could lead to cancer. Yeah. So that was new information to me. I remember the shock of discovering that and thinking everybody should know about this. It's really shocking. W/P17 HPV+ CIN2-3A South Asian woman expressed similar views and wished that she had known sooner about the link in order to make changes to her behaviour once she had HPV:I actually did a lot of research and it was only then that I realised that it is actually sexually related because I was under the impression that it was just my cells going crazy in me, having cancer all of a sudden. … The information about where it actually originates and how you can deal with it can help a lot. … I would have … insisted on, say, condoms … so it would have made a world of difference. SA/P7 HPV+ CIN2-3Many of these women expressed a sense of surprise and disbelief that they had never heard about the link between cervical cancer and sexual activity before. They were frequently well-educated women who took an interest in health issues, and were astonished that they had never heard of it. For some, there was a sense of anger that doctors must have been aware of a link between cervical cancer and sex, but that this information was not in the public domain, in what one woman described as a ‘conspiracy of silence’.This group was made up of women who had previous awareness of the link between sexual activity and cervical cancer, and who were able to integrate the new information about HPV into their existing causal framework: ‘I always understood that one of the exacerbators of cervical cancer or the promoters, facilitators of cervical cancer was not only your own body malfunctioning at random, was also the nun syndrome’ . The extent to which cervical cancer was therefore seen as a sexually transmitted disease, and to which this was made explicit in the interview, varied.A white woman described her longstanding knowledge that the incidence of cervical cancer is lower in ‘Jewish ladies’ and nuns. This made her think that ‘it's obviously down to some kind of sexual preference and possibly foreskin’. However, the information about HPV made this much more explicit, and caused a shift in her model of cervical cancer towards a sexually transmitted aetiology:Before I heard about this [HPV] I would have just classed [cervical cancer] as the same form of cancer. Since I've heard about this and talked to people I would say it's totally dissimilar to any other kind of cancer. … It almost feels like it's more of, like a sexual transmitted disease. It's that, it's picking up something off a sexual partner that's causing the cancer, where there's no other kind of cancer that you can catch, basically, from somebody else. W/P30 HPV+ smear normalThis account illustrates the way in which cervical cancer is now conceptualised as being more similar to a sexually transmitted disease than to other cancers.The preceding typology has illustrated the way in which women's models of cervical cancer might be affected by information about HPV. If screening is introduced and information about HPV becomes more widely available, it is likely that most people will shift into typologies 6 and 7, understanding the relationship between an STI and cervical cancer, either as a new concept or within an existing causal framework. In this sample, understanding the sexually transmitted nature of HPV was associated with psychosocial responses typical of other STIs, like stigma, blame or problems with disclosure. These are described in detail elsewhere .Women were reassured by the fact that HPV can ‘clear up’ on its own and that treatment is not normally necessary. This allowed comparison with other trivial infections like colds: ‘in the majority of cases the system will clear, as in the common cold’ .As described elsewhere  of our sample had University education. Further research may be needed among women with lower levels of education. Indeed, further research to quantify the typologies among a representative sample of British women undergoing HPV testing and to indicate the dominance of certain typologies over others and to examine changes over time would be useful. The qualitative method and purposive sampling used in this study make any quantification of the data inappropriate and beyond the scope of the study.This is the first study to use qualitative methods to gain an in-depth understanding of the perceptions of women taking part in HPV testing in the context of cervical cancer screening, rather than questioning women hypothetically (In total, the findings point to the need for the development of consistent and clear information about HPV, and identify a role for general practitioners and other clinicians in providing women with this information. One US study has begun to develop responses to frequently asked questions about HPV (


Human papillomaviruses (HPVs) remain a serious world health problem due to their association with anogenital/oral cancers and warts. While over 100 HPV types have been identified, a subset is associated with malignancy. HPV16 and 18 are the most prevalent oncogenic types, while HPV6 and 11 are most commonly responsible for anogenital warts. While other quantitative PCR (qPCR) assays detect oncogenic HPV, there is no single tube assay distinguishing the most frequent oncogenic types and the most common types found in warts.1 to 2 × 106copies/reaction providing a reliable method of quantitating type-specific HPV in 140 anogenital/cutaneous/oral benign and malignant specimens. 35 oncogenic and low risk alpha genus HPV types were detected. Concordance was detected in previously typed specimens. Comparisons to the gold standard detected an overall sensitivity of 89% (95% CI: 77% - 96%) and specificity of 90% (95%CI: 52% - 98%).A Sybr Green-based qPCR assay was developed utilizing degenerate primers to the highly conserved HPV E1 theoretically detecting any HPV type. A single tube multiplex qPCR assay was also developed using type-specific primer pairs and TaqMan probes that allowed for detection and quantitation of HPV6,11,16,18. Each HPV type was detected over a range from 2 × 10There was good agreement between the ability of the qPCR assays described here to identify HPV types in malignancies previously typed using standard methods. These novel qPCR assays will allow rapid detection and quantitation of HPVs to assess their role in viral pathogenesis. Papillomaviridae comprise a diverse family of non-enveloped, small circular double-stranded DNA viruses, capable of infecting mammals and birds . In humaHPV types are divided into low- and high-risk groups with regards to their association with malignancy . Low-risPCR represents a sensitive method for the detection of HPV DNA. Currently, standard nested HPV PCR can be performed using degenerative primers followed by direct sequencing of the PCR product. Alternatively, PCR products can be hybridized to DNA of known HPV types, to determine the type of HPV present in the PCR-amplified sample (e.g. Roche HPV Amplicor system). Both assays are time consuming and do not allow for the quantitation of viral DNA to address the role of viral load in disease progression.Real time quantitative PCR (qPCR) allows for quantitation of DNA over 8 orders of magnitude . While qThis report describes two real time qPCR assays that can be used in tandem for detection of both common and uncommon HPV infection. Many distinct HPV types have been associated with disease hence, the first qPCR assay is a degenerate assay that targets the HPV E1 region of known HPVs and should allow for detection of any of these types. The second qPCR assay targets the coding region of the hypervariable loop V of the L1 gene of HPV6, 11, 16 and 18. These HPV types are associated with the majority of HPV related disease and are represented in the currently available quadrivalent vaccine. The primers and probes used in the development of the assay were designed to target and differentiate between these HPV types. In initial studies the vaccine has proven effective for prophylaxis against the initial infection by these types of HPV ,21. VaccThis study was approved by the School of Medicine, Institutional Review Board University of North Carolina, Chapel Hill (IRB# 05-DENT-1263-ORC). Study subjects were identified through the UNC Healthcare Cancer Registry of >22,000 cases (1995-present). This Registry maintains a database of all patients diagnosed and/or treated for malignant neoplasm's at UNC Healthcare. Cases were subjects with a histologically-diagnosed cancer (confirmed by two independent pathologists). Well-characterized HPV positive controls from skin and anogenital lesions were provided by Joel Palefsky. For gynecological samples, cells were obtained after cervical lavage from HIV-positive subjects (IRB# 2080-05). Controls were chosen based on biopsies histologically-confirmed as benign. Paraffin embedded benign control tissues were defined as those not demonstrating any properties associated with malignancy .CaSki and HeLa cell genomic DNA was obtained from Advanced Biotechnologies Inc. SiHA and DG-75 cellular DNA was isolated from cells using a Qiagen DNeasy Kit and used as positive controls in the real time PCR assay. Paraffin-embedded patient tissue was deparaffinized with xylene. Tissue was washed twice with 100% ethanol and dried. DNA was isolated using a Qiagen DNeasy kit according to the manufacturer's instructions.GGATCCCCATGTACCAATGTTGCA-3') and HPV16BamHIR (5'-CCCGGATCCTTTGCCCCAGTGTTCC-3'). The 7.9 kb PCR fragment was TA-cloned into pCR2.1-topo vector to generate pHPV16. The plasmids pHPV6 and pHPV11 containing the entire genome of HPV6 and HPV11, respectively, were obtained from the American Type Culture Collection (ATCC) and were used to derive standard curves for HPV6 and 11 in the real time PCR assay.The 136 bp HPV16 L1 amplicon (6605-6741) was PCR-amplified from CaSki cell genomic DNA using Taq polymerase and standard PCR conditions. The 120 bp HPV18 L1 amplicon (6587-6707) was PCR-amplified from HeLa cell genomic DNA using Taq polymerase and standard PCR conditions. Both HPV16 L1 and HPV18 L1 amplicons were TA-cloned into pCR2.1-topo vector (Invitrogen) according to the manufacturer's instructions to obtain the plasmids, pHPV16L1 and pHPV18L1, respectively. Purified plasmids were sequenced to verify that the correct sequence was present and used to derive standard curves in the real time PCR assay for the detection of HPV16 and 18 L1 amplicons. Full-length HPV16 genome was PCR-amplified from Caski cell DNA using a Roche Expand Long Template PCR System and the primers HPV16BamHIF  was added to 7 microliters of positive reactions. Reactions were incubated at 37°C for 15 minutes followed by incubation at 80° for 15 minutes. The entire volume was used for DNA sequencing using HPVE1F as a sequencing primer (Eton Bioscience Inc.). Blast sequence analysis was performed on generated sequences to identify homologies with other known HPV DNA.1 to 2 × 106 copies/reaction. Quantitation of PCR products was performed using Roche Lightcycler 480 software. Color compensation was turned on in all assays to subtract bleed through between adjacent channels used to detect specific fluorescent tags.Real time PCR reactions were performed using Roche Lightcycler TaqMan master mix. Each reaction consisted of 1X Roche Lightcycler TaqMan master mix, HPV specific primer pairs and fluorescently-tagged probes for types 6, 11, 16 and 18 in a total reaction volume of 10 μl  of each type-specific plasmids. In each type specific qPCR assay, primers and probes were able to distinguish and quantitate between their respective type-specific HPV (2 × 104 copies) and the other HPV types (6 × 104 copies) with minimal differences between the standard curve and the type-specific HPV present in the mixture  in each of the samples, the minimum level of HAPB was 103 as previously described [DNA isolated from 25 cervical lavage samples obtained from HIV-positive women was used to determine if the multiplex qPCR assay could be used to detect the 4 most common HPV types in gynecological samples Table . Samplesescribed . HPV DNAescribed . AdditioRecent evidence has suggested that HPV plays a role in the development of oral cancers -7,24. InInitially, the multiplex qPCR assay was performed on 54 oral cancer samples from the population of patients with a history of smoking/drinking. Of these 54 samples, 8 (15%) had >1000 copies of HPV16/μg total DNA and were considered positive for HPV16  patients . To assecompared our novel qPCR assay, which is a combination of E1 and L1 PCR results, to the gold standard method of "previously typed HPV" anogenital and oral cancer specimens (Table In summary, we ns Table . PreviouThe causal relationship between oncogenic HPV and malignancy indicates the importance of being able to quickly detect and quantify specific HPV types when it is suspected that a lesion may harbor an HPV infection. This would aid in the assessment of precancerous lesions and impact on the decision to treat the lesion before it progressed to a more severe form of disease or allow the lesion to resolve on its own. In addition, low risk types of HPV also impact negatively on quality of life indicating the importance of tracking and identifying HPV types involved in the development of warts. Assays that are capable of distinguishing between common types of HPV responsible for cancers as well as those involved in the development of warts would facilitate the understanding of HPV epidemiology and pathology. In order to do so, two qPCR assays were developed for use in tandem. An E1 degenerate broad spectrum Sybr green-based assay was developed that would detect any HPV. In addition, the real-time qPCR that utilizes specific TaqMan probes labeled with different fluorophores represented an attractive method for quickly identifying and quantifying the presence of multiple viruses in a single sample, simultaneously,  and coulAssays were developed that detect HPV types 6, 11, 16 and 18; types targeted by the prophylactic quadrivalent vaccine. Each type-specific TaqMan probe contained a fluorophore that differed significantly in its excitation/emission spectra compared to other type-specific probes in the assay, and worked with equal efficiency allowing for the detection of multiple probes in a single reaction tube and reducing the time and reagents necessary to perform multiple individual reactions. The presence of large amounts of cellular genomic DNA did not affect the specific amplification and detection of amplicons. This assay had a linear range of detection over 6 orders of magnitude, allowing identification/typing of viral genomes and detection of viral load . The qPCIn cases where other HPV types are involved, the "broad spectrum" HPV qPCR assay is instrumental in detection of HPV types that may be present but are not detected by the multiplex assay. While HPV16 and 18 have been shown to be responsible for the majority of HPV-related cancers, there are additional oncogenic types of HPV involved in malignancy. We used E1 degenerate primers in a sybr green-based qPCR assay that could amplify all HPV types. The E1 consensus region is approximately 150-200 bp, and is much more amenable to real time qPCR than the MY11-MY9 region which is 600 bp. To date, we are unaware of other primers sets used for HPV degenerate qPCR, however, the L1 based spf1/2 primers could serve as an alternative . These pThe ability to detect and quantify specific HPV types in clinical samples allows for assessment of HPV-related disease. While used on cloned DNA/plasmids for types 6,11,16 and 18, the multiplex assay also performed optimally on well-validated anogenital and skin specimens. Our test shows both high sensitivity and specificity 89% and 90%, but it should be noted that the specificity estimate is based on only 9 true negatives, and thus, has a large confidence interval. Our sensitivity estimate's narrow confidence interval indicates that the true sensitivity of our test is likely higher than 77%. Takac et al ,28.With real time PCR technology becoming an increasingly common technology for clinical labs, this assay will allow for the rapid identification and quantification of pathogenic types of HPV. As viral replication often precedes the development of virus-associated pathology, the ability to quantitate HPV in persons 'at risk' for HPV associated disease may be an informative prognostic indicator. The novel qPCR assays described here may provide insight into the epidemiology and natural history of HPV infections within individuals and groups, providing prognostic capability and leading to the development of intervention strategies to prevent disease progression.We developed a single tube real time PCR assay capable of differentially detecting and quantifying 4 types of HPV represented in an FDA approved vaccine, types 6,11,16, and 18.The ability of the assay to distinguish between these 4 types of HPV in a complex mixture of DNA and in the presence of human genomic DNA was validated. A "broad spectrum" sybr green-based qPCR assay that utilizes E1 degenerate primers that is capable of detecting multiple HPV types was also developed and validated. We showed that our assays performed as well as traditional nested PCR followed by sequencing/hybridization in distinguishing between different types of HPV in anogenital and oral fluids and tissues from high risk/diseased subjects.HPV: Human papillomaviruses; HAPB: human apolipoproteinB; qPCR: quantitative PCR; ATCC: American Type Culture CollectionThe authors declare that they have no competing interests.WTS and JW-C prepared the manuscript and developed and performed the PCR assays. EA and MC identified and obtained oral cancer tissue. EMK and SC-U and identified and obtained cervical lavage samples from HIV infected individuals. JP identified and obtained well characterized HPV-positive anogenital samples used in validating the assays. AD performed the statistical analysis. All authors read and approved the final manuscript.


The United States (US) Food & Drug Administration (FDA) recently approved a human papillomavirus (HPV) vaccine with the purpose of reducing the risk of cervical cancers caused by HPV 16 and HPV 18. It is important that the general population be educated about HPV and the HPV vaccine in order to make the appropriate decision whether or not to vaccinate against this virus. Participants from the adult US general population of Pittsburgh, Pennsylvania, USA and Hampton, Virginia, USA (18+ years old) were surveyed to determine their knowledge about HPV and the HPV vaccine, and to evaluate their perception of the vaccine efficacy and safety.We report herein preliminary data for 202 participants. Fifty-five percent (55%) of the study population was White, 45% Black, and 1% was from other ethnic groups or did not disclose their ethnicity. A large proportion of participants had heard of the human papillomavirus . Participants of African descent were slightly less aware of HPV than Whites . Although the majority of participants knew that HPV caused cervical cancer (84%), Whites were more informed than Black participants . Eighty-seven percent (87%) of participants had heard of the HPV vaccine ; a higher proportion of Whites were aware of the vaccine when compared with Blacks . However, only 18% of the population knew that the current FDA-approved vaccine protected against genital warts and most cervical cancer .These data suggest that although the general population might be aware of HPV and the HPV vaccine, knowledge of the benefits of the HPV vaccination may not be apparent. Knowledge of HPV and the HPV vaccine could result in a likely choice of HPV vaccination and would subsequently reduce the incidence of cervical cancer. Human papillomavirus (HPV) is a family of viruses that are etiologically linked to number of disease conditions: cancers as well as benign conditions such as warts and condylomas. Although there are treatments for the clinical manifestations of HPV infection, there is no cure for the infection. There are at least 15 high-risk HPV types that cause cervical cancer and most anogenital cancers; HPV types 16 and 18 are the most common. In addition, HPV16 is thought to be linked to the development of a subset of head and neck cancers .The United States (US) Food & Drug Administration (FDA) recently approved an HPV vaccine with the purpose of reducing the risk of cervical cancers caused by HPV 16 and HPV 18 . The CenThe HPV vaccine prevents infections from HPV types 6, 11, 16 and 18. HPV types 6 and 11 are primarily responsible for the development of genital warts, while HPV types 16 and 18 are attributed to the development of approximately 70% of all cervical cancers ,6. The CWe have developed a survey that assesses the general population's knowledge and perception of HPV as well as the HPV vaccination. This report summarizes data collected from a sample of the general population residing in Pittsburgh, Pennsylvania, USA and Hampton, Virginia, USA. We have compared the knowledge and attitudes between the populations from these states.The survey was administered to participants from the general population of Pittsburgh, Pennsylvania and Hampton, Virginia, 18 years of age and older. Insitutional Review board approval was obtained from both the University of Pittsburgh and Hampton University. The surveys were distributed face-to-face or by mail. The Pittsburgh population consisted of participants who were enrolled in a population-based registry of people from Pittsburgh and surrounding communities. These participants were recurited through flyers posted at churches, community centers, outpatient clinics, health fairs, school events, libraries, the local newspapers, and the University of Pittsburgh Medical Center newsletters. A letter of invitation to participate was mailed along with the questionnaire and interested participants completed and returned the survey by mail. A total of 209  surveys were mailed and 103 participants (49.3%) responded . Additional participants  were recruited face-to-face, from an ongoing study on participants who were at one time seen as patients at the Magee Womens Hospital. The response rate for the face-to-face recruitment was 23/60 (38%). The Hampton population consisted of participants from Hampton and surrounding communities, such as the local plasma donation center, churches, the local police station, and also students and staff members from the Hampton University campus . These participants were recruited face-to-face. All of the surveys for both study populations were completed anonymously.The questionnaire development was guided by our research hypotheses and a review of the literature, and consists of questions that define the participant's age, gender, ethnicity, birthplace, marital status, parental status, number of children, level of education, religion, health insurance coverage and yearly household income. Participants were also asked to answer questions that would evaluate their level of knowledge of HPV and the HPV vaccine. Questions related to the participant's perception of the safety, efficacy and impact of HPV vaccination were also included in the survey. A preliminary content assesment of the survey was performed prior to the initiation of this study.All statistical analyses were performed using STATA SE (version 10) software . A two-sample proportions test of significance was performed when comparing demographic variables and the survey answers between stratified groups. Comparisons of continuous variables were performed using the two-sample t-test. A p-value < 0.05 was considered statistically significant. Adjusted prevalence rates for each survey answer were calculated for all participants and stratified by ethnic groups and population source (Pittsburgh and Hampton) after adjusting for potential confounding variables, such as age, marital status, education, income, recruitment location, and parental status. Comparisons of the number of correct answers for HPV knowledge and HPV vaccine knowledge questions stratified by race and recruitment location were calculated using two-way ANOVA models after adjusting for age, marital status, education, income, recruitment location and parental status. Box plots were generated using the adjuste mean vaules for each stratifed model.A total of 202 participants completed the survey , compared with 81% of White participants, this difference was only marginally statistically significant (p = 0.104). Statistical significant differences were observed between Blacks and Whites for three specific questions. Only 64% of Black participants knew that HPV infection was relatively common compared with 88% of White participants (p = 0.013). Similarly, 48% of Black participants knew that there was no cure for HPV infection compared with 68% of Whites (p = 0.044). Furthermore, although a large proportion of participants knew that HPV caused cervical cancer (84%), Whites were more informed than Blacks .For the majority of questions (8/10), the proportion of Black participants that answered correctly was less 70% (range: 19.5%–69.2). In contrast, for 5/10 questions, the proportion of White participants that knew the correct answers was less than 70% (range: 16.5%–68.4%). There were four questions that both Black and White participants answered poorly. Only 37% of Blacks and 52% of White participants knew that HPV caused genital warts; 20% of Blacks and 17% of Whites knew that genital warts were not caused by the same HPV type that caused cervical cancer. Furthermore, when asked: "Who can become infected with HPV?" only 54% of African-Americans and 65% of Whites knew that both men and women could be infected. Most importantly, only 69% of African-Americans and 66% of Whites were aware that the incidence of HPV in women is highest among women in their 20 s and 30 s.Figure Five questions were posed for the knowledge assessment of the HPV vaccine, summarized in Table Although marginally statistically significant, a lower proportion of Blacks were aware that only females were eligible for the HPV vaccine (64%) at this time compared with 81% of White participants (p = 0.106). In contrast, statistically significant differences were observed for other questions. Forty-nine percent of Blacks compared with 81% of Whites knew that the HPV vaccine was approved for participants who have never been infected with HPV (p = 0.004). Furthermore, 63% of Blacks and 90% of Whites knew that 9–26 years was the correct age group for which the HPV vaccine was recommended (p = 0.012).Among the participants that provided correct answers to the HPV vaccine knowledge questions, the majority of participants were able to answer four out of the five questions correctly Figure . OverallSix questions were posed in order to evaluate the study participant's perception of the HPV vaccine Figure . When paA number of US studies have been conducted to address knowledge and attitudes related to HPV and the HPV vaccine. However, few are population-based. Many of these have been based on focus groups -11 or arTwo large population-based surveys involving random samples of 1,006 participants in the US  and of UWe compared the distribution of correct answers to the HPV knowledge questions between geographic locations and observed that overall the mean number of correct answers was higher for Hampton participants compared with Pittsburgh participants, although this difference was not statistically significant. When we compared the Black and White participants from Pittsburgh, we observed that Blacks had a smaller mean number of correct answers compared with Whites, while there was no difference between races for Hampton participants. Overall, these findings suggest a need for increased educational programs on HPV and the clinical manifestations of HPV infections for the general popualtion residing in the Pittsbugrh area as well as for Black participants living in both geographic areas.We have reported that 87% of participants had heard of the HPV vaccine. However, despite this high proportion of participants, the majority did not know about the protective impact. Only 18% of participants knew that the HPV vaccine protected against most cervical cancer and genital warts. This suggests that the general population may not be equipped with the necessary information to make an informed decision about HPV vaccination. We also observed that Blacks were less well informed about the HPV vaccine compared with Whites. However, the differences were statistically significant only for the Pittsburgh population, suggesting a need for targeted education programs on the HPV vaccine in this group.These data suggest that although the general population might be aware of HPV and the HPV vaccine, knowledge of the benefits from the HPV vaccination may not be apparent. There were also differences in the level of knowledge based on ethnicity and geographic location. The development of educational interventions is necessary to ensure that the general public is able to make an informed decision regarding HPV vaccination.The authors declare that they have no competing interests.CR, ET, RPE, SMG and DEH conceived the study and participated in the study design. CR developed the survey instrument, performed the data entry and analysis. CAS and CB were responsible for overseeing the data collection at Hampton, VA. KH, EJ, CM and AS participated in the participant recruitment and data collection at Hampton, VA; JJ, AA, NET and LR participated in participant recruitment and data collection in Pittsburgh, PA. All authors read and approved the final manuscript.


Chile has broad variations in weather, economics and population from the far desert north (Region 1) to the cold, icy south (Region 12). A home-based self-collected vaginal sampling was nested in the 2003 Chilean population-based health survey in order to explore the possibility of a type-specific geographical variation for human papillomavirusThe population was a national probability sample of people 17 years of age and over. Consenting women provided self-collected cervicovaginal swabs in universal collection media (UCM). DNA was extracted and typed to 37 HPV genotypes using PGMY consensus PCR and line blot assay. Weighted prevalence rates and adjusted OR were calculated.Of the 1,883 women participating in the health survey, 1,219 (64.7%) provided a cervicovaginal sample and in 1,110 (56.2% of participants and 66.5% of those eligible) the samples were adequate for analysis. Refusal rate was 16.9%. HPV prevalence was 29.2% (15.1% high-risk HPV and 14.1% low-risk HPV). Predominant high-risk types were HPV 16, 52, 51, 56 and 58. Predominant low-risk HPVs were HPV 84, CP6108, 62, 53 and 61. High-risk and low-risk HPV rates were inversely correlated between the regions. High-risk HPV prevalence was highest among the youngest women, whereas low-risk HPV increased slightly with age.Self-obtained vaginal sampling is adequate for monitoring HPV in the community, for identifying high-risk areas, and for surveying the long term impact of interventions. The availability of highly effective human papillomavirus (HPV) vaccines has led to a discussion about their incorporation in public health vaccine programs ,2. A basChile is a long  and narrow (200 km wide) country Figure  with a cThe study population included all women participating in the ENS 2003. The sample for the ENS 2003 was a national stratified multistage probability sample of non-institutionalized people aged 18 years and above, representing the Chilean population and comparing regions, rural and urban, four age groups, and three socio-economic strata. The sampling error was set at less than 2%. The ENS 2003 is the first household based health survey with biological sampling  body measurements , clinical examinations  and comprehensive health questionnaires administered by a public health certified nurse and a trained interviewer. Only one subject, selected by the Kish method, participated per household . The surAfter receiving information about the exam and providing written informed consent, eligible women who were not menstruating, not pregnant, had not had sexual relations the previous day, with no prior hysterectomy, and had initiated sexual activity were taught, using pictorial pamphlets, how to obtain a vaginal sample. The nurse provided a Digene sachet containing a conical brush and a tube with the transport media  . Women wIn the Catholic University Pathology Laboratory, DNA from the self-obtained vaginal sample was extracted with the DNeasy tissue kit  following the manufacturer's instructions. All extracted DNA samples were sent to Johns Hopkins University where they were typed using PGMY consensus PCR and prototype line blot assay (Roche Molecular Systems) to identify 37 HPV genotypes -25. DNA To explain the variation in the prevalence of HPV among the 13 Chilean Regions, we collected available regional population data for women's characteristics , socio-demographic characteristics , access to health care (Papanicolaou coverage), HIV prevalence rate  and cervical cancer mortality. We obtained mortality data and health information from the Ministry of Health and population data from the National Institute of Statistics.Prevalence rates were calculated using sampling weights based on the two stage sampling design and adjusted for post stratification population totals using the Chilean 2003 population statistics. Considering the complex sample design, the standard error and 95 percent confidence intervals were calculated with the Taylor linear approximation method using SPSS version 14 . AdjusteA total of 1,883 women participated in the ENS2003; 12% were not eligible – reasons for ineligibility included women currently menstruating, having had sexual intercourse less than 24 hours previously (9.1%), or prior hysterectomy (2.9%); 8.1% could not be included because the interviewers did not have swabs when conducting the survey; 16.9% refused to take the self-sample leaving a total of 1,219 (64.7%) women who provided a self exam. 109 (8.9%) of the samples were insufficient for HPV analysis as indicated by the absence of the human beta-globin control amplification (1.6%) or were untested because the tube was broken or empty. Therefore, 1,110 women (56.2% of the participants and 66.5% of the eligible women) provided an analyzable vaginal sample. Women refusing to collect the sample were similar to those who accepted the exam with regard to region of residence and urban-rural zone, but higher refusals were observed among the younger (< 25 years old), the older (> 60 years old), the lower educational group, the single, and the widowed.The mean age of the survey participants was 41.9 years (range 16–97) and the majority lived in urban areas (88.1%) ] reported no discomfort with the self-administered swabs and the majority [79.4% (95%CI 75.9–82.6)] indicated self sampling caused less discomfort than the Papanicolaou smear (manuscript in preparation).Overall, we observed 29.2% point prevalence for any HPV infection in a population-based survey of adult Chilean women. Of the infected women, 146 (15.3%) had at least one high risk HPV genotype detected and 83 (8.4%) had exclusively high-risk HPV types. Only low-risk HPV types were detected in the remaining infected women . A total of 488 infections were identified (some women may be infected with more than one HPV type); of those 202 (41.4%) were caused by high-risk HPVs and 286 (58.6%) by low-risk HPVs. HPV 16 was the predominant type of high-risk HPV, followed by HPV 52, 51, 56 and 58. Among the low-risk HPVs the most frequently detected types were HPV 84, CP6108, 62, 53 and 61 (Table 2.8 (95% CI 1.4–5.7), 0.9 (95% CI 0.6–1.5), 0.6 (95% CI 0.3–0.98) and 1.09 (95% CI 0.4–3.0), for the North, Central, South and Extreme South areas respectively. The mean ages of the population were: 39.8, 42.7, 41.1 and 40.0 for North, Central, South and Extreme South regions, respectively. Neither high-risk HPV nor low-risk HPV was associated with cervical cancer mortality . In 2004, according to the ministry of health statistics, the Papanicolaou coverage for women 35–64 years old varied from 54.7% in the Metropolitan South-eastern Health Service to 87.3% in the Metropolitan Central Health Service. Nevertheless, Papanicolaou coverage was not significantly associated with either high-risk (Pearson correlation 0.15 p = 0.6) or low-risk HPV (Pearson correlation -0.35 p = 0.23).Total HPV infection (high-risk plus low-risk HPVs) varied from 43.5% 95% IC, 23.5–65.9) in Region I (the northernmost region) to 25%  in Region V  correlated significantly with the prevalence of high-risk HPV . Prevalence of current smokers, prevalence rate of HIV and proportion of singles, were inversely correlated with low-risk HPV .High-risk HPV prevalence was highest in the younger age group (under 25 years old) and declined significantly with age Figure . Low-risSurveillance of adult health status and its risk factors has become an essential tool for public health planning and evaluation. To date this surveillance has focused on cardiovascular diseases and its risk factors and, therefore, this is one of the first surveys to incorporate HPV testing as one of the priority problems for adult health surveillance. The overall prevalence of any HPV was strikingly similar to a recent US national survey using similar methods; however we did note an interesting contrast between high-risk and low-risk HPV prevalence and regional variability that was not previously reported .In the multivariate analysis, residing in the north of Chile was a risk factor for high-risk HPV infection. The relative contribution of high risk HPV to the total burden of HPV infection was almost 3 times higher in the north than the national average while in the south it was almost half the national average . The relative excess of high-risk types in the north appears to be associated with a younger age and with variations in factors associated with sexual behaviour. While we could not explore sexual behaviour directly, secondary data shows that northern regions have higher rates of smoking, higher birth rates and higher rates of HIV while they are less rural and have less poverty than the southern regions (data not presented). On the other hand, the excess of low- risk HPV in the south appears to be associated with older age, poverty and rurality. Other authors have also described a diverse epidemiological profile for low and high risk HPVs . To explThe age-specific prevalence of HPV were the same in the current survey and in our previous study, with high-risk HPV prevalence peaking below 25 years old while low-risk HPV increased slowly after age 50 . The incWhen comparing the HPV types found in these vaginal samples with the published data on HPV types isolated from cervical samples in Chile's general population  we foundSelf-sampling was highly acceptable for Chilean women, as has been repeatedly demonstrated in different cultural settings in Canada , USA 1616, GermaThere are several caveats in the interpretations and generalizations based on this population-based survey of HPV type-specific prevalence. The relatively low response rate may bias the results. Nevertheless, since the non-participants are weighted, part of the bias may have been removed. We estimated the bias by correcting the estimates based on propensity scores, but the estimated prevalence changed minimally (Vives A. manuscript in preparation), therefore we believe that these biases do not significantly change our inferences.The most important limitation in estimating the real HPV burden is the fact that we are measuring HPV at a single point in time, with no information about the historical exposure of these women to HPV. Winer and colleagues  estimateSelf-obtained vaginal sampling is an adequate method for monitoring the burden of HPV in the community. Coupling this sample collection with routine census procedures allows high-risk areas to be identified in order to prioritize interventions and to carry out routine surveillance to assess the impact of the interventions  over time.The author(s) declare that they have no competing interests.CF conceived the study, and participated in its design and coordination and drafted the manuscript, AC carried out the extraction of DNA and coordinated the lab work, PM participated in the design of the study and coordination of field work, PV performed the statistical analysis. CG participated in study design and coordination, XA participated in study design and coordination, PG carried out the molecular studies and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Non-keratotic scc derives from transmission of hpv 16. uterine cervical cancer is also causally associated with hpv infection and strongly associated with hpv 16 and hpv 18. Transmission may occur during sexual intercourse, orogenital sexual contact, and saviolum kissing  Human papilloma viruses  and its activation pathway are targeted by the viruses Functionally, high-risk hpv types 6, 11, 16, and 18 hpv infection and preventing hpv from causing scc in females.Gardasil  is a recombinant quadrivalent intramuscular injection vaccine derived from hpv infection and transmission, not only should young females be inoculated before commencing sexual activity, but young males should be similarly targeted with a preventive strategy.Given that young, sexually active males are reservoir carriers and a major source of


The characteristics of human papillomavirus-positive and human papillomavirus-negative husbands were compared using odds ratios and 95% confidence intervals. Thirteen per cent of the husbands of control women, 18% of the husbands of women with invasive cervical carcinoma, and 21% of the husbands of in situ cervical carcinoma women were positive for penile human papillomavirus DNA. Human papillomavirus 16 was detected in 45 husbands, human papillomavirus 18, 31 or 33 in 19, and human papillomavirus 6/11 in 6, but the majority of human papillomavirus infection (158) was with other or unspecified human papillomavirus types. The same human papillomavirus type was seldom identified in both husband and wife. The strongest variation in penile human papillomavirus infection was by country, with percentages among the husbands of control women ranging between 3% in Spain and 39% in Brazil. Having had over 50 lifetime sexual partners, compared with only one, was associated with an odds ratio of 2.3.Four-hundred-forty-five husbands of women with invasive cervical carcinoma, 165 of women with British Journal of Cancer (2002) 86, 705–711. DOI: 10.1038/sj/bjc/6600194www.bjcancer.comCancer Research UK© 2002  The importance of the ‘male factor’  and in iThe development of increasingly accurate assays for HPV detection has brought a clearer understanding of the prevalence of, and risk factors for, cervical HPV infection in women. Human papillomavirus DNA has been identified in 99% of CC specimens .in situ (CIS) all carried out by IARC. The fieldwork was conducted from 1985 through 1993 in Spain (two studies), Colombia (two studies), Brazil, Thailand, and the Philippines. The detailed methods of each of these studies have been described elsewhere  and two case-control studies of cervical carcinoma The subjects of the present report are the husbands or current stable partners of case and control women enrolled in these studies. Current partners (herein referred to as husbands) were defined as men having had regular sexual intercourse with the index women for at least six months, irrespective of whether they were married.Of the 3790 women (1896 cases and 1894 controls) enrolled in the original case-control studies, 2800 (1329 cases and 1471 controls) reported having a living husband at study entry. Nine hundred and eighty-four (74%) husbands of case women and 937 (64%) husbands of control women were interviewed. A total of 807 (82%) husbands of case women and 717 (77%) husbands of control women provided penile cytological specimens, of whom 610 (76%) and 533 (74%) yielded a PCR-based valid HPV result, respectively. Among 610 husbands of case women, 445 were husbands of women with ICC and 165 of women with CIS. The median ages of the husbands of control women and of ICC and CIS cases were, respectively: 45 (range 19–82), 50 (range 22–79), and 38 (range 22–76) years. The husbands for whom HPV testing results were available did not differ from those who did not wish to be included in the study or from those who had an inadequate penile sample, with respect to various indicators of sexual behaviour; the mean number of lifetime sexual partners was in the 11-to-20 category in both participants and non-participants.All participating husbands and wives were interviewed separately using a face-to-face, structured questionnaire administered by specially trained interviewers of the same gender as the interviewee. The questionnaire elicited detailed information on demographic and socio-economic characteristics and a complete lifetime history of the subject's sexual experiences including genital hygiene habits. The lifetime numbers of regular and casual sexual partners and of partners who were prostitutes were evaluated separately and added together to obtain the total number of lifetime sexual partners.After interview, two samples of exfoliated cells were taken from the penis: one from the distal urethra, using a very thin wet cotton-tipped swab, and another one from the external surface of the glans and coronal sulcus, using a standard wet cotton-tipped swab. A smear was prepared for cytology and the remaining cells were eluted in phosphate-buffered saline, pelleted and stored at −20°C. Cervical exfoliated cells were also collected from the women as described for each study  were used to evaluate the agreement in HPV findings between husbands and wives. When the observed agreement exceeds chance agreement, kappa and CI are positive.Associations with the presence of penile HPV infection were evaluated using unconditional multiple logistic regression models with maximum likelihood estimation of parameter values to obtain odds ratios (OR) and corresponding 95% CIs . All logHeterogeneity among countries in the association between penile HPV infection and number of sexual partners was tested by comparing the difference between the −2 log likelihood of the model estimating a common OR and that estimating a specific OR for each group to the chi-square distribution with degrees of freedom given by the number of groups minus one. The results for total number of lifetime sexual partners are presented as a graph, plotting, for each country, the ORs as a black square, whose size is inversely proportional to the variance of the estimate. Diamonds are used to plot the summary OR for all studies together. The centre of the diamond represents the OR and the extremes the 95% confidence intervals.P values were derived from two-sided statistical tests.All Thirteen per cent of the husbands of control women were found to have penile HPV infection, the most commonly identified types being HPV 16 (15 men), followed by 18 and 6/11 (five each) , and of partners who were prostitutes (OR for ⩾51 vs 0=1.5) were directly correlated with the risk of penile HPV infection. For total number of lifetime sexual partners, the OR was 2.3 (95% CI: 1.1–4.6) for ⩾51 vs 1 partner  . The OR among those who never used a condom with prostitutes 0.3–1.5) , with novs ⩽10 lifetime sexual partners was 1.8 (95% CI: 1.2–2.5), but there was heterogeneity between countries. In Colombia the OR  was significantly lower than the pooled estimate and no increased OR was found in Brazil (OR=1.0). When the association with the number of sexual partners who were prostitutes was examined by country and overall , again no risk increase emerged for Brazil (OR=1.0) or Colombia (0.9). Two regular partners or more, compared with one, was associated with a pooled OR of 1.4 (95% CI: 1.0–2.0), and in Brazil and Colombia with an OR of 1.1 (95% CI: 0.5–2.4) and 2.1 (95% CI: 1.1–4.0), respectively (data not shown).Figure 2We have identified, by means of PCR-based assays, a prevalence of penile HPV infection among the husbands of women with or without cervical carcinoma ranging between 3 and 39%, depending upon country. Thus, the prevalence of HPV DNA in the male genital tract seems similar to that in the cervix uteri of control women in the same populations and age groups, if not higher . Ninety-two per cent of ICC female cases were positive for HPV DNA, yet penile HPV DNA was found in only 18% of the corresponding husbands.A relatively poor correlation in HPV-positivity has also been reported in previous studies of women and their male sexual partners  , a favouOur study has certain weaknesses but also some strengths. Unfortunately, we were able to search for relatively few mucosal HPV types, and no skin type. Viral load could not be assessed, but, on the basis of rather low hybridisation signals, we had the impression that viral copy numbers in men are generally lower than in women.vs hospital-based studies, the choice of various hospital wards, etc.) also obliged us to interpret between-country comparisons cautiously. The prevalence of penile HPV infection in our study is, however, positively correlated with cervical cancer incidence rates in the populations under study  (As three of seven studies were hospital-based, the determined prevalence of HPV DNA is not necessarily representative of that in the general male population. Differences in study design (i.e., population- vs 1 lifetime sexual partners among the husbands of control women only, and 1.4 for 3 vs 1 regular partners.Within-country comparisons of HPV-positive and negative men should not suffer from selection or recall bias, since all interviews were conducted prior to HPV-testing. Also reassuring is the close similarity, with respect to various indicators of sexual behaviour, between the 1143 husbands for whom HPV findings were available and the 778 ones who either refused to participate or had inadequate penile cell specimens. In order to increase the study power, husbands of control women and CC case women were pooled together in some analyses, on account of the similarity in most findings. Wives' case/control status was, however, always adjusted for and the consistency of findings was confirmed by stratified analyses. For instance, the OR for penile HPV infection was 1.5 for 51 The present study is notable for the large number of husbands and their wives from a wide range of age groups and countries with different background risks of cervical cancer. Detailed information on sexual habits and accurate procedures for the collection and HPV-testing of penile cell specimens represent additional strengths. The relatively low within-couple agreement in HPV-positivity at a single point in time and the steady prevalence of penile HPV infection with age suggest that the natural history of HPV may differ between men and women. Despite their difficulty, new cross-sectional and prospective studies in men are warranted to provide a basis for designing effective HPV prevention strategies.


TSG101 gene in this region, and also demonstrated a high frequency of abnormalities of this gene in human breast cancer. To determine the role of the TSG101 gene in the carcinogenesis of cervical and uterine carcinoma, 19 cases of cervical carcinoma and five cases of endometrial carcinoma, as well as nearby non-cancerous tissue from the same patients, and 16 blood samples from healthy persons as normal control were analysed by Southern blot analysis of genomic DNA, reverse transcription of the TSG101 mRNA followed by PCR amplification and sequencing of the products. We found that abnormal transcripts of the TSG101 gene were common both in cancerous or non-cancerous tissues of the uterus and cervix and in normal peripheral mononuclear cells. There was no genomic deletion or rearrangement in spite of the presence of abnormal transcripts, and no definite relationship between the abnormal transcripts and HPV infection was found. Although the frequency of abnormal transcripts was higher in cancerous than in non-cancerous tissue, normal peripheral mononuclear cells also had abnormal transcripts. Given these findings, the role of the TSG101 gene as a tumour-suppressor gene should be re-evaluated. Because some aberrant transcripts could be found at the first PCR reaction, we suggest that the aberrant transcripts might be the result of imperfect minor splicesome products. © 1999 Cancer Research CampaignCarcinoma of the uterine cervix is a common malignancy among women that has been found to show loss of heterozygosity in the chromosome 11p. Recent studies have localized the


These strains have attracted more interest because they are known to disrupt tumour-suppressor genes that control the cell cycle, rendering those genes less effective at keeping cell division in check.Human papilloma virus  joints might decrease oral hpv among cannabis smokers. Future research should therefore investigate the prevalence of oral hpv in cannabis smokers to better understand its epidemiology.Within the last decade, an increase in oral  Oral sex with an hpv-infected person has been shown possibly to increase the likelihood of contracting oral hpvhpv (types 16 and 18) oncoprotein is known to interfere with the cell-cycle tumour suppressors p53 and pBR. Sustained expression of these oncoproteins is ultimately able to drive chromosomal mutations, which lead to cancerous cellsThe American Cancer Society estimates that, in the United States, more than 6 million people contract human papilloma virus . Additionally, Rose Ragin et al.hpv-related cervical cancer had a higher chance of head-and-neck cancer. Using data from the National Cancer Institute’s Surveillance, Epidemiology, and End Results database, they found that women with cervical cancer had a greater chance of developing head-and-neck squamous cell carcinomas. The authors suggested that the head-and-neck cancers are caused by secondary infections from hpv. D’Souza et al.hpv are strongly linked. They also suggest that oral hpv is often contracted through oral sex. However, Sok and Grandishpv infection are unknown. Regardless, many people have suggested that a vaccine against oral hpv might be important in preventing oral hpv infectionsThe rapid rise in oral cancers among young people is expected to continue. This rise has largely been attributed to contraction of oral hpv-linked cancers, studies have tried to find a relationship between cannabis smoking and a variety of types of cancers. For example, Almadori et al.et al.et al.et al.Given these considerations, there has been much debate on whether cannabis has been a causative agent of oral cancers. As with hpv as a possible factor in the development of cancer was not discussed. The importance of understanding the role that cannabis smoking might play in hpv-related cancers is difficult to overstate. Indeed, a recent report by the World Health Organization notes that countries must begin to take action toward dealing with oral cancer preventionhpv, steps should be taken by governments to educate their citizens to help mitigate oral cancer rates.However, in all of the above-mentioned studies and reviews, World Drug Reportet al.hpv can be passed among cannabis users is therefore significant.Worldwide consumption of cannabis has been documented by the United Nations hpv remains there until another user places the same area of the smoking device onto their lips. This scenario could easily have continued for many years as a possible method of oral hpv transmission.The human papilloma virus can be found on the surface of the lips, the lining of the mouth, on the tongue, and so on. Therefore, as an infected person places a cannabis cigarette or smoking device on their lips, they simultaneously deposit viral particles on the device. The et al.Although partaking in cannabis smoking may be an individual process, cannabis smokers are also known to pass and share their cannabis freely. For instance, various studies have found that, although some cannabis users smoke alone, others share with close friends or at parties, making smoking a social activityhpv and postulated reasons that vaccines might be useful in controlling hpv-related cancers in later life. They cited use of alcohol and tobacco (because of the carcinogenic nature of those substances) as additional contributors to the likelihood that these types of cancers may develop. The mention of tobacco is interesting, because it, too, may serve as an indirect route of transmission. For example, Knishkowy and Amitaihpv is not mentioned. Still, sharing tobacco-smoking devices could also serve as an additional route of oral hpv contraction. To compound matters further, it not exactly known how easily oral hpv can be transmitted between individuals .Gillison and Lowyhpv would soon be available. Such a test might prove useful in a clinical setting, for research purposes, or for personal knowledge. Currently, in individuals positive for oral hpv, hpv antibodies can be detected in the mucosal areas. Marais et al.hpv antibodies from oral swabs. This same method might be desirable in a controlled study of cannabis users in future research. A study of this nature could provide a relatively rapid analysis of cannabis users and rates of hpv . Additionally, because cannabis use is often higher among men, higher rates of oral cancer might be observed in men than in women. Studying the frequency of cannabis use might also result in important findings such as an increased likelihood of users testing positive for oral hpv. Comparing individuals that share cannabis in group settings with those who consume cannabis alone might provide insight into more definitive patterns of oral hpv and thus help to predict the likelihood of head-and-neck cancers developing in later life.With such uncertainty, one would hope that a rapid assay for oral hpv-infected individual to an uninfected individual could easily provide a route of transmission for the virus between users. Frequency and setting should therefore be considered two major factors that might contribute to the likelihood of acquiring oral hpv. Thus, the relationship between cannabis and various cancer types might not be from cannabis use itself, but rather from contracting high-risk types of oral hpv that lead to cancer in later life.It certainly may not be the cannabis smoke that causes oral cancers in heavy cannabis users. Most people who have ever smoked cannabis have most likely done so by sharing a rolled cigarette or pipe in a group setting. The sharing and passing of these smoking devices from an oral