In this study, we examined the perceptual associations women hold with regard to cervical cancer testing and vaccination across two countries, the U.S. and Australia. In a large-scale online survey, we presented participants with ‘trigger’ words, and asked them to state sequentially other words that came to mind. We used this data to construct detailed term co-occurrence network graphs, which we analyzed using basic topological ranking techniques. The results showed that women hold divergent perceptual associations regarding trigger words relating to cervical cancer screening tools, i.e. human papillomavirus (HPV) testing and vaccination, which indicate health knowledge deficiencies with non-HPV related associations emerging from the data. This result was found to be consistent across the country groups studied. Our findings are critical in optimizing consumer education and public service announcements to minimize misperceptions relating to HPV testing and vaccination in order to maximize adoption of cervical cancer prevention tools. Growing evidence has demonstrated that the human papillomavirus (HPV) is the most common sexually transmitted infection (STI) responsible in a range of cervical, anogenital and oropharyngeal cancer cases. Specifically, 83% of all cervical cancer cases worldwide are attributable to the HPV infection and are therefore preventable through vaccination and screening tools . In spitIn contrast to cervical cytology, new evidence and technology has illustrated that HPV testing provides a cost-effective and more sensitive approach in detecting high-degree lesions , and conVariation in cervical cancer cases has therefore been linked to the presence of adequate ECDP and other relevant resources within countries, as well as the population presence of the cervical HPV infection . For exaThe sensitive, personal and private nature surrounding public health concerns and, in this context, cervical cancer and screening, has often resulted in participants being unwilling to answer direct questions , 11. ThuUtilizing this data-driven approach, in this study we analyze the perceptual word associations women hold with regard to ECDP screening tools  across two countries, the United States and Australia. We examined these two countries as they use the ECDP screening tools in different ways, thus enabling us to see how informed women drawn from the general population are and to identify information gaps within each country. We undertook a semi-structured data-mining exercise, which enabled the construction of co-occurrence network graphs that were then analyzed using basic topological ranking techniques. To this end, we aimed to answer the following research questions:What word associations surrounding HPV testing do women hold and are these associations consistent across similar country groups?What word associations surrounding HPV vaccination do women hold and are these associations consistent across similar country groups?What can the types of terms produced and the connections between them tell us about the usefulness of word-association research in the public health context?ECDP screening, which until recently, was based solely on cytology, in the form of the Pap smear, is currently shifting to rely on HPV testing procedures instead (accompanied by a HPV vaccination program) , 21. ForCurrently in Australia, the Pap test is the primary ECDP screening tool, with clinical guidelines recommending women aged 18 to 69 undergo a Pap test every two years . This vaIn the United States, these cervical cancer clinical guidelines differ, with women aged 21 to 65 years recommended to undergo a Pap test every three years . FurtherBased on the above discussion, Australia and the United States share similar ECDPs. However, a core difference between these two countries lies in their use of HPV vaccination and testing. Therefore, we aim to generate understanding of the perceptual associations that arise from women’s thinking about ECDP screening tools  across these two countries. A key aspect of our work is that co-occurrence network graphs will enable greater understanding surrounding cervical cancer screening and, ultimately, work towards the optimization of consumer education and public service announcements.Using the consumer database from a reputable marketing research firm (SurveyMonkey), a large-scale online survey was conducted December 18–21, 2015. Participants were randomly selected from SurveyMonkey’s U.S. and Australian databases, using this study’s pre-defined selection criteria of women aged 18 to 64 years. An email invitation was sent to potential participants outlining the purpose of the study, giving instructions to complete the survey and including the link to the online survey. Implied consent to the study was provided through participants’ registration with SurveyMonkey, as well as the anonymous completion of this study’s survey. Participants who completed the survey were compensated via non-monetary incentives including donations to their preferred charity, and were given entries into a draw to win sweepstakes . FurtherA total sample of 1473 (68%) was achieved with 704 from the U.S. and 769 from Australia. The total number of incomplete responses was 697 accounting for 32% of the sample, with 346 of these, participants from the U.S. sample and 351 participants from the Australian sample. SurveyMonkey also provided basic demographic information from participants, such as age and household income brackets, which is summarized in In the survey, we randomly presented participants with several trigger words to which they were asked to provide, in sequential order, the first three words (i.e. response words) that came to mind. The trigger words shown to participants comprised “cervical cancer”, “cervical cancer testing” and “cervical cancer vaccination” in succession. We divided the network analysis of participants’ response words (and subsequent presentation of results) into “vaccination”  and “testing” (trigger words “HPV (human papillomavirus) test” and “pap smear”), and then further divided the responses by country groups . For example, an Australian participant shown the trigger word ‘HPV (Human papillomavirus) test’ provided the response words of “cervix”, “cancer” and “virus”.We used the data from the surveys to construct detailed, weighted term co-occurrence network graphs. Co-occurrence is a fundamentally simple concept, with relevance in “hard-science” applications  and sociCo-occurrence between response words was computed by taking the n-gram (i.e. set of adjacent words) co-occurrence statistic data  that parWe also removed n-grams related to the terms “unknown” and “n/a” provided by participants as we took these to denote a non-response. We included all other n-grams. Edges were thus created connecting n-grams provided by the same unique participant, in response to the same trigger word. The co-occurrence data for each participant was then merged into separate network graphs according to each trigger word. When the participant-level data was combined, the nodes representing identical entries (in response to trigger words) were merged. Identical co-occurrence pairings (edges) were also merged. This approach enabled the most salient n-grams (i.e. nodes) to emerge as naturally as possible.Having generated networks from the word co-occurrence data collected from participants, we then analyzed the topological properties of the resulting networks. This involved examining the sub-structures of the networks (i.e. groupings of nodes and patterns in connections between nodes), as well as ranking nodes using some basic topological measures . SpecifiVisualization was performed using Gephi , wherebyIn the following sections, the network properties and structures of each of the developed ‘trigger word’ network graphs are discussed. The results show that the HPV and Pap smear testing networks illustrated similarities with the salient n-grams (i.e. “necessary”) that arose, whilst negative n-grams (i.e. “uncomfortable”) were most apparent in the Pap smear testing networks. Furthermore, upon visual inspection of the HPV and cervical cancer vaccination networks across both country groups, the preventative and beneficial nature of the trigger word “vaccination” was exhibited through the identified n-grams.Network A, seeded from the trigger word “HPV Testing” for the U.S. country group comprised, 794 nodes connected by 1974 edges with an average degree of 4.904 . This neIn reference to Network B, which was seeded from the trigger word “Pap smear testing”, the U.S. country group is comprised of 667 nodes connected by 1790 edges with an average degree of 5.367 . This neIn comparison to the U.S. country networks, the findings from the Australian network groups demonstrate similar n-grams. Specifically, Network C, seeded from the trigger words “HPV testing”, comprised 718 nodes connected by 1703 edges with an average degree of 5.136 . This neNetwork D, seeded from the trigger word “Pap smear testing” within the Australian sample, comprised 625 nodes connected by 1703 edges with an average degree of 5.45 . This neConversely, the n-grams from the HPV test network graphs see Figs  and 3 acWithin the U.S. sample, Network E, seeded from the trigger words “HPV vaccination”, comprised 833 nodes connected by 1972 edges with an average degree of 4.735 . This neIn reference to the Australian country group, Network G, which was seeded from the trigger words “HPV vaccination”, comprised 777 nodes connected by 1923 edges with an average degree of 4.95 . This neIn review of We structure our discussion around each of the research questions outlined at the beginning of this study. First, in spite of the differences between the ECDP across both countries, the associations regarding the trigger words HPV testing produced positive perceptual associations by female participants in the U.S. and Australian samples studied. We also found that negative connotations were raised by participants relating to the uncomfortable nature of the Pap test.The overarching theme representing this particular form of testing was signified across both country samples by n-grams such as “uncomfortable”, “awkward” and “invasive”. This theme encapsulates the negative connotations that participants have associated with the Pap smear test, implied by the terms “discomfort”, “painful” and “awkward”. Although, the Pap smear network graphs within each country sample highlight the necessary and preventative nature of the test in identifying cervical cancer, this form of cervical cancer testing engenders negative perceptions, which may function to inhibit preventative action amongst women. Consequently, better education of health professionals is required to make the testing process and service environment less uncomfortable, which may work to increase the participation rate.The results show that both the U.S. and Australian country samples drew links between the trigger words “HPV and cervical vaccination” and sexually transmitted infections (STIs), with the terms “sex”, “std”, “virus” and “disease” reported by the participants. Both country samples also identified a correct association between the triggers word “HPV vaccination” and the n-grams “warts”. This shows that there is knowledge in each country sample that HPV can cause genital warts and is an STI. However, both country samples identified incorrect STI associations between these trigger words (“HPV vaccination”) and the n-grams “HIV”, “herpes” and “AIDS”. Such findings might indicate that women across both country samples do not differentiate between STIs, as well as holding false assumptions about HPV testing using the same medical procedures as HIV testing (a ‘simple blood test’). Therefore, this finding illustrates potential health themes for educational public service announcements and intervention programs that encourage adoption of the HPV vaccine and preventative sexual behaviors.Taken collectively, these findings are significant based on the explicit word choices of negative connotations toward this form of cervical cancer screening may function to inhibit women’s decision-making with regard to the adoption of preventative health behavior actions (i.e. undergoing regular Pap smear tests). Consequently, it is advisable that cervical screening education programs are designed to inform the public as to the precise details of HPV vaccination and screening schedules as well as mitigate flawed assumptions and misconceptions regarding the nature of the procedures. By addressing concerns on the part of women about timing and comfort, such action may improve HPV and Pap smear-testing goals.Second, regarding associations surrounding HPV vaccination, we found across both country samples that women hold correct and favorable associations relating to the preventative and beneficial nature of the vaccination. For example, participants consistently referred to the n-grams “school”, “teens” and “young”. This finding signifies that participants across both country samples are aware that the vaccination is administered to pre-teen females via doctors or school immunization programs .Third, in terms of broad relevance for public health research, this study reveals a number of interesting insights. In particular, the approach used in this paper allowed us to assess the diversity and variation in vocabularies used by patients to describe their perceptions and associations across two country samples. We then showed a simple method for identifying the relative importance of terms to specific trigger words.In this study, we have demonstrated the usefulness of our approach in identifying community groups and sub-structures within networked patient associations across each country sample. Further clarity can be achieved with targeted filtering of the networks to examine network sub-structures more closely. We have also demonstrated how easily words pertaining to specific topics, content, or sentiment types can be compared. Our study has several limitations. First, the data set used in this study may not be representative of the female population aged 18+ in the targeted countries, as the algorithm for selecting participants is not disclosed and the pool of potential participants as a whole may be inherently biased. Second, the survey was conducted in a very narrow timeframe , which may have introduced some bias but would also have excluded any bias from perception shifts that might have occurred in the targeted population over an extended time. Third, we based our analysis on exact string matches without any pre-processing such as stemming, lemmatization or fuzzy matching. Thus, the relevance of some concepts may be underestimated.A number of research directions arise from this study. Using a more representative sample of the population, future research could consider deeper analysis focused on semantics  and alsoFuture research will consider applying similar approaches to unstructured data . This cS1 FileThe survey presented to the probands.(PDF)Click here for additional data file.S2 FileThe data file (.xlsx) with the survey responses and metadata.(XLSX)Click here for additional data file.


Oral tongue Squamous Cell carcinoma (SCC) commonly involves males between the sixth to eighth decades of life. Major risk factors are tobacco usage and alcohol consumption. The increasing number of patients developing oral tongue cancer without these well-known risk factors suggests that a viral infection, such as Human Papillomavirus (HPV), may be responsible for this increase, by acting as an oncogenic agent. This study investigated the prevalence of HPV infection and its clinicopathologic significance in oral tongue SCCs.Tissue blocks from a total of 50 cases  and 50 controls  were selected. DNA was extracted from tumoral and non-tumoral tissue blocks. Detection of common HPV DNA by nested Polymerase Chain Reaction (PCR), and high-risk genotypes, HPV 16 and HPV 18, by conventional PCR, was achieved and the results correlated with clinicopathological parameters.Of the 50 patients , 7 (14%) had HPV positive results. None of the control group subjects had HPV DNA positive results . The HPV genotype 16/18 was not detected in positive cases. No statistically significant association was found between HPV status and gender, age, tumor grade, tumor stage or lymph node involvement.Although there was a significantly higher prevalence of HPV in oral tongue SCC, its association with carcinogenesis in this area requires further studies. Head and Neck Squamous Cell Carcinoma (HNSCC) is the sixth most common malignancy around the world ,2. Oral Human Papillomavirus (HPV) is considered as an oncogenic virus ,9 and maHuman Papillomavirus positive tumors are more common in young patients and present small sized tumors with advanced neck involvement. Histologically, these tumors are poorly differentiated and non-keratinized SCC with basaloid features ,12,13. HThere is limited information on the epidemiology of oral tongue SCC and HPV in Iran. In this study, clinical and tumor characteristics, as well as HPV status in oral tongue SCC, in the south of Iran, was assessed.Fifty histopathologically-confirmed formalin-fixed, paraffin-embedded tissue blocks of oral tongue SCC, product of partial or complete hemiglossectomy, were obtained from the archives of Khalili Hospital Pathology Laboratory, affiliated to Shiraz University of Medical Sciences, Province of Shiraz, Iran, from 2010 to 2015.th Edition, 2010  according to the American Joint Committee on Cancer staging (AJCC) 7on, 2010 , histoloon, 2010 ,7.Molecular StudySix-micrometer sections from all formalin-fixed, paraffin-embedded tissue blocks were prepared for DNA extraction using the Yekta Tajhiz Azma DNA extraction mini kit for tissue (Iran), according to the manufacturer's instructions.Detection of common HPV DNA by nested PCR and high-risk genotypes, HPV 16 and HPV 18, by conventional PCR, was performed . β-actin°C for 45 seconds, annealing at 55 °C for 45 seconds, extension at 72 °C for 45 seconds with a final extension at 72 °C for 5 minutes. Amplicons were run on 2.5% agarose gel, followed by Gel Red staining and visualization with transilluminatorThe PCR conditions were as follows; initial denaturation at 94 °C for 5 minutes, followed by 40 cycles of denaturation at 94 Human PapillomavirusGenotyping2, 200 µM dNTPs, 1 unit taq DNA polymerase (Yekta Tajhiz Azma) and 0.2 µM of HPV 16 primers or 0.2 µM HPV 18 primers .For identification of HPV 16 and HPV 18, conventional PCR was carried out separately on the HPV positive samples (9). The PCR reactions consisted of a total volume of 25 µL and contained 200 ng of template DNA, 1X PCR buffer, 1.5 mM mgCl°C for 1-minute, followed by 35 cycles of denaturation at 94 °C for 1 minute, annealing at 58 °C for 2 minutes, extension at 72 °C for 3 minutes, and final extension step at 72 °C for 10 minutes. Amplicons were run on a 2.5% agarose gel, followed by Gel Red staining and visualization with a transilluminator.The PCR reaction was performed with initial denaturation at 94 Statistical AnalysisThe correlation between HPV status in oral tongue SCC and clinicopathological parameters was analyzed using Chi-square and Fisher’s exact tests with the SPSS software (version 14). P-values less than 0.05 were considered statistically significant.The patients’ age ranged from 27 to 86 years old (mean age of 57.36±12.18 years), and 36% were male and 64% female. Among the controls, 46% were male and 54% female, and age ranged from 29 to 68 years (mean age of 49.72±10.10 years) (P>0.05). Fourteen cases (28%) were aged ≤45 years and were, therefore, considered as young patients .Human Papillomavirus DNA was detected in 7 out of 50 (14%) cases with oral tongue SCC .All tonsillar tissues were negative for HPV genome; this difference was statistically significant . The mean age of HPV-positive and HPV-negative patients was 56.71±11.14 and 57.46±11.18 years, respectively .HPV infection was more common in male compared to female patients, although the difference was not statistically significant . None of the specimens (0%) were positive for HPV 16/18 genotype. Two of 14 (14.3%) young patients (≤45 years old) were HPV positive. In HPV positive cases, most of the patients were more than 45 years old (71.4%) compared with young patients (28.6%), although the difference was not statistically significant .HPV infection was more common in male compared to female patients, although the difference was not statistically significant . None of the specimens (0%) were positive for HPV 16/18 genotype. Two of 14 (14.3%) young patients (≤45 years old) were HPV positive. In HPV positive cases, most of the patients were more than 45 years old (71.4%) compared with young patients (28.6%), although the difference was not statistically significant .The frequency of HPV infection was higher in well differentiated than poorly differentiated tumors, yet, the difference was not statistically significant . None of the moderately differentiated tumors showed HPV positivity.On the other hand, in HPV positive cases, most of the tumors were well differentiated, yet, the difference was not statistically significant .Although HPV positivity was more prevalent in stage II tumors (28.6%), no statistically significant differences were observed between HPV status and tumor stage .Also, no statistically significant differences were observed between HPV positivity and lymph node status .There was no statistically significant association between HPV status and gender, age, tumor grade, tumor stage or lymph node involvement. Correlation of HPV status with the characteristics of cases is shown in Table 1.Multiple studies have established the causative role of HPV infection in the onset of tonsillar and base of tongue SCC worldwide, yet, its role as a risk factor in oral tongue SCC, has been controversial . In our Elango et al. from India studied 60 oral tongue SCCs and 46 normal oral mucosal samples. Human Papillomavirus DNA was found in 50% of patients and 67% of the control group, and HPV-16 was detected in 48.3% of the patients  and older patients (>45 years) . Familial history was considered as an important etiological factor and its effect was more significant than tobacco and alcohol consumption. The HPV DNA was not detected in these patients . carcinoma of oral cavity, and evaluated high risk HPV 16, 18, 31 and 33 by PCR. Human Papillomavirus 16 and 18 were found in 14.3% of verrucous carcinomas, and were located in vestibule of the mandible (Saghravanian et al. studied oral leukoplakia and verrucous mandible .Seraj et al. studied 94 paraffin-embedded tissue blocks of patients with oral tongue SCC by the PCR assay for the detection of HPV 16/18. The frequency of HPV 16 and HPV 18 infection was 10.6% and 16%, respectively . Human PIt seems that the prevalence of common and high risk HPV is highly variable in different studies and in different geographic regions. In our study, HPV infection was more common in male compared to female patients. There was no significant difference in mean age of HPV-positive and HPV-negative patients. Also, no significant difference was detected in the frequency of HPV positivity between younger and older patients.In the current study, the frequency of HPV infection was higher in well differentiated than in poorly differentiated tumors. Other researchers like Elango et al.  and Sera In our study there was a significantly higher prevalence of HPV in oral tongue SCC than in the normal control group, while high risk HPV was not detected. No statistically significant correlation was found between HPV DNA positivity and clinicopathological characteristics. The results of the present study did not support the role of HPV infection in carcinogenesis in oral tongue SCC. The possible environmental and host genetic factors must be considered.


Penile carcinoma is a rare disease, with incidence rates varying in the range of 1–10 cases per 100,000 men depending on ethnicity, geographic area, cultural background and social habits . Tumorig® and Cervarix® . While Gardasil contains virus-like particles from HPV-16 and HPV-18, but also from low-risk carcinogenic genotypes 6 and 11, which cause benign genital warts, Cervarix contains virus-like particles from HPV-16 and HPV-18 only [The HPV proteins E6 and E7 play a key role in HPV-mediated carcinogenesis. In addition to inactivating p53, E6 can bind to transcription factors (myc), autocrine motility factors that regulate cell adhesion and polarity (paxillin), apoptosis-inducing factors (Bcl2) and replication and DNA repair factors (mcm7), while the E7 protein inactivates the retinoblastoma tumor-suppressor protein via proteasome-dependent degradation and causes p16INK4a overexpression, which can be detected on immunohistochemistry and can be employed as a reliable diagnostic marker of high-risk HPV infection . Interes-18 only .(+) and CD4+ T-cell response [The novel immunotherapy agent VGX-3100 , which is delivered via electroporation, is based on two property DNA synthetic plasmids that encode the E6 and E7 genes of HPV-16 and HPV-18 . Electroresponse . In a suresponse , 167 patresponse . Prognosresponse ,16. We sresponse . Of noteIn conclusion, although the industry may show little interest in rare diseases such as penile cancer, a continued effort should be made by independent investigators to contribute to advances in the treatment of such a devastating disease, given its high morbidity and mortality.


Oral Human Papillomavirus (HPV) infection is rare in the general population but common in high-risk individuals. Recent data indicate that oral HPV is associated with the development of head and neck carcinomas. HPV16 infection, in particular, increases the risk of oropharyngeal cancer.We evaluated oral HPV prevalence and determinants of infection in cancer-free HIV-infected and uninfected men who have sex with men (MSM) recruited among attendees of an STI/HIV centre. Oral rinse and gargles were collected using a mouthwash and analyzed with the Linear Array HPV Genotyping Test. Socio-demographic and behavioral data were collected through face-to-face interviews.Overall, 170 MSM participated: 98 HIV-uninfected and 72 HIV-infected (91.7% under cART). Oral HPV was detected in 17.3% and 27.8% of the subjects, respectively (p = 0.13). Non-carcinogenic HPVs were significantly more common among HIV-infected MSM . Prevalence of the HPV types included in the quadrivalent HPV vaccine was similar . HPV16 was the most frequent type in HIV-negative (5.1%), and HIV-positive individuals, in the latter group together with HPV18, 72 and 84 (4.2% each). Older age at first sex  and a higher lifetime number of receptive oral sex partners  were determinants of oral HPV among HIV-infected MSM.Oral HPV infection among MSM attending an urban STI center is very frequent compared to the general population. Sexual behavior appears to be the major determinant of infection among the HIV-infected individuals. Oral infection by Human Papillomavirus (HPV) increases risk for the development of oropharyngeal squamous cell carcinoma (OPSCC). HPV16 represents the genotype involved in the etiology of the majority of HPV-related OPSCC. Remarkably, oral HPV16 infection is associated with a 22-fold increased risk of incident OPSCC [5. They also showed that oral infection is more frequent in men than women (10.1% vs. 3.6%). Being male is in fact an established risk factor for prevalent oral HPV [Because of the role of HPV in the development of orophrayngeal cancer and the steady increase in the incidence of this neoplasia observed in several countries –4, interoral HPV .Sexual behavior plays a major role in the acquisition of oral HPV infections and changes in sexual activity are probably contributing to the increase in the incidence of HPV-positive OPSCC, together with changes in smoking habits, particularly among some populations. Importantly, specific sexual practices  that may enhance the exposure of oropharyngeal mucosa to HPV infection represent important risk factors for HNSCC ,9. A greDespite the fact that the epidemiology of oral HPV in high-risk populations has been increasingly investigated, only few studies have been conducted in Europe –20. SparWe conducted a cross-sectional study to evaluate oral HPV infection in HIV-infected and uninfected cancer-free MSM attending an STI/HIV centre, and to investigate the determinants of infection in the two groups.Oral/Oropharyngeal HPV in Men At Risk) study. Individuals that met the following inclusion criteria were included: 1. age ≥18 years; 2. sexual intercourse with a man in the preceding 6 months; 3. no history of HNSCC; 4. no clinically suspicious lesions for HNSCC, as ascertained during a full otolaryngology examination conducted at enrollment. HIV-infected MSM were also included in the study. Face-to-face interviews were used to collect socio-demographic data and risk factor information. Clinical, virological and immunological data of the HIV-infected patients were retrieved from their medical records. A written informed consent was obtained from the participants. All procedures were performed in accordance with the Helsinki Declaration. The study was cleared by the institutional Ethics Committee, I.F.O. Section –Fondazione Bietti (CE/417/14).From November 2014 to May 2016, all MSM attendees of the STI/HIV centre of the San Gallicano Dermatological Institute  were asked to participate in the OHMAR . Subsequently, the pellet was resuspended in 2 ml of PreservCyt.The Linear Array HPV genotyping test , which detects 37 genotypes  was used. Total nucleic acids were extracted from 250 μl of the PreservCyt sample using the Amplilute Liquid Media Extraction kit, part of the Linear Array HPV genotyping test, following the manufacturer’s instructions. 50 μl of the eluate was used for amplification. Automated detection was performed in a Profiblot T48 . Results were interpreted as indicated by the producer. Samples with presence of one or more HPV hybridization bands, independently from the presence of the internal control, represented by ß-globin, were considered as positive.Descriptive statistics were computed for all the variables of interest in order to provide summarized descriptions of the study population. Regarding drinking habits, participants were asked to indicate their consumption of wine, beer, and spirits separately: 350 ml of beer, 120 ml of wine, and 50 of spirits were considered as one dose of alcoholic beverage . Study subjects were then classified as follows: non-drinker ; light drinker (≤1 dose per day); moderate drinker (up to 3 doses per day); heavy drinker (>3 doses per day). Frequency of receptive oral sex was classified as follows: occasionally (<1 time per week), often (1–2 times per week), very often (≥3 times per week). The Mann-Whitney test was used for comparisons between median values. Socio-behavioral characteristics and lifestyle habits of HIV-positive and HIV-negative individuals were compared using Chi-square tests.Participants were considered positive for any HPV whenever at least one of the 37 types detectable by the Linear Array was evidenced in the oral rinse. HPV genotypes were considered as carcinogenic, possibly carcinogenic, or non-carcinogenic based on the risk assigned to each genotype by the International Agency for Research on Cancer , and as To assess the relationship between categorical variables, we used the Pearson’s Chi-square test and the Fisher Exact test, depending on the size of groups compared. A multivariate logistic regression model was generated for each of the two study groups. Both for the HIV-negative and positive MSM, the final model included: i) all the variables significant in the univariate assessment for any of the groups : age at first sex with a man, number of lifetime partners for any sex and receptive oral sex, number of recent partners for any sex and receptive oral sex, history of ano-genital warts; ii) covariates known to be associated with oral HPV based on the literature, regardless of their significance in the univariate analysis: age, smoking status, occasional partners for any sex and receptive oral sex. The multivariate logistic regression models were built using a stepwise regression approach (forward selection) and the related estimates reported as Adjusted Odds Ratio (AOR) and 95% Confidence Interval (CI). The enter and remove limits were p = 0.10 and p = 0.15, respectively. Statistical analyses were carried out using SPSS software .During the study period, a total of 170 MSM, mostly Caucasian , were recruited for this cross-sectional study: 98 (57.6%) HIV-uninfected and 72 HIV-infected individuals (42.4%).The main socio-demographic and behavioral characteristics of the participants are shown in The 72 HIV-infected participants had a median nadir CD4+ count of 300 cells/mm3 (IQR: 200–391). At enrollment, the median CD4+ count was 622 cells/mm3 (IQR: 479–817). Only 4 patients (5.5%) had received a diagnosis of AIDS. The majority of the HIV-positive individuals were on cART ; almost all the cART-experienced MSM  were aviremic at enrollment.A valid HPV test result was obtained for all the samples analyzed. Overall, HPV was detected in 37 of the 170 collected oral rinses (21.7%). Specifically, HPV infection was found in 17.3% and 27.8% of the HIV-negative and positive MSM, respectively (p = 0.13) . No signA total of 23 different HPV types were detected among HIV-infected MSM, while only 15 genotypes were found in the HIV-uninfected participants. Type-specific prevalence of all the genotypes found is shown in Associations between oral HPV infection by any HPV genotype and sexual behavior, STI history, oral health, and lifestyle (smoking and drinking habits) were investigated separately for each study group. The results of the univariate and multivariate analyses by HIV status are shown in HIV-uninfected MSM who reported a history of ano-genital warts were significantly more likely to harbor oral HPV infection .Among the HIV-infected MSM, the odds of oral infection increased with age at first sexual intercourse , the number of lifetime partners for any sex  and for receptive oral sex . A significant increase in oral HPV prevalence was also observed among those who reported more than 4 recent partners for any sex  and receptive oral sex . HIV-positive MSM who referred to having sex with occasional partners also showed a higher prevalence of infection . Oral HPV was more frequent among HIV-infected MSM of more than 40 years of age . Regarding the HIV parameters, a borderline association was observed with the CDC-93 stage. In fact, oral HPV infection was more frequent among individuals in stage C compared to those in stage A/B .Neither factors associated with oral health nor presence of tonsils appeared to modify the risk for oral HPV infection in the two study groups. After the beginning of the study, the otolaryngologist who performed the clinical examination was asked to rate the oral hygiene of the participants. This evaluation was available for 113 individuals. A non-significant increase in oral HPV infection was found for MSM with very poor/poor/fair hygiene.For the HIV-uninfected MSM, none of the covariates was retained in the final adjusted model. For the HIV-infected MSM, an independent association for oral infection by any HPV was observed with age at first sex with a man  and number of lifetime receptive oral sex partners .This cross-sectional study provided data on the overall and type-specific prevalence of oral HPV infection in HIV-infected and uninfected MSM. It also evidenced differences in the correlates of infection for these two groups of individuals. To the best of our knowledge, this is the largest Italian study on this topic. Epidemiological data on oral HPV infection may be useful to evaluate the potential impact of HPV vaccination on MSM, although very few data on the efficacy of the HPV vaccines against oral infection have been provided to date. The Costa Rica Trial has shown a reduced prevalence in the vaccinated women compared to the control group , but we In this study, we used oral rinse and gargles for the assessment of HPV infection. This type of sample, notwithstanding the inability to reveal the specific site of infection, has been shown to be better than other specimens for oral HPV detection ,21,27,28Our estimates for the prevalence of any HPV among HIV-negative and HIV-positive MSM are 4 to 7-fold higher in comparison with the prevalence observed in young adults recruited in Italy , while tHPV16 was the most prevalent genotype in both study groups, confirming that HPV16 is the most common genotype in oral infections, besides being by far the most frequent type in HPV-associated orophrayngeal cancers . NeverthOur study confirmed that oral HPV is more common among MSM with HIV infection. Although statistical significance was not reached, others have shown that HIV status is independently associated with oral HPV ,27. The We investigated socio-demographic variables, lifestyle, oral health and sexual habits in order to assess the determinants of oral HPV infection in the two study groups. We did not observe any association with recent oral sex behavior for the HIV-negative MSM, differently from other studies . In the Number of lifetime partners for oral sex emerged as a determinant of prevalent oral HPV infection among HIV-infected MSM, in line with previous studies ,32,34,35This investigation failed to evidence a role for several other variables known to be associated with the risk for oral HPV infection, such as oral sex ,34 and tWe also investigated the possible role of oral hygiene, since a large cross-sectional study has previously identified four different indicators of scarce oral health as being associated with increased likelihood of oral HPV , and pooAs regards the HIV parameters, we observed that HIV-positive MSM in C-CDC 93 stage, i.e., subjects diagnosed with an AIDS-associated disease, had a higher prevalence of infection, at borderline significance. This finding seems to suggest that a severe immunocompromised status favors oral HPV infection. However, we did not observe any significant association with nadir and current CD4 counts, consistently with other studies ,27,36,40Some limitations of the present study can be evidenced. Firstly, the analyses may have been underpowered due to the small size of the study groups. Secondly, the participants homogeneously reported a high risk sexual behavior, so our results may not be generalizable to all urban MSM. Finally, the group of HIV-infected MSM was largely lacking in individuals with severe immunosuppression and this may have limited the validity of the association measures between oral HPV infection and the parameters of immunodeficiency.In conclusion, this study showed that the prevalence of oral HPV in MSM is 3–5 fold higher in comparison with the general population and the infection is particularly frequent even among aviremic and immunologically balanced HIV-infected MSM. However, the sample size needs to be increased to have reliable estimates for the predictors of this infection. Since no established screening programs for OPSCC exist, further studies are needed to clarify whether or not individuals with oral HPV infection have to undergo specific management.


High-risk HPV (hrHPV) is related to cervical carcinogenesis, although clinical data comparing the natural history and carcinogenic potential of type-specific HPV remain limited. Furthermore, the nationwide prevalence rates of overall and type-specific HPV among women with cervical precancerous lesions and cancer have not been reported. Here, a meta-analysis was performed for type-specific HPV distribution among 30,165 HPV-positive women, including 12,094 invasive cervical cancers (ICCs), 10,026 cervical intraepithelial neoplasia grade 2/3 (CIN2/3), 3246 CIN1, and 4799 normal cervices from 45 PCR-based studies. We found that HPV16 was the most common hrHPV type involved in cervical disease. The HPV16 positivity rate varied little across normal (22.7%) and CIN1 individuals (23.6%) but increased through the CIN2 (37.6%) and CIN3 patients (51.9%) to 65.6% in ICC cases. HPV16, 18, 35, 39, 45, and 59 were more frequent in ICC than CIN3, with ICC:CIN3 ratios ranging from 2.3 for HPV18 to 1.1 for HPV35/45. HPV31, 33, 52, and 58 were more frequent in CIN3 compared with normal cervices but less common in ICC compared with CIN3 (ICC:CIN3 ratios ranging from 0.6 for HPV58 and 0.4 for HPV52). The ICC:normal ratios were particularly high for HPV18, 52 and 58 in West China  and for HPV45 and 59 in North China . In summary, this study is the most comprehensive analysis of type-specific HPV distribution in cervical carcinogenesis and could be valuable for HPV-based cervical cancer screening strategies and vaccination policies in China. Cervical cancer is the second most common female malignancy worldwide. In China, approximately 98,900 new cases were reported in 2015, which accounted for 18.7% of the global incidence . In thisCervical cancer incidence and mortality have been increasing and are a major public health problem in China. China has the world's largest population (approximately 1.37 billion), with approximately 70% of individuals living in rural regions where the incidence of cervical cancer is extremely high . Most ceIn this study, we performed a systematic review and meta-analysis of type-specific HPV distribution across the complete spectrum of cervical diagnoses from normal to invasive cervical cancer (ICC). With updated data and detailed analyses, we further evaluated how influential parameters  affected the results from the meta-analysis.We retrieved 1274 citations from the search strategy (Appendix S1), and 190 potentially relevant articles were identified for full-text review. Data were abstracted from 45 eligible studies that met the eligibility criteria –54. The Forty-five eligible studies published between 1996 and 2016, including forty-one single-center –50 and fA total of 49,997 eligible women from 32 provinces and municipalities were recruited to participate in these studies  . With regard to PCR primers, HPV prevalence was higher in samples that were tested using SPF1/GP6+  and/or SP10  primers when compared with MY09/11  and/or PGMY09/11  primers (P < 0.001). Meanwhile, the meta-analysis of the HPV prevalence in women with cervical cancer based on HPV DNA source, different region, publication calendar period, and PCR primers is shown in Table After stratified by HPV DNA source, we found that the prevalence rates of overall HPV types in cervical cancer from tissues were consistently significantly higher than that from exfoliated cells in all geographical regions .The quality assessment of all eligible studies was based on the Agency for Healthcare Research and Quality (AHRQ) scale, which is shown in HPV is a sexually transmitted infection, and high-risk HPV types have been shown to be the etiological agents of cervical cancer. Two meta-analyses have been published on the distribution of HPV types in the cervix among Chinese females, but the results were controversial , 56. FirIn these summarized data from China, we found that HPV16 was the most frequently detected hrHPV type in each cervical disease grade, and the positivity rate steadily increased from normal histology to ICCs among all geographical regions , indicatConsistent with previous epidemiological studies, HPV16, 52 and 58 were the dominant hrHPV types in the general Chinese population , 64. OurP < 0.001). Moreover, HPV18 was the most common alpha-7 type (44.4% in ADC vs. 9.1% in SCC), and similar patterns were also found for HPV39, 45, 59 and 68.Alpha-7 species containing HPV18, 39, 45, 59 and 68, which are proportionally overrepresented in ADC , are knoHPV35, 51, 56, 66, and 68 types found in < 1.5% of ICC represented an important proportion of low-grade cervical lesions. The lower ICC:normal ratios suggested that such types have relatively low carcinogenic potential. Of note, the ICC:normal ratios for HPV45 and HPV58 were consistently higher, suggesting a higher carcinogenic potential compared with all other non-HPV16/18 types.Meta-analysis on the prevalence of overall HPV types showed a higher rate detected in a subgroup of tissues than in exfoliated cells Table . HoweverIt is necessary to consider the limitations of our meta-analysis while interpreting the results. First, potential heterogeneity associated with the cross-sectional study design and its inherent risk of bias, including the variations in population characteristics, PCR-based HPV detection protocols, quality of diagnosis and cervical screening strategies among the studies, must be considered. Second, heterogeneity could not be ruled out even given the pre-designed subgroup analysis by geographical region, PCR primer sets and publication calendar period. To address this issue, we chose the random effect model meta-analysis to combine data. Third, 77.4% of the patients included in the meta-analysis came from only two macro-geographical regions of mainland China . Thus, one should be cautious when extrapolating our summary results to all regions of China. Fourth, several studies did not include for a broad range for type-specific HPV , 51, 53.Our present meta-analysis suggested a significantly increased risk of cervical cancer associated with high-risk HPV genotype infection. HPV16, 18 and 58 were the most frequently observed genotypes in cervical cancer specimens and showed a strong association with the development of cancer. However, the association between type-specific HPV distribution and cervical cancer risk was slightly influenced by factors such as geographical regions, HPV DNA sources, and PCR primers. It should be noted that the laboratory standardization and quality assurance of HPV genotyping methods may increase data comparability and improve virological surveillance in the future vaccine era of China.As this study was a systematic review and meta-analysis, we did not include any humans and/or animals. This study was approved by the Institutional Medical Ethics Review Board of Taizhou Hospital in Zhejiang Province.This meta-analysis was performed in adherence with the guidelines outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)   using consensus PCR primers, 2) overall and type-specific HPV elicitation, and 3) confirmed by cervical pathological diagnosis. The exclusion criteria were as follows: 1) duplicated data, 2) reviews, letters, conference reports or degree thesis, 3) studies on HIV patients or other sexually transmitted pathogens, 4) studies on gestational or vaccinated women, 5) HPV genotypes not stratified by lesion grade or fewer than 10 cases, and 6) HPV DNA types fewer than 3 high-risk genotypes identified.Two investigators (SS. Dong and XJ. Feng) independently extracted data from eligible studies. Disagreements were resolved by discussion or involvement of a third investigator (HH. Xu). For each eligible study, the following items were extracted: first author, publication year, region of China, study design, HPV DNA source, PCR primers, pathological diagnosis, sample size, and the number of overall or type-specific HPV-positive samples. For a subset of studies reporting such data, the overall prevalence of multiple infections  was also extracted. Detail information on all included studies is presented in https://www.ncbi.nlm.nih.gov/books/NBK35156/) [Two investigators (LZ. Zheng and A. Lin) independently assessed the quality/risk of bias for each eligible study according the quality assessment forms from the AHRQ (K35156/) . A thirdP values were two-sided, and statistical significance was accepted if the P value was 0.05 or less.We calculated the prevalence of the overall HPV and type-specific HPV  among Chinese women with cervical precancerous lesions and ICCs. Type-specific HPV prevalence was defined as the proportion of HPV-positive women in which a particular HPV type was detected, so sample sizes differed among the type-specific analyses. Odds ratios (ORs) and relative 95% confidence intervals (95% CI) were calculated using SPSS version 15.0 . 2 statistic quantified the heterogeneity among the studies, and P < 0.10 was considered indicative of significant heterogeneity. Forest plots were used to display the results graphically. To examine the potential publication bias, we used the Egger's and Begg's tests, where P < 0.05 was considered to be statistically significant. All analyses were performed using the R statistical software, and the Metaprop command was used as it provides appropriate methods for dealing with proportions with 100% [Meta-analysis was conducted using a random effects model. The Iith 100% .


In order to evaluate the newly implemented gender-neutral HPV vaccination program, knowledge on the pre-vaccine prevalence of HPV infection is of paramount importance. Data on HPV infection among the women with no known previous cytological abnormalities are inexistent in Austria. This study presents data on the prevalence and distribution of HPV genotypes among women with no known cytological abnormalities in west Austria.Women between 18 and 65 years of age attending annual cervical cancer screening examinations were included in the study. Data on socio-demographic and reproductive factors were collected using structured questionnaires. Corresponding cervical swab samples were tested for the presence of HPV DNA and were genotyped. Questionnaire data and HPV status were linked with the corresponding cytological findings.A total of 542 women were included in the study. The mean age of the study participants was 35.9 (SD = 11.5). The prevalence of HPV infection was 20.5 %. HPV 16 (6.5 %), HPV 33 (3.3 %) and HPV 31 (3.0 %) were the dominant genotypes detected. Multivariate analysis showed that women younger than 30 years of age, smokers, women with a higher number of lifetime sexual partners and those living in the eastern districts of the study region were at significantly higher risk of HPV infection.With this study we present the first data on the prevalence of cervical HPV genotypes among a screening population in Austria. The results not only fill the missing information on HPV infection in this group of women in the country, they also provide baseline data for a future evaluation of the impact of the Austrian gender-neutral HPV immunization program. Moreover, our finding of higher HPV prevalence in the eastern compared to the western district of the study region may – at least partly – explain the east–west gradient in the standardized incidence rate of cervical cancer in the region.The online version of this article (doi:10.1186/s12889-016-3581-0) contains supplementary material, which is available to authorized users. Genital human papillomavirus (HPV) infection is the most common sexually transmitted viral infection . It is m, Gardasil 9®  and Cervarix®  – have been approved for use [For the prevention of cervical and other genital neoplasia, three vaccines – Gardasil®  for use . Develop for use .In Austria these vaccines have been recommended and available for use since their approval , 12. HowData on the prevalence of HPV infection is scarce in Austria. Until the end of 2013 the only data available were those on HPV prevalence in cervical cancer samples . L RösslThe main aim of this study is to present data on the distribution of HPV genotypes among screening population of women in west Austria. With this study, we also aim to address the role of HPV infection in an interesting difference in the cervical cancer incidence observed between eastern (standardized incidence rate (SIR) in the range of 1.2 to 1.5) and western (SIR in the range of 0.6 to 0.9) districts of the study region . To our The study population included sexually active women aged 18–65 years undergoing routine gynaecological screening at five randomly selected gynaecological clinics in west Austria (Tyrol) between March 2013 and February 2015. Screening for cervical cancer in Austria is opportunistic in nature but is provided free-of-charge at a yearly basis. Women who have consented to participate in the study filled out questionnaires on socio-demographic, reproductive and sexual characteristics. The questionnaires were then sent back to our institute  with the corresponding cervical samples.For the ascertainment of persistent HPV infection, those women who tested positive for one or more of the known hrHPV types were invited for a follow up HPV testing approximately a year after the baseline.One of the two swabs taken from the patient was sent to our institute, the other one was sent to a pathology laboratory (Dr. P. O.) for cytological (PAP) examination. Cervical swabs were taken with Abbott Cervi-Collect specimen collection kit. DNA extraction (Biomerieux EasyMag 2.0) took place within 2 days of arrival of samples at our institute. The extracted DNA samples were stored at −20 °C until HPV testing.For the detection and genotyping of HPV, we used a two-step testing procedure. The first test is a real-time PCR that identifies the presence or absence of HPV DNA . The second step involves genotyping of all positive samples using a reverse line blot hybridization system . This genotyping kit was able to identify 40 different HPV types, including all high-risk, probable high-risk and low-risk types. Membrane stripes coated with genotype specific DNA probes are used to identify the different genotypes through hybridization of denatured PCR product. Multiple infections were easily detected. The analysis includes dUTP/UNG system for the prevention of contamination due to carry-over.Cytological examinations were interpreted according to Munich Nomenclature for the Cytological Diagnosis of Cervical Pap smears . In our P-values <0.05 were considered significant. Prevalence ratio of HPV infection was also computed across Tyrolean districts.HPV prevalence was computed in crude and age standardized manner. Chi square or Fischer’s exact test (two-tailed) were used for analysis of distribution of several hrHPV genotypes. Logistic regression model was used to compute odds ratios for HPV positivity across several variables including smoking status, educational level, marital status, number of life time sexual partners and age at first sexual contact with corresponding 95 % confidence intervals. Statistical analyses were performed in SPSS .Baseline characteristics of the study participants are presented in Table Immunisation coverage among the studied population was very low (3.7 %). The attitude of the study participants towards HPV vaccine is presented in Table Figure Fifty women 45.5 %) had HPV infection with multiple genotypes whereas the slight majority presented with single-genotype infections  as the clinical and diagnostic relevance of HPV infection is higher in women beyond the age of 30 (Table P = 0.53). Multivariable analysis of HPV prevalence in this age group showed still significantly higher HPV prevalence in the eastern compared to the western districts.Table P = 0.001) and for common high risk type infections (P = 0.035).The peak age of overall HPV infection, multiple infections and infection with the commonest genotypes lies between 21 and 25 years. This is followed by two lower peaks at 36 to 40 years and at 50 to 55 years. Figure The compliance for HPV re-testing a year after the initial test was low. A total of only 48 (47.1 %) women initially positive for any hrHPV genotype were re-tested 1 year after the baseline examination. Twenty five (52.1 %) of the infections were persistent. No statistically significant association was observed between HPV persistence and any of the sociodemographic factors.Data on cytological examination were available for a total of 384 women  seen among women aged 21 to 25 years. Although the overall prevalence was slightly higher than the crude HPV prevalence worldwide, the pattern of age specific HPV prevalence was shown to correspond to that seen in other regions –21. SligAs in several other studies, HPV 16 is clearly the most dominant genotype. It is detected in cervical samples of one out of 20 of the study population. Although HPV 18 is the second common genotype present in cervical cancer samples, it is obviously surpassed by several other genotypes among women with no known cytological abnormalities . GenotypOur study showed a threefold higher risk of HPV infection among current smokers, which persisted even after adjusting for other behavioural factors like number of lifetime sexual partners and age at first sexual contact. This might indicate that smoking per se predisposes to HPV infection as is also shown by other studies –33. TobaOur finding of higher HPV prevalence in eastern districts of Tyrol compared to those in the west seems to parallel the regional differences in cervical cancer incidence and mortality observed by W Oberaigner et al. . This asSurveys from several countries that have introduced free-of-charge HPV vaccination program since the approval of the vaccines have demonstrated a high vaccine coverage rate of more than 70 % , 34. AccThis study presents the first data on prevalence and genotype distribution of cervical HPV infections among women with no previously known cytological abnormalities in west Austria. Factors including smoking, number of life time sexual partners, age at first sexual contact and several socio-demographic factors, namely marital status and geographical region were identified as risk factors for age adjusted HPV prevalence. The finding of higher HPV prevalence in the eastern compared to the western district of the study region may - at least partly - explain the east–west gradient in the standardized incidence rate of cervical cancer in the region. The strikingly low HPV vaccine coverage may change with the recently introduced school-based vaccination program . On the


Several studies show that human papillomavirus (HPV) positive head and neck cancers (HNSCC) are typically characterized by low tumor and high regional node stages, intrinsically indicating high local metastatic potential. Despite this, the distant metastasis rates of HPV positive and negative HNSCC are similar. To date, majority of the studies focus on molecular characterization of HPV positive disease and on treatment outcome. Here we assessed the biological mechanisms of metastasis by combining in vitro and in vivo head and neck carcinoma xenograft models with patient data. We provide experimental evidence for a dual role of p16, a surrogate marker for HPV infections, in the metastasis process of HNSCC. We found that p16 regulates the invasiveness and metastatic potential of HNSCC cells by impairing angiogenesis. In parallel, we found that p16 is regulating the nodal spread by mediating lymphatic vessel formation through the upregulation of integrins. These findings not only provide understanding of the biology of the different dissemination patterns but also suggest that inhibition of lymphangiogenesis in HPV positive cancers and inhibition of angiogenesis in HPV negative cancers can form a treatment strategy against metastasis.The online version of this article (doi:10.1186/s12943-017-0678-8) contains supplementary material, which is available to authorized users. Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy worldwide with 600,000 cases every year and is associated with high morbidity and mortality . HNSCC pAlthough recent studies show favorable local and survival outcome of HPV related HNSCC patients, the distant metastasis (DM) rate is similar for HPV positive and negative HNSCC patients , 6. The p = 0.025) of HPV positive patients showing T1/2 stage tumors whereas this was 29%  in the HPV negative group. Moreover, HPV positive tumors showed significantly higher (p = 0.014) nodal involvement with 72% (42 out of 58) of HPV positive patients showing N2/N3 tumors whereas this was only 54% (95 out of 175) in the HPV negative group. Although the relationship between p16 status and N stage was not significant, a trend to higher nodal involvement and p16 positivity was seen. Sixty-three% of p16 positive patients showed N2/N3 tumors, whereas this was only 54% in the p16 negative group  patients treated with (chemo)radiation (c)RT. The human tumor samples were acquired according to protocols approved by the Ethical board of the University Hospitals Leuven  and implied consent of all the patients were obtained. Clinicopathological data were extracted from patient charts and the mean follow-up time was 4.19 years. HPV positive patients were characterized by lower T stages with 45%  for T1/T2 and T3/4 tumors respectively  showed a higher risk to distant failure compared to N0/1 tumors    rates with 5-year control rates of 83% and 70% , is a conduit for cancer cell spread and metastasis and promotes aggressive tumor progression , 21, 22.We further investigated the relation between angiogenesis and p16 with in vivo xenografts injected with SCC154 HPV positive cells manipulated with shp16 or shluc. A higher number of blood vessels was detected in mice tumors with low p16 expression compared to control tumors Fig. . FurtherThese results still do not explain the occurrence of the similar distant relapse rates in HPV/p16 positive and negative HNSCC patients and certainly do not explain the highly significant association between HPV positivity and nodal involvement described in our and several other studies , 16. Thip = 0.09), shluc tumors showed a higher percentage of integrin compared to shp16 tumors  in HPV negative cancers and by the inhibition of lymphangiogenesis  in HPV positive cancers. However, further preclinical and clinical studies are necessary to confirm these results and to investigate the utility and specificity of these treatment approaches.Additional file 1: Figure S1.P values are determined by log-rank tests. (PDF 411 kb)HPV/p16 positive and negative HNSCC patients show differences in nodal involvement. (A) Distant control (DC) rates in HNSCC patients with different T stages presented by Kaplan-Meier curves. (B) Distant control (DC) rates in HNSCC patients with different N stages presented by Kaplan-Meier curves (C) Distant control (DC) rates in HNSCC patients with different HPV status by Kaplan-Meier curves. (A-C) Additional file 2: Figure S2.n = 5. (B) Average number of mitotic cells in SCC154 shp16 and SCC154 shluc xenograft mouse models; n = 5. (C) Average tumor volume of SCC154 shp16 and SCC154 shluc xenograft mouse models assessed by caliper measurements; n = 5. (A-C) P-values are calculated by two-sided t-test. (PDF 351 kb)Dual role of p16 in dissemination of HNSCC. (A) Average tumor necrosis in SCC154 shp16 and SCC154 shluc xenograft mouse models; Additional file 3:Supplementary material and methods. Detailed description of the material and methods. (DOCX 19 kb)


Despite the advent of concomitant chemoradiotherapy (CCRT), the prognosis of advanced head and neck squamous cell carcinoma (HNSCC) patients remains particularly poor. Classically, HNSCC, especially oropharyngeal carcinomas, associated with human papillomavirus (HPV) exhibits better treatment outcomes than HNSCCs in non-infected patients, eliciting a call for the de-escalation of current therapies. To improve the management of HNSCC patients, we aimed to determine the impact of active HPV infection on patient response, recurrence and survival after CCRT in a population of heavy tobacco and alcohol consumers.Paraffin-embedded samples from 218 advanced HNSCC patients, mostly smokers and/or drinkers treated by CCRT, were tested for the presence of HPV DNA by surrogate type-specific E6/E7 qPCR and p16 immunohistochemistry. Associations between the response to CCRT and patient outcomes according to HPV status and clinical data were evaluated by Kaplan–Meier analysis and both univariate and multivariate Cox regression.p = 0.003) and non-smokers (p = 0.03). Survival analyses also revealed that the outcome is compromised in stage IV patients (p = 0.007) and, in particular, for oral cavity, hypopharynx and oropharynx carcinoma patients (p = 0.001).Type-specific E6/E7 PCR demonstrated HPV positivity in 20 % of HNSCC. Regarding HPV status, we did not find any significant relation with response to therapy in terms of progression-free survival or overall survival. However, we observed a significantly worse prognosis for consumers of alcohol and tobacco compared to nondrinkers (The risk of death from HNSCC significantly increases when patients are exposed to tobacco and alcohol during their therapy, regardless of HPV status. Head and neck squamous cell carcinoma (HNSCC) represents the fifth most common malignancy diagnosed worldwide. In 2012, HNSCCs accounted for approximately 59.000 new cases in the USA and more than 77.000 in Western and Eastern Europe . These cancers form a group of heterogeneous tumors presenting distinct etiology, histology, risk factors and treatment approaches. Over the last twenty years, a clear increase in the incidence of oropharyngeal and oral cavity carcinomas has been observed, particularly in young adults in both the US and Europe, whereas the incidence of laryngeal carcinomas tended to remain stable or decrease slightly  in the early 2000s occurred in the phase III trial of Forastière et al’s study  infection has emerged as an additional risk factor and could be involved in increased worldwide incidence of a subset of HNSCCs, especially oropharyngeal cancers  who underwent concomitant chemoradiotherapy at the Saint-Pieter Hospital (Brussels) and Epicura Hospital (Baudour). Patients treated by cisplatin or Erbitux concomitant with radiotherapy were included in this study, and more than 95 % of the patients were stage III or IV. The response to treatment was evaluated three months after the end of treatment based on a clinical examination (endoscopy) and imaging technique (CT scan or MRI). On the basis of their cigarette and alcohol exposure, participants were classified as current, former or non-smokers and nondrinkers. Smokers/drinkers were defined as patients who continue to smoke and/or drink during their treatment, while formers include patients who stopped their consumption at diagnosis or for years before. Non-smokers and nondrinkers are individuals who have never used tobacco or alcohol. The clinical data collected from this series of 218 HNSCC patients are detailed in Table n = 218) were sectioned (10 × 5 µm), deparaffinized, and digested with proteinase K by overnight incubation at 56 °C. DNA was purified using the QIAamp DNA Mini Kit  according to the manufacturer’s recommended protocol. All DNA extracts were tested for the presence of 18 different HPV genotypes using TaqMan-based real-time PCR, as described previously   and response to CCRT. All statistical analyses were performed using Statistica  and SPSS 15.0 Inc. .Independent groups of categorical data were compared using the Pearson Chi-square test. Progression-free survival (PFS) and overall survival (OS) data were measured in terms of months from the date of diagnosis until disease recurrence or death or until the date at which the patient was last known to be alive. Standard survival time analyses were performed using Kaplan–Meier curves. For comparing two (or more) curves, univariate analyses were performed using the Cox regression model to estimate hazard ratios (HR), 95 % confidence intervals (CI), and associated p = 0.003) (data not shown). Gender did not significantly impact survival, although women seemed to present a higher lifetime survival (p = 0.11)    . In this subgroup of patients, there was a clear predominance of smokers  compared to patients who are former smokers  or who did not consume tobacco . In addition, about half of the patients were drinkers , but the proportion of nondrinkers was also high . However, no significant relation was found between HPV status and clinical data, including gender, smoking status, alcohol status, TNM stage, and treatment (Table The HPV+/p16+ group was composed of more men than women ranging from 48–79 years of age and mostly presenting stage IV disease (3 stage III and 14 stage IV) (Table p = 0.7) , there was no significant difference in the rate of responders versus non-responders because the percentage of responders versus non-responders was only slightly higher in HPV− (55 vs. 45 %) and HPV+/p16+ patients (53 vs. 47 %) (p > 0.05). Regarding Fig. p = 0.4).We did not observe any significant difference between the three populations of patients grouped by HPV status in terms of recurrence and survival Fig. a, b. Indp = 0.03)   and observed a significant association between smoking and a worse prognosis (03) Fig. a. Consis03) Fig. b.Fig. 4Sp = 0.025; HR 1.55; 95 % CI 1.06–2.27; Fig. p = 0.02)   Fig. d. We proMultivariate Cox regression models detailed in Table Locally advanced HPV+ HNSCCs represent a challenge for clinicians in terms of treatment strategy. This group of patients raises many therapeutic questions, including the choice of optimal treatment modality and the implications of HPV infection on the prognosis and response to CCRT. In our large population-based study, we demonstrated that the HPV status was neither associated with the response to CCRT nor the survival of HNSCC patients. We therefore reviewed previous studies examining HPV infection, response to CCRT and survival Table . We notiWide geographic variation has been reported regarding tobacco and alcohol consumption in Europe. Indeed, in western and eastern countries, the vast majority of patients are avid consumers, whereas a greater decline in smoking habits was observed among Norwegian, Finnish, and Dutch populations (Giskes et al. The effect of tobacco use on disease recurrence was also examined among patients with HPV-positive oropharyngeal carcinomas. The typically good prognosis of HPV+ oropharyngeal carcinomas was not observed in our at-risk population. In fact, the HPV+ smoker group exhibited an increased risk of recurrence and distant metastases as well as reduced survival compared with the HPV+ non-smoker group (Maxwell et al. Moreover, there is increasing support that HPV has developed several mechanisms to escape from immune surveillance and to maintain infection. Additionally, the tobacco use is known to suppress immune function, thereby facilitating persistent infection. Thus, the immunosuppressive mechanisms of smoking may prevent the patient from activating immunologic responses to eradicate the viral infection (Arnson et al. At this time, our data have demonstrated that active HPV infection cannot be used as a prognostic tool in non-oropharyngeal cancer patients. Our analysis is subject to limitations related to the low available number of HPV+/p16+ specimens as supported by a recent meta-analysis demonstrating that transcriptionally active infection rates are generally low for oral cavity and larynx cancer with 16.3 and 8.6 %, respectively (Gama et al.


Use of non-traditional settings such as community pharmacies has been suggested to increase human papillomavirus (HPV) vaccination uptake and completion rates. The objectives of this study were to explore HPV vaccination services and strategies employed by pharmacies to increase HPV vaccine uptake, pharmacists’ attitudes towards the HPV vaccine, and pharmacists’ perceived barriers to providing HPV vaccination services in community pharmacies. A pre-piloted mail survey was sent to 350 randomly selected community pharmacies in Alabama in 2014. Measures included types of vaccines administered and marketing/recommendation strategies, pharmacists’ attitudes towards the HPV vaccine, and perceived system and parental barriers. Data analysis largely took the form of descriptive statistics. 154 pharmacists completed the survey (response rate = 44%). The majority believed vaccination is the best protection against cervical cancer (85.3%), HPV is a serious threat to health for girls (78.8%) and boys (55.6%), and children should not wait until they are sexually active to be vaccinated (80.1%). Perceived system barriers included insufficient patient demand (56.5%), insurance plans not covering vaccination cost (54.8%), and vaccine expiration before use (54.1%). Respondents also perceived parents to have inadequate education and understanding about HPV infection (86.6%) and vaccine safety (78.7%). Pharmacists have positive perceptions regarding the HPV vaccine. Barriers related to system factors and perceived parental concerns must be overcome to increase pharmacist involvement in HPV vaccinations. Almost 80 million people are infected with HPV in the United States, and most sexually active individuals will contract some form of HPV during their lifetime . HPV str strains . In the  strains . Further strains . This lo strains .Barriers to initiation and completion of the HPV vaccine series reported in existing literature include lack of recommendation by primary care providers, cost, insurance coverage, necessity of multiple visits to primary care providers, and parental concerns . Also, aPharmacists are increasingly becoming accepted as immunization providers for adult vaccinations by patients, physicians, and national organizations in the United States , and gloThis study utilized a cross-sectional survey of community pharmacies in Alabama. The unit of analysis was at the pharmacy level. One key informant represented each pharmacy; they included pharmacy owners, managers, or staff pharmacists. All procedures were approved by the first author’s Institutional Review Board as an expedited review. The sampling frame used in this study to select community pharmacies was Hayes’ Directory, a database of community pharmacies in the United States, which provided name, mailing address, county name, telephone number, and fax number for each community pharmacy. Pharmacies that did not serve the typical public  or dispense medications were excluded from participation. Pharmacies were not required to provide HPV vaccination services in order to participate in this study. Of the 1176 community pharmacies in Alabama, 350 community pharmacies were randomly sampled. The decision to invite 350 pharmacies was made after careful consideration of the balance between survey costs and survey errors. Based on our previous survey studies with community pharmacies, we anticipated response rates to fall between 30% and 40%, which would result in an expected sample size of 105–140 ,20. SettThe survey was administered from June to August 2014 based on a modified version of Dillman’s Tailored Design Method . To maxi“How much do you agree or disagree with the following statements about the parents of teens and adolescents and their perceptions regarding HPV vaccine?” with answer choices ranging from strongly disagree to strongly agree. Survey questions assessing vaccination services and strategies to increase uptake were informed by our prior research in vaccination services, while items measuring perceptions of HPV and the vaccine were modified from an existing instrument utilized by Khan and colleagues [The survey was comprised of 65 questions and required approximately 15 min to complete. Measures can be categorized into five sections: (1) key informant and pharmacy site demographic characteristics; (2) general vaccination services and strategies used to increase HPV vaccine uptake; (3) pharmacists’ perceptions of HPV and the vaccine; (4) perceived system barriers to the provision of HPV vaccinations; and (5) perceived parental reasons for HPV vaccine hesitancy. The majority of questions were formatted as 5-point Likert-type rating scales. For example, lleagues . To asselleagues ,24,25. Llleagues . The survey questions were written and refined by the research team. To ensure the content validity of survey questions, the research team consulted with a licensed pharmacist. After changes were made, the survey was pre-tested with 6 community pharmacists in Alabama in order to assess the face validity of the included measures. Based on their feedback, minor modifications to the formatting and answer choices were made to improve clarity. Due to their participation in pre-testing of the survey questions, these 6 pharmacists were excluded from the sampling frame prior to selecting the random sample. A non-response investigation was conducted after survey completion to determine if respondents’ demographic characteristics and the vaccination services they offered differed significantly when compared to non-respondents. Community pharmacies that did not respond to survey requests were randomly selected and contacted via telephone. Using a five-minute structured telephone interview, scripted interview questions gathered information regarding key informant and pharmacy site demographics as well as general vaccination services provided. Non-respondents’ data was aggregated and compared to that of respondents to assess any differences. All data analysis was performed using IBM SPSS Statistics version 22 software . Descriptive statistics were used to describe respondent characteristics, current vaccination practices, attitudes, and barriers. Comparison of non-respondents and respondents to investigate non-response bias was completed using one-way analysis of variance for continuous variables and chi-square for categorical variables. A significance level of 0.05 was used for all statistical analyses.A total of 154 pharmacies completed the survey (44% response rate). Of the 18 pharmacies that reported having the HPV vaccine available in stock, only 5 pharmacies had actually administered the HPV vaccine, averaging less than 2 doses in the past year. Three of the five pharmacies that provided the vaccine in the past 12 months did so through a written protocol with a physician, while another stated that they contacted a physician they had worked with in the past in order to obtain a prescription for the patient allowing them to administer the HPV vaccine. The fifth pharmacy administered the HPV vaccine only after the patient obtained and delivered a written prescription from his or her physician. Although only 18 pharmacies reported having HPV vaccine in stock and only 5 had actually administered the vaccine in the past 12 months, 36 (31.9%) indicated that they planned to offer or continue offering the vaccine in the next 12 months.It is worth noting the various marketing strategies the 5 pharmacies that administered the HPV vaccine in the past 12 months employed. Methods reported to market HPV vaccinations included: general flyers accompanying dispensed prescriptions, billboards, posters at the pharmacy, and generic telephone messages. When asked if they used a system to identify patients who were eligible for their first dose of HPV vaccine, 3 of 5 said no; they did not use any personalized methods to market their HPV vaccination services. When comparing general vaccination strategies used by those pharmacies that had administered the HPV vaccine in the past 12 months to those that had not, the proportion using flyers, generic telephone messages, billboards, and posters were similar . PharmacPharmacists reported a number of perceived system barriers to providing HPV vaccination services . Over haHPV vaccination rates are disproportionately low in the Southern United States, which is especially concerning due to the higher rate of cervical cancer in this region when compared to other regions of the U.S. . UtiliziPharmacists generally reported positive perceptions of the HPV vaccine; however, there were many perceived system barriers identified that could be limiting the provision of this vaccine in the community pharmacy setting. Some of these barriers are related to the vaccine itself while others are related to coverage and reimbursement for the vaccine. Lack of reimbursement has been identified in previous research as a barrier to general vaccine provision ,28. CounOverall, the results of this study show that a greater proportion of pharmacists rated perceptions of parental concerns and hesitancy as likely barriers to a greater extent when compared to the system-related factors. This suggests that while system factors may hinder the provision of HPV vaccination services, pharmacists’ perceptions of parental concerns and hesitancy may be more of a factor in impeding pharmacists’ from making recommendations to parents. This is not surprising, as many system-related barriers may have already been addressed in the development of immunization services for other vaccinations. Looking specifically at parental concerns, the majority of pharmacists believe that parents lack adequate understanding regarding the HPV infection in general. This perception may be valid, as studies in southern regions have reported that parents have limited knowledge and awareness of the HPV infection and HPV vaccine ,31. OverResearch has shown that provider recommendations are a key factor influencing vaccine uptake . HoweverThis study has several limitations that must be considered. First, although the overall response rate was 44% (154 pharmacies out of 350 sampled), only 5 respondents (3.2%) reported administering the HPV vaccine in the past 12 months, which might limit meaningful interpretation of pharmacies’ marketing strategies to increase HPV vaccinations. HPV vaccine specific marketing strategies used by respondents who had not administered the HPV vaccine in the past 12 months were not assessed. It is possible that these pharmacies were using HPV vaccine specific marketing strategies but that they were not successful. Future research should further examine marketing strategies in greater detail, including variations in success for specific vaccines. Furthermore, identification of potential vaccine recipients is the first step. As such, future research should assess how pharmacists identify potential recipients and their confidence in doing so. While this study assessed pharmacists’ attitudes toward the HPV vaccine, pharmacists’ confidence in speaking to parents and patients about the vaccine was not addressed. This is an area of future study that will be necessary for the development of suggested educational training programs. Additionally, a greater proportion of key informants were female (57.5%) and employed as pharmacy managers (54.5%). Thus, the study’s findings may not be generalizable to all pharmacists in Alabama. Also, the study’s population of interest was community pharmacies in Alabama, and therefore results may not be generalizable to community pharmacies in other countries and areas of the United States. As this study collected self-reported attitudes and behaviors, social-desirability and recall bias may be a concern. Finally, individuals who responded to the survey may differ from non-respondents. However, no statistically significant differences were found in the non-response bias investigation. Pharmacists have positive attitudes regarding provision of the HPV vaccine to teens and adolescents. However, system factors and perceived parental concerns may prevent pharmacists from engaging in the provision of the HPV vaccination in community pharmacies. Overcoming these barriers is necessary to increase pharmacist involvement in HPV vaccinations. Strategies to do so may include pharmacy staff training, reminder systems, and physician partnerships among others.


In the natural history of HPV infections, the HPV virions can induce two different pathways, namely the infec- tious virion producing pathway and the clonal transforming pathway. An overview is given of the burden that is associated with HPV infections that can both lead to cervical cancer and/or temporal subfertility. That HPV infections cause serious global health burden due to HPV-associated cancers is common knowledge, but that it is also responsible for a substantial part of idiopathic subfertility is greatly underestimated. The bulk of the detected HPV DNA whether in men or women is however infectious from origin. Because the dissociation between HPV viruses and HPV virions or infection and disease remains difficult for clinicians as well as for HPV detection, we propose a review of the different effects caused by the two different HPV virion induced pathways, and highlight the mechanisms that are responsible for causing transient subfertility and cancer. For almost two decades it has been recognized that infection with human Papillomavirus (HPV) is one of the major causes of infection-related cancer worldwide , as wellStill today there is debate whether a virus is alive or not and this is largely due to semantic differences in the definition of what a virus is or which characteristics are needed to describe its biological entity. It was only at the end of last century that Bandea proposed the idea that virus and virion are distinct entities . AccordiIn the vegetative state or mature phase of the viruses, their component molecules are dispersed within the host cell. There is less debate for the infectious particles or virions not being viruses. The infectious particle is designed for the transmission of nucleic acid genome among host or host cells and for HPV the problem lies in the fact that DNA based tests detect both virus and virions since they contain the same viral DNA. Because viral HPV DNA can be present in both virions and virus and in both non- dividing virion producing cells as well as in HPV viral transformed dividing cells. The distinction on a molecular base can be hard to make, the effects however are quite different. If we accept that the virus is the infected cell, then it becomes obviously clear that pathologists and clinicians have confused the virion and the virus.By dividing the ontogenetic HPV cycle into its different phenotypic phases we demonstrate that the HPV virions lie at the bases of both temporal subfertility and in some rare cases of cancer .A good example of confusing virus and virion is HPV DNA measurement. HPV is a circular double stranded DNA virus comprising 6 early  and 2 late genes (L1 and L2) and when only a part of the viral genome is measured it becomes even more difficult to separate virions from viruses. The expression of E6 and E7 oncogenes is required for maintaining the malignant growth of cervical cancer cells, specifically by inhibiting the tumour suppressors p53 en RB . They arDetection of HPV RNA does not allow to distinguish between virion and virus either because part of the double stranded HPV DNA can denature to single strand DNA and be picked up by RNA tests since the HPV RNA and DNA sequence are identical .Because none of the current HPV tests take into consideration the origin of the detected HPV DNA, the specificity of HPV based tests to detect disease is low, and triage of HPV positive women remains a problematic issue .We therefore proposed to use serial type specific viral load measurements (≥ 3) to differentiate between transient virion producing HPV infections and HPV transformed clonal cell populations .That the HPV infectious life cycle is closely linked to the differentiation state of the stratified epithelium it infected, has been known for some time . The HPVFirst the HPV virion infects cells of the poorly differentiated, proliferative, basal compartment of stratified epithelia. In these cells with dividing capacity, the viral genome sets up residence as a low-copy nuclear plasmid, with only a subset of viral genes (early genes) expressed at low levels, and no virions are made. HPV virions are very infectious, with a very low multiplicity of infection, 1-10 viral genome equivalents per cell is sufficient to establish infection . The recAlthough the infectious virion producing and clonal cell-transforming pathway can occur simultaneously at a single location (e.g. cervix) in patients  lesions, HPV DNA is present in episomal form that can be assembled into virions, whereas in the majority of the cervical tumours it is integrated into the host cell genome  Cullen .The sole purpose of virion production is to secure the survival of the HPV organism. By producing massive amounts of new virions in non-dividing cells, HPV ensures that it can infect new target cells.Ironically in the case of temporal subfertility, early reports start with the detection of HPV in amniotic fluids from pregnant woman with cervical lesions . It is iAlthough a number of studies followed showing that an infection with HPV during pregnancy is associated with the risk of spontaneous abortion , prematuAlso here it is clear that both HPV virion and HPV virus have been measured simultaneously and has resulted in apparently contradictory results confusing the role of HPV in abortion. For some papers/authors the study on HPV detection on pregnant women  argues aIn studies were the localization of the HPV DNA was also performed, it is clear that trophoblast are involved . TrophobIronically it is these kind of cells that were used to describe the HPV 16 and HPV 31 life cycle  cells that are producing virions, for women however a substantial amount of HPV DNA detected at the cervix has a clonal origin  and leadA recent meta-analysis and systematic review of HPV prevalence in semen identified 27 studies reporting HPV DNA prevalence in 4029 semen samples varying from 0 to 100% . For theHPV infection can exerts its detrimental effects in different ways through its virions. The free virions can bind the spermatozoa’s head and directly reduce sperm motility, and while some find DNA strand breakages in spermatozoa exposed to HPV E6/E7 fragments  others dSince 1994 a growing number of studies demonstrated a possible correlation between HPV sperm infection and cases of idiopathic asthenozoospermia and unexplained infertility .Almost 20 years before HPV virions were shown to attach to two distinct sites at the spermatozoon’s head  and was associated with histological acute chorioamniotis . The stuIt is clear that in cervical HPV infection during pregnancy both the virion producing and clonal transforming pathways are involved. Whereas premature rupture of the membranes , spontanA recent study showed that prophylactic HPV vaccination in men improves the clearance of HPV semen infection .That the transformation of a clonal cell population by the E6/E7 HPV oncogenes can be detrimental for the patient is evident. But also for the HPV virus it means the end of its life cycle since dividing cells do not allow to produce infectious progeny. That the small fraction of HPV DNA present in cervical and other HPV induced cancers are self-limiting and do not allow infectious spreading of HPV viruses did not stop the HPV viruses from being intimate with humans for the last 500 000 years. This half million year old relationship argues against resolving HPV infections as a result of a cell-mediated immune response because the interaction between the virus and the host's immune system strongly influences viral evolution .Papillomaviruses (PV) are well adapted to their host, and can in most instances complete their life- cycle and be maintained in the population without causing any apparent disease . Such chLooking at the overview of HPV induced processes, defined on the basis of dividing and non-dividing HPV DNA harbouring cells, a strong immune response would be surprising considering the scare contact of virions with the host immune system. Unlike other viruses, HPV does not infect or replicate in antigen-presenting cells of the epithelium nor induce cell lysis, so there is no chance for antigen-presenting cells to present antigens derived from the virion to the immune system. In real life this results in seroconversion of only 50% of infections present in the patients, the production of antibodies usually occurs only months after the initial infection , and somA recent systematic review and meta-analysis on fertility and early pregnancy outcomes after treatment for CIN showed a higher overall pregnancy rate for treated women than for untreated women  . SuggestConsidering the incomplete data of the HPV effect on fertility and conflicting results from studies with control groups showing an effect of HPV on sperm parameters and studies without control groups unable to show an HPV effect on measured sperm parameters , it is nFrom our own data from a prospective study on HPV typing of 142 semen samples from 62 sperm donors, on the residual semen material of the semen sample used on the day of insemination, only 3 from the 62 donors were positive for oncogenic HPV (4.84%). None of the 7 inseminations from these HPV positive donors resulted in a pregnancy in any of the 5 women who underwent an intra uterine insemination on the day of ovulation. In the remaining 135 inseminations, 20 pregnancies were achieved. In the group of IUI with husband/partner semen 13.85% (59/426 IUI cycles) were performed with high-risk HPV positive semen. Based on this observation it could be highly beneficial for assisted reproductive technology methods if one could establish a link between the presence of a HPV infection and a significant decrease in the success rate of IUI. According to the results report generated from European registers by ESHRE for the year 2012  a total Only a systematic prospective study including an appropriate number of husband/partner or donor semen used in IUI should allow to establish a potential link between HPV infected semen and a low pregnancy rate in IUI. From cost/benefit point of view the cost of systematic HPV screening on IUI semen should be compared to the benefit of avoiding IUI treatments with low pregnancy rate prognosis.When reviewing the evidence it seems evident that determining the origin of the detected HPV DNA is the key to predict the impact of the HPV infection.When the detected viral HPV DNA originates from a dividing cell, the detected HPV DNA is never infectious (dividing cells do not support virion production) and does not affect fertility, but the viral DNA can transform the dividing cell it resides in, which could in time lead to pre-cancer and cancer. High-risk HPV types have oncogenes (E6/E7) that produce oncogenic proteins that can transform dividing cells or even leads to blocking of the cell division of the early embryo. It always leads to a self-limiting HPV infection since no progeny virions can be made and the HPV life cycle ends.When the detected viral HPV DNA originates from non-dividing differentiated cells or from free virions, it is infectious and exerts its deleterious effects thru weakening or incapacitating the cells it resides in. For the already dying epithelial cells the new virions are released when the cells desquamate and allow to restart the HPV life cycle (HPV is not a lytic virus). In embryos the accumulation of newly formed virions in the syncytiotrophoblasts results in the weakening of the implantation bond with the endometrium and diminished energy uptake leads to miscarriage. For spermatozoa the binding or internalization of viral DNA also leads to a decrease in functionality of sperm .Although in the majority of cases only one of the two HPV induced pathways is present, in almost one fifth of HPV infected women (18%) both the virion producing and HPV transforming pathway occurs at the same time. In most cases multiple HPV types are present , but it Independent of the number of HPV types detected, serial measurement of type specific viral load allows to identify the origin of the detected HPV DNA and makes it possible to assess the impact of the HPV infection for cancer screening or fertility.Although HPV is not a lytic virus, harbouring its DNA will ultimately lead to cell death or immortality depending on the cell type.