Cervical cancer risk is associated with low education even in an unscreened population, but it is not clear whether human papillomavirus (HPV) infection follows the same pattern.Two large multicentric studies  including nearly 20 000 women. GP5+/GP6+ PCR was used to detect HPV.vs 1–5 years=1.50, 95% confidence interval (CI): 1.25–1.80 and 0.69, 95% CI: 0.57–0.82, respectively, P for trend <0.0001). In contrast, no association emerged between education level and HPV infection in either of the two IARC studies. A majority of the women studied had never had a Pap smear. The association between low education level and cervical cancer was most strongly attenuated by adjustment for age at first sexual intercourse and first pregnancy. Parity and screening history  also seemed to be important confounding factors.Education level was consistently associated with cervical cancer risk (odds ratio (OR) for 0 and >5 years The excess of cervical cancer found in women with a low socio-economic status seems, therefore, not to be explained by a concomitant excess of HPV prevalence, but rather by early events in a woman's sexually active life that may modify the cancer-causing potential of HPV infection. Cervical cancer risk is associated with a low socio-economic status (SES), as defined by education or income levels , and posIt is now believed that the majority of cervical cancer is preceded by a long-term infection with high-risk types of the human papillomavirus (HPV), a sexually transmitted infection , that is, the IARC Multicentric Case–Control Study . Owing to small numbers, the last two groups were merged in the case–control studies. Regularised logistic regression  and study area. Adjustment was also made for lifetime number of sexual partners , age at first sexual intercourse , husband's extramarital sexual relationships , number of full-term pregnancies , age at first pregnancy , use of hormonal contraceptives and condom , smoking , and history of Pap smear , as reported.χ2 statistic. For purposes of assessing heterogeneity, study areas with five or fewer individuals in a given category of education were not considered, as they could not provide OR estimates. All statistical tests were two-sided.Heterogeneity of ORs between study areas was tested by fitting separate models to each area and then comparing the observed with the expected dispersion of estimates around the pooled mean using a Results in the text are presented as ORs with conventional CIs. Where results are presented in the form of plots, floating absolute risks  were usevs 1–5 years=1.50, 95% CI: 1.25–1.80; and 0.69, 95% CI: 0.57–0.82, respectively, P for trend <0.0001) in case–control studies . In contrast, education level was not associated with HPV positivity among control women   .vs 6–10 years=1.03, 95% CI: 0.90–1.18; 0.88, 95% CI: 0.76–1.02; and 1.06, 95% CI: 0.87–1.28, respectively, P for trend=0.67)  . Althougvs >5 years of education was 1.41 (95% CI: 1.11–1.79), that is, 47% lower than the OR adjusted for age and study area only.The influence of adjusting for different confounding variables on the association between cervical cancer risk and education (dichotomised as ⩽5 and >5 years) in the case–control studies is shown in Education level was inversely and consistently associated with cervical cancer risk, but not with HPV prevalence, in a broad range of world populations included in the IARC studies. The lack of excess of HPV positivity in low-education women was consistently found among control women in case–control studies , as well as in the larger number of women included in the HPV prevalence surveys that were carried out in part in different countries than the case–control studies.Obviously, education level cannot be considered as a well-defined exposure, but as a marker for a combination of characteristics that predominate among women with a low SES. The aim of our study was not, therefore, to rule out bias and confounding, but rather to evaluate the principal risk factors responsible for any socio-economic gradient.In screened populations, education level is most likely to be a surrogate of inadequate screening  and husband's sexual behaviour   and ear


Previous cross-sectional data suggest a positive association between serum cholesterol and brain neoplasms, but the results of cohort studies are inconclusive. There is evidence that in women the growth of meningiomas and astrocytomas depends on the hormonal status. The present investigation comprised data on serum cholesterol and beta-lipoprotein concentration among 229 participants in a health survey with subsequently diagnosed central nervous system (CNS) tumours. Data analyses included comparison of mean serum cholesterol and beta-lipoprotein level between cases and randomly selected controls--five for each case, matched for sex, age at screening and time of examination. The results showed a positive relation between the beta-lipoprotein level and the development of a CNS tumour  in women under 50 years of age, and a negative association in those of older age with development of malignant tumours, which implies a possible influence of the menopausal status. Repeating the computations after excluding cases diagnosed within 5 years from screening revealed significant associations also between the serum cholesterol concentration and the development of a malignant CNS tumour, with a pattern similar to that of beta-lipoprotein. In conclusion, in women, irregular variation in the beta-lipoprotein level, which is involved in the synthesis of progesterone in the CNS, may enhance oncogenic transformation of astrocytes and meningeal cells; however, transformation of the latter is restricted to younger women.


Genital warts, which are caused by infection with human papillomavirus (HPV), are one of the most common sexually transmitted diseases in Europe. Although genital warts are commonly perceived as a non-serious condition, treatment is often long, of varying effectiveness and the recurrence rate is high. Very few studies have been performed on the personal consequences of genital warts. The aim of this qualitative study, set in Denmark, was to examine the ways in which genital warts may affect patients' quality of life.To obtain an in-depth understanding of patients' perceptions of genital warts, we used qualitative focus-group interviews with five men and five women aged between 18 and 30 years who had genital warts. The interview guide was based on a literature review that identified important issues and questions. The data were analysed using a medical anthropological approach.Patients' experiences were related to cultural conceptions of venereal diseases and the respective identities and sexuality of the sexes. The disease had negative psychological and social effects both for men and for women and it affected their sex and love lives, in particular. The psychological burden of the disease was increased by the uncertain timeline and the varying effectiveness of treatment. We identified a need for more patient information about the disease and its psycho-sexual aspects.The men and women participating in this study considered their quality of life to be significantly lowered because of genital warts. The experiences described by the participants give insights that may be valuable in treatment and counselling.The quadrivalent HPV vaccine that has now been added to the childhood vaccination programme for girls in Denmark for the prevention of cervical cancer can also prevent 90% of cases of genital warts. Our results suggest that HPV vaccination could considerably reduce the largely unacknowledged psychological and social burden associated with genital warts, in men as well as women. It was recently reported that 10.6% of women aged 18-45 years in northern Europe have had genital warts (GWs) and that the incidence of GWs among young women is rising . The treGWs are caused by infection with certain types of human papillomavirus (HPV). More than 100 types of HPV exist, of which between 30 and 40 are associated with the mucosa and skin of the anogenital area -8. Appro®) protects not only against HPV types 16 and 18, which cause approximately 70% of cervical cancers, but also against types 6 and 11 and thus has the potential to prevent 90% of GWs . But it wasn't exactly like that. Now, I've changed my perception pretty much. I'm really sick of it now. [23-year-old woman]A few participants regarded GWs as a very serious condition because they thought that GWs increased the risk of developing cervical cancer. The majority, however, considered that GWs had mainly important psycho-sexual effects on their quality of life.The majority of participants indicated that it was their sex and love life that had suffered most from having GWs. Their libido was low and their sexual initiative was reduced, and pleasure and spontaneity was often lost during intercourse because of awareness of the warts, fear of transmitting the disease or repulsing the partner, negative self-perception and soreness due to treatment. This affected steady relationships and for those who were single it affected their ambition to seek a new partner.It [the GW] has definitely had a huge impact on my sex life. It's a barrier for meeting new girls. 'Cause I stand there thinking "Wow, she's nice. I'd like to take her home". But then, I don't want to approach her 'cause... I'm simply not up to explaining it. To me, it has meant that I don't really feel like going out and looking for a new steady partner. That also totally destroys your self-confidence, I mean, that you actually lose the desire to meet girls. [26-year-old man]The participants described themselves as 'impure, repulsive and sexually unattractive' and seriously questioned how others might find them attractive when they did not even like themselves. Problems often arose in existing relationships because of worries about the source of the infection or a lack of sexual desire. Men, in particular, often felt a pressure for sexual affirmation.I think they [the GWs] affect you a lot, especially when you kind of lose the desire for sex. I mean, it's not that you don't think your girlfriend's attractive or anything... It's like, it affects you psychologically and you say: "No, I don't think so. I don't really care that much for myself when I'm like this". This resulted in my girlfriend feeling that I didn't find her sexy or beautiful, and just saying that she is wasn't enough all of a sudden. And you can't really do much more, 'cause if you don't feel like having sex, well, you just don't feel like it, damn it! [...] One of the most tedious aspects of being treated with cryotherapy is that nothing bloody works until the ulcers heal again - and then you have to almost train it again afterwards. It's also really stressful in that when it finally works again, you feel that you have to perform because the tool has been out of order for a while. At least, until my girlfriend and I talked about it, I felt that she had these expectations: "Well, are you able today?" And if you're able, you sort of have to, 'cause: "Jeez, there's only four days until your next treatment so we better make use of the time". I felt like there was this pressure. [22-year old man]The psychological, social and sexual effects of having GWs are all interrelated. Some participants had feelings of guilt or anger because they had not protected themselves and others more carefully. Some men were annoyed that they had put off seeking treatment for too long. All participants had developed lower self esteem and a negative body-perception as a result of the disease.Sometimes, when you think about it or you notice them [the GWs], you just become so discouraged and sad because...you can't do anything about it. I mean, you just have to wait and there's nothing you can do yourself, is there? And then I get this feeling that I simply can't relate to my own body or even look at it. Then I feel repulsive, you see? [21-year-old woman]With time, the participants had learned to live with the disease to some extent, but the lengthy course of treatment, the powerlessness and uncertainty as to when it would end were wearing. The realisation that the disease can remain dormant and return later in life added to the perception of GWs as a serious condition. For the participants who had had symptom-free periods, the psychological impact was severe when the GWs reappeared.Because of fear of stigmatisation, the participants wanted to control who knew they had GWs. They were worried that others might find them unclean, careless or "of easy virtue" - the latter applied to men as well as women. They were afraid that the disease would be an important factor in shaping others' opinions about them.You're afraid of being stigmatised. I remember having heard that somebody had a venereal disease... And that's just what you'll always remember about them, even if you don't even see them anymore. Or if you've heard that about a girl that you might have thought was quite cute, then you would think "wasn't it her who had that thing?" In the same way you think that's probably how others will think about you when you have GWs, that they think "Oh, it's that guy with GWs". That's why I have only told people I'm very close to. [30-year-old man]Several participants mentioned that the disease is particularly stigmatising because it is infectious and they were concerned about people's ignorance about the danger of infection. As a consequence, some participants stopped doing sport or other activities that might reveal their disease. Some women felt unattractive because they could not shave intimately as well as they would have liked. Some men were concerned that others might spot the GWs or the ulcerations caused by treatment. The fear of stigmatisation also meant that the participants avoided informing other people that they were attending the venereal diseases clinic for treatment. Many had to take significant time away from their studies or work that was not easy to explain. Most participants had only spoken about their disease to their closest relatives and friends.The participants found that different physicians managed individual treatments and the complete course of treatment for GWs in different ways. Many expressed frustration with a course of treatment that seemed to be inconsistent and experimental. Their expectations of medical solutions were at odds with the fact that there is no 'magic bullet' against this disease. The varying effectiveness of treatment had a considerable impact on the patient's state of mind; improvement or disappearance of the GWs was met with delight, while a recurrence or worsening of the GWs had a correspondingly negative effect.Several participants expressed a huge need for more knowledge about GWs. Men in particular said they did not like to ask for the information and would have preferred to be offered information about good hygienic practices, how to avoid infection (for themselves and others), the realistic prospects of the course of the disease and its possible psychological and sexual effects.These were the kind of things that there was little information about [in the leaflets that the patients were handed at the clinic]. I mean, that you're not alone in feeling that it hurts your soul when you've got this and that you can have problems with your sex life and all such things. There isn't one single leaflet on dangerous diseases, such as AIDS, where it doesn't say something about those psychological things. It's like it [GW] isn't taken that seriously, because after all, it doesn't do that much harm. Even though you actually have a lot of questions like that and there are all these psychological things that hit you... [23-year-old man]The participants in this study all expressed a significant reduction in their quality of life as a result of having GWs. The unknown delay to cure, the uncertain perspectives of recovery as well as their inability to control their disease all had a negative psychological effect on them. The stigma associated with the disease affected their self-perception and their social lives. The fact that they had GWs was difficult to ignore because they were constantly reminded, in particular, by the repeated treatments, the disruption of their social lives and the negative effects on their sex and love life Figure . These rGWs was considered to be a serious disease, especially by those participants who associated GWs with an increased risk of developing cervical cancer, because both are caused by human papilloma viruses (HPV) . The resIn this study, qualitative methodology was used to obtain an in-depth insight into the experiences of patients with GWs. The method of recruitment of the participants may have introduced some selection bias. Patients with a more negative experience of GWs may be more likely to volunteer to participate in a study of this kind. However, the patients with GWs attending the venereal diseases clinic at Bispebjerg Hospital are considered to be representative, in terms of the severity of their symptoms, of Danish patients with GWs in general, in that often they attend the clinic without having previously received treatment elsewhere or they are referred by a general practitioner after just a few attempts at treatment. Finally, the age of our participants may explain why, unlike those in some studies ,33,35, tWe do not think that more focus-group interviews would have produced more qualitative knowledge about the experiences of this age group since the results are consistent with those of previous studies. However, further studies could investigate the effect of GWs on the quality of life of older patients or among ethnic minorities. Since the first publication of the results of this study ,a followThis study contributes to our knowledge about patient perspectives on HPV-related diseases and it suggests that GWs affect men as much as women, psychologically, socially and sexually. Men and women in this study described experiences that were related to cultural perceptions of venereal diseases and the respective identities  of the sexes. Cultural notions of the male identity, sexual desire and performance were at odds with the feelings of vulnerability and lack of desire expressed by these men. Our results suggest that there is a considerable need for more patient information about the disease and improved doctor-patient communication. Men, in particular, seemed to experience psychological barriers to seeking information and counselling. It is clear that although GWs are not a life-threatening disease from a medical practitioner's point of view, they have wide-ranging effects on the patient's quality of life, and these need to be taken into consideration.The development of vaccines against HPV is a milestone in the prevention of GW, as well as cervical lesions and cancer. The quadrivalent HPV vaccine that has now been added to the childhood vaccination programme for girls in Denmark could prevent 90% of genital warts. Our results suggest that HPV vaccination could contribute substantially to reducing the largely unacknowledged psychological and social burden associated with genital warts, in men as well as in women.GLM has received a research grant for this study from Sanofi Pasteur MSD. The study was conceived and the protocol was developed independently of this funding. HKL: NoneGLM conceived the study and its design, carried out the data collection, analysed and interpreted the data and drafted the manuscript. HKL participated in the inclusion of patients, drafted the medical parts of the manuscript and revised the whole manuscript critically for important intellectual content. Both authors have read and approved the final manuscript.GLM has a MA in social anthropology and is specialised in medical anthropology. She currently works as a research consultant at AnthroConsult specialised in qualitative patient studies.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/113/prepub


Given the high burden of cervical cancer in low-income settings, there is a need for a convenient and affordable method for detecting and treating pre-cancerous lesions.Samples for comparing the accuracy of cytology, virology and histology were collected. Identification of HPV E6/E7 mRNA was performed using PreTect HPV-Proofer. HPV DNA detection was performed by GP5+/6+ PCR, followed by reverse line blot (RLB) for typing.A total of 343 women, aged 25–60 years, attending gynaecological polyclinics in DR Congo were included for sample enrolment. The test positivity rate was conventional and liquid-based cytology (LBC) at cutoff ASCUS+ of 6.9 and 6.6%, respectively; PreTect HPV-Proofer of 7.3% and consensus DNA PCR for 14 HR types of 18.5%. Sixteen cases of CIN2+ lesions were identified. Of these, conventional cytology identified 66.7% with a specificity of 96.2%, LBC identified 73.3% with a specificity of 96.9%, all at cutoff ASCUS+. HR-HPV DNA detected all CIN2+ cases with a specificity of 85.9%, whereas PreTect HPV-Proofer gave a sensitivity of 81.3% and a specificity of 96.6%.P<0.0001).Both HPV detection assays showed a higher sensitivity for CIN2+ than did cytological methods. Detecting E6/E7 mRNA from only a subset of HR HPVs, as is the case with PreTect HPV-Proofer, resulted in a similar specificity to cytology and a significantly higher specificity than consensus HR HPV DNA ( In African countries, the incidence of cervical cancer is high, particularly in Sub-Saharan Africa, where cervical cancer is the most common form of cancer among women , naked eye visual inspection using acetic acid or lugol iodine of the uterine cervix and molecular methods for HPV detection , in addition to HPV DNA- and mRNA-based assays, for detecting histologically confirmed cervical intraepithelial neoplasia grade 2 or worse (CIN2+) in a mixed population , to determine the most effective screening tool for pre-cancerous lesions in African countries. The study was set up in a high-risk urban area in the eastern part of the Democratic Republic of Congo, which has been affected by civil war and violence against women for more than a decade.In low-income countries, screen and treat strategies, with complex triage schemes, are preferable, but specificity is then an indispensable criterion to avoid treating large proportions of the screened population. In this paper, such a strategy was developed. A high-risk population was chosen, to guarantee identification of cases of CIN2+. Sensitivity and specificity estimates can be considered as representative for an African female population consulting gynaecological services; however, positive predictive values are expected to be inflated because of the relatively high prevalence of CIN2+.The study was approved by the ‘Regional Committees for Medical Research Ethics’ in Norway and was performed in accordance with the ethical standards set by the Declaration of Helsinki 1975, revised 2000. It was carried out in agreement with the ethical recommendations of the provincial health authorities in Bukavu because of the absence of a local ethical committee. All aspects of the study protocol was thoroughly discussed by Congolese physicians, co-authors of this paper, who were highly qualified to evaluate any ethical issues.Women attending three gynaecological clinics in Bukavu, Democratic Republic of Congo, during November and December 2003 were recruited for the study.A health worker informed all women about the study. A printed consent form translated into the local language was signed by the participants. Demographic data and information about reproductive health were obtained. Exclusion criteria were pregnancy, severe gynaecological bleeding, previous hysterectomy and age <25 or >60 years. The examination and sampling procedures are presented in Gynaecological examinations were carried out by gynaecologists and general practitioners, all of whom received intensive training during a 2-week introduction course given by a Norwegian expert in low-resource gynaecology and gynaecological oncology.PAP smears, PreservCyt vials and histological material were stored at room temperature and shipped to Norway and Sweden for preparation and interpretation by well-experienced cytotechnicians and pathologists.Histological material ) was obtained from all women for gold standard verification of the disease status, thereby detecting as many women with cervical disease as possible and also reducing verification bias.Biopsy samples and ECC material were immediately transferred into PreservCyt vials. Histological examinations were carried out by an experienced pathologist (AKL) at the Norwegian Radium Hospital (Oslo) according to the WHO classification  and positive smears were reviewed by a cytopathologist (BR). Slides for LBC were prepared and interpreted at the Sahlgrenska University Hospital  using a ThinPrep-3000 processor and an automated slide preparation unit, producing uniform thin-layer slides. All results were categorised according to the 2001 version of The Bethesda System . The extracts were stored at −80°C.Nucleic acids (DNA/RNA) were isolated at NorChip AS  using the NucliSENS manual extraction kit  as previously described  was used, focusing on the reportedly most common oncogenic HPV types 16, 18, 31, 33, 35, 45, 51, 52 and 58  according to the manufacturer's instructions .To avoid false negatives due to degradation of mRNA, primers and probes against human U1A mRNA are included in the PreTect HPV-Proofer kit as a performance and integrity control.Presence of HPV 35, 51, 52 and 58 E6/E7 mRNA was analysed by NASBA using specific primers and molecular beacons for each HPV type. Artificial oligonucleotides corresponding to the viral mRNA were used as positive controls (NorChip AS). Negative controls consisted of Rnase-free water and were included in each run.β-globin gene were included as DNA control.The same nucleic acid extracts were used both for the NASBA assays and for HPV DNA detection by PCR, the latter using the consensus primer GP5+/6+ with an enzyme immunoassay readout as previously described .χ2-test was used to study associations between two categorical variables. Exact binomial confidence intervals (CIs) were computed where appropriate  were included in this study. The women came from different locations from the province of South Kivu (Democratic Republic of Congo).In Altogether, 16 out of 343 women had CIN2+ (eight cases with CIN3), which translates into a prevalence of 4.7% (95% CI: 2.7–7.5%). No cancers were diagnosed in the study, most probably because severe gynaecological bleeding was one of the exclusion criteria. Histology was unsatisfactory in 30 cases (8.7%), and these cases were left out of the overall statistical calculations, leaving a total of 313 cases. Three of the 16 CIN2 or worse lesions were identified in cone specimens, which were taken because of jointly positive cytology (HSIL) and nucleic acid assays (HR types) in spite of benign/low-grade histology in the punch biopsy.Four of the 16 (25.0%) CIN2 or worse lesions were diagnosed in women from whom standardised punch biopsy samples were taken because of the absence of colposcopically suspicious areas.In 72 of the 343 (21.0%) women, a colposcopic normal impression was observed, but colposcopy was regarded as unsatisfactory because the squamocolumnar junction was not visible.In 40.9% of women, a positive colposcopic finding was noted, whereas in 6.3% a CIN2 or more serious lesion was suspected. Regarding the unsatisfactory colposcopic impressions, the histological outcomes were in 88.9% obtained by sampling with ECC, the results of which were benign in 79.7% of cases, low grade in 6.3%, high grade in 1.6% and unsatisfactory in 12.5%.Nine PAP (2.6%) and 14 liquid-based smears (4.1%) were assessed as unsatisfactory. Almost 7% of satisfactory smears were considered abnormal ASCUS+, : HSIL orβ-globin DNA control. The PCR amplification followed by the EIA revealed the presence of HPV DNA in 104 out of the 343 women (30.3%). In all, 77 of the 104 HPV DNA-positive cases (74.0%) were positive by the EIA mixture A, which included all high-risk HPV types; 46 of 104 (44.2%) were positive for the EIA mixture B and 19 of 104 (18.3%) cases were positive for both the A and B mixtures.The HPV DNA results obtained in the cytological material are presented in n=30) were excluded and the subsequent genotyping data were limited to the 14 HR types or the five HR types targeted by the PreTect HPV-Proofer, the positivity rate was reduced to 58 (18.5%) or 28 cases (8.9%), respectively.When unsatisfactory histology samples , 13.9% were found to be DNA positive in histologically normal cases, 15.8% in HPV/CIN1 lesions and 100% in CIN2 or more serious lesions. Twelve of the 16 (75.0%) CIN2+ cases tested positive for DNA of HPV types 16, 18, 33 and/or 45. Eight of the CIN2+ cases were diagnosed as CIN3 and all were DNA positive, which gave 100% sensitivity and 83.6% in specificity (accuracy of 84.0%).When comparing DNA positivity (14 HR types) with the different histological diagnoses . Furthermore, the specificity of the HR-HPV DNA assay was significantly lower than both cytology methods at cutoff ASCUS+ for outcome CIN2+ (P for McNemar's χ2 lower <0.0001).Sensitivity of HR-HPV DNA detection  for CIN2+ (100.0% 95% CI:82.9–100.0%) was significantly higher than that of both cytology methods, even at cutoff ASCUS+ . The most frequently detected HPV mRNA type was 45, followed by HPV 18 and HPV 16. Thirteen of 16 (81.3% sensitivity) biopsy samples confirmed to be CIN 2+ were positive for one of the five types presented in the PreTect HPV-Proofer assay. E6/E7 mRNA of one or more of four additional types, HPV 35, 51, 52 and 58, was found in 11 cases. Seven of the eight CIN3 cases were mRNA positive for one of the five types presented in the PreTect HPV-Proofer assay, which gave a sensitivity of 87.5 and 94.8% in specificity (accuracy of 94.6%). The last CIN3 case was DNA 66 positive.We found 3.7% PreTect HPV-Proofer positives in women without CIN, no positives in CIN1 and 81.3% in CIN2+. The most ideal combinations of HPV types detected by NASBA giving maximum sensitivity and specificity (with the nine types) for detection of CIN2+ are shown in Among samples that were both HPV mRNA and DNA positive, a 73.0% concordance in typing results was obtained when the criterion was full identity of all detected types including multiple infections. In 10 cases, we observed a discrepancy between one or more HPV types  and becaCompatible results between HPV mRNA and DNA tests (meaning at least one common type in a given sample between these tests) were found for 83.8% of the positive cases.In this study, cervical samples from 343 women have been investigated in a low-income setting by different cytological and HPV molecular methods to give an overview over test characteristics and to seek an alternative to cytology. To our knowledge, this is the first study performed in Africa that has included HPV mRNA analyses and that involved full gold standard information. As all samples were tested with all methods including histology, this may also be one of the rare studies related to cervical pre-cancerous stages without the need for correction of verification bias.The prevalence of CIN2+ (4.7%) was high but not exceptional compared with other African settings in the same geographical area: 5.3% in Kinshasa (DR Congo) and 5.6% in Brazzaville (R Congo) (Four of the 16 (25.0%) CIN 2+ cases were diagnosed by taking punch biopsy samples standardised at the 12 o’clock position, which are in accordance with previous results . The higBy both PAP and LBC, a high proportion of histologically confirmed CIN2+ lesions were diagnosed as normal or low grade (10 of 16).The DNA assay , focusinP-value for McNemar's χ2 test was 0.32 and 0.16 for differences in sensitivity and specificity, respectively, between DNA and mRNA testing when including the same number of HPV types.An assay with 14 high-risk types yielded a specificity of 85.9%, which is relatively low compared with, for example, cytology that reached a specificity of 96.2%. A cocktail of HPV16-18-31-33 and 45 (similar to PreTect HPV-Proofer) in a DNA assay would give a sensitivity of 75.0% and a specificity of 94.6%. This is lower than those of PreTect HPV-Proofer assay  for the same HPV types. On the other hand, DNA analysis with a different set of five types  yielded similar sensitivity and specificity values for CIN2+  as PreTect HPV-Proofer. The vs 99.0%). The second most prevalent mRNA HPV type in CIN2+ was HPV 18 and a combination of only HPV 16 and 18 showed a sensitivity of 56.3% and a specificity of 99.0%. Maximum sensitivity (93.8%) was attained by targeting six types: HPV 16-18-33-35-51-45, showing a specificity of 95.3%.For the mRNA-based assay, HPV 16 would also be the first type to be included  in an idPreTect HPV-Proofer showed higher sensitivity for CIN2+ than for LBC or PAP, considering ASCUS+ as cutoff. Adding four more HPV mRNA types (HPV 35-51-52-58) resulted in the detection of two more CIN2+ cases. However, by including these four additional types, the number of false positives was increased by eight cases.vs 81.4–89.6% P<0.0001) and the NASBA 9 types (95% CI: 90.6–96.4 vs 81.4–89.6% P<0.0001) were significantly more specific for CIN2+ than for HR-HPV DNA (14 types) detection.Finally, both the the PreTect HPV-Proofer  was not significant. Nevertheless, the 2.5% higher accuracy obtained by PreTect HPV-Proofer and the favourable effects of using five types instead of nine types regarding cost and the follow-up in a low-resource setting give basis to prefer PreTect HPV-Proofer over a nine mRNA-type assay. The reason for including additional mRNA types was to determine whether one or more of these extra types could be particularly prevalent in this area in which no former HPV epidemiological data exist. The data did not give reason to believe that this was the case.The difference in specificity for detection of CIN2+ using five HPV mRNA types Small differences in HPV-type distribution in cervical carcinomas exist between different parts of the world. However, in the meta-analyses performed by The main problem with HPV DNA testing for all 14 HR types is the high test-positivity rate, namely, 18.5% in the population examined in this study.vs 56.5%).This translates into twice the test positivity rate compared with the PreTect HPV-Proofer assay. Despite a very high negative predicted value of this assay  test will develop cancer), more than 75% of all HR HPV infections will not persist  and therOwing to the fact that a number of CIN2 or worse lesions spontaneously regress and that the golden standard, histology, often does not accurately identify the malignant disease, the ‘perfect test’ may therefore actually be located to the left side and below the 100% mark of sensitivity in the ROC diagram . The accIn many settings in low-income countries, there is a need for robust testing systems with good (but not necessarily the highest possible) sensitivity and specificity and applicable on the spot (giving the test result on the same day). A test targeting only the five most prevalent HPV types in cervical cancer could fulfil this criterion. In our study, such a five-type DNA test resulted in a sensitivity of 75.0% and a specificity of 94.6%, using CIN2+ as threshold for disease. With PreTect HPV-Proofer, the sensitivity and specificity were 81.3 and 96.6%, respectively. A reasonable hypothesis is that 18.7% of the CIN2 or worse lesions would have a low chance of progression. However, the cross-sectional design does not allow the confirmation of this hypothesis. A combination of both types of restriction and the fact that PreTect HPV-Proofer detects mRNA have resulted in a higher accuracy for PreTect HPV-Proofer compared with HR-HPV DNA. Even if the number of CIN2+ cases is relatively small in this study, we still see a contribution to the increasing sensitivity (75.0%–81.3) and specificity (94.6–96.6%) when including the same five HR HPV types in an assay performing an mRNA compared with a DNA-based assay.The HPV DNA testing in Africa has been suggested by several experts, as has HPV mRNA testing. However, to date, there is limited information on the possibilities of using HPV-based tests in Africa. This study demonstrated for the first time that collection and storage of mRNA for molecular analysis is feasible in a low-income setting.The most realistic way to screen for management of cervical cancer in low-income settings is by adopting a ‘screen-and-treat’ strategy . TherefocareHPV test, based on the hybrid capture 2 (hc2) test , detecting 14 high-risk types, is one of these tests. careHPV is more feasible for usage in low-resource areas than is hc2; it is less expensive but is relatively nonspecific , indicates a potential value of PreTect HPV-Proofer as a diagnostic method in areas without cytology-based screening possibilities.The combination of over two times higher PPV and a significantly higher specificity than HR-HPV DNA, in addition to a substantially higher sensitivity than cytological PAP at cutoff ASCUS+ (81.3 In this study, PreTect HPV-Proofer showed a lower sensitivity for identifying CIN2+ compared with HR-HPV DNA typing with 14 types. Longitudinal studies are necessary to answer whether this difference in sensitivity is significant in terms of missed cancers. However, the pooled analyses indicate that the five types included in PreTect HPV-Proofer cover approximately 90% of HR HPV-positive cervical cancers worldwide (


A study has been made of the relationship between socio-economic factors and the incidence of acute lymphoblastic leukaemia (ALL) of childhood. It was found that the incidence of childhood ALL in 12 areas of Queensland. Australia, correlated well with some indicators of above-average socio-economic status for these areas. A similar result was found when Brisbane City was studied separately. Social class was determined from the fathers' occupations at the time of diagnosis. There was found to be a higher than expected number of ALL cases in each of the upper 5 social classes and a lower than expected number in the remaining 2 lower classes. Factors associated with differences in lifestyle amongst the various social classes may increase or decrease the risk of development of ALL.


To investigate the prevalence of, and risk factors for, cervical infection with human papillomavirus (HPV) in Shenyang City, People's Republic of China, we interviewed and obtained cervical cell samples from 685 women aged 15–59 years enumerated from local population lists. Human papillomavirus DNA was detected in cervical cell samples using a GP5+/6+-based PCR assay for 44 HPV types. Human papillomavirus prevalence was 16.8% overall and 13.6% among women without cervical abnormalities , with no significant trends in HPV prevalence by age group. Of the 32 types identified, high-risk HPV types predominated in all age groups, HPV16 being the most common , followed by HPV52 (2.5%) and 58 (1.9%). Multiple-type infections accounted for 31.3% of all infected women. Not being married, reporting multiple sexual partners and husband's extramarital sexual relationships were all significantly associated with being HPV-positive. The disclosure of a relatively high HPV prevalence in Shenyang, in comparison with other worldwide populations, raises important questions concerning the prevention of cervical cancer in China, especially given the promising efficacy of prophylactic HPV vaccines. Human papillomavirus (HPV) has been established as a necessary cause of cervical cancer, and HPV prevalence in any given population correlates well with cervical cancer risk (http://www.stats.gov.cn). No recent data on cervical cancer exist from the city. The present study aimed to collect data on the age- and type-specific distribution of HPV infection in the urban environment of Shenyang, China, in the framework of a multicentre study coordinated by the International Agency for Research on Cancer (IARC)  did not accept the invitation to participate in the study, mainly citing that they did not have enough time or did not think they needed a gynaecological examination. The proportion of nonparticipation was largest (31.2%) among women under 25 years of age. Of an additional 293 interviewed participants who came to the study clinic but refused to undergo gynaecological examination and, hence, a cervical cell specimen collection, 273 (93.2%) were unmarried.All participants signed an informed consent form according to the recommendations of the IARC and the Cancer Institute of the Chinese Academy of Medical Sciences ethical review committees, which approved the study.Study procedures were identical to those reported in a preceding IARC HPV prevalence survey in China  for HPV positivity and corresponding 95% confidence intervals (CIs) were calculated by means of unconditional logistic regression equations, adjusted for age . The statistical significance of trends for ORs was assessed by considering the categorical variables as a continuous variable in the logistic model.β-globin-negative samples, leaving 685 women with valid cytology and HPV results, which were included in the analyses that follow. Among them, 29 (4.2%) had histologically confirmed cervical abnormalities, including 19 CIN1, eight CIN2 and two CIN3.Of the 707 women who provided cervical cell samples, eight had inadequate cytology results and 14 had The prevalence of any HPV type was 16.8%  than low-risk types (6.4%). The most common types in either single- or multiple-type infections were HPV16 (3.4%), 52 (2.5%) and 58 (1.9%), but HPV type distribution varied by the presence of cervical abnormalities. High-risk HPV types were found in 79.3% of women with cervical abnormalities. The two women identified with CIN3 were HPV16-positive.vs 1 partner⩾2 =1.8, 95% CI: 1.1–3.0) and husband's extra-marital sexual relationships  were significantly associated with HPV positivity. Intrauterine device was the most commonly used contraceptive method (78.4% of study women), followed by condoms (58.1%), whereas only 11.5% of study women reported any oral contraceptive use. There was no significant association between HPV positivity and the use of any type of contraceptive method.No significant association was found between HPV positivity and education level, occupation, smoking (reported by only 6.4% of women), age at menarche, menopause or first birth, number of births, or history of spontaneous or voluntary abortion (reported by 73.6% of women). Only 44 women reported to have had at least one previous cytological smear (data not shown).When we evaluated correlates of positivity for high-risk HPV types only, findings were similar to those found for any HPV type (data not shown).Compared with similar studies in China using comparable methodology, our age-standardised HPV prevalence estimate in Shenyang (17%) is slightly higher than that in the central rural province of Shanxi, known to be at high cervical cancer risk (14%, In contrast to previous studies in high-resource countries .As approximately 80% of HPV infections are estimated to be cleared in 12 months (The reporting of indicators of sexual behaviour, such as number of sexual partners and husband's extramarital sexual relationships were confirmed, as elsewhere (As in most previous population-based surveys (Our present study has strengths and limitations. Among the former, the use of highly sensitive PCR assays and invitation of a representative sample of the general female population. The main limitation of the present study was the lack of complete participation of invited women. However, as HPV infection is asymptomatic, it is unlikely that participation was related to women's HPV infection status. Obtaining cervical cell specimens from unmarried women was confirmed to be difficult (In conclusion, in the present absence of data on cervical cancer incidence and/or mortality, the disclosure of a high HPV prevalence would suggest an important underlying cervical cancer burden in Shenyang and similar Chinese populations. The historical picture of China being at relatively low-risk for cervical cancer may not apply to the whole country, and may be changing as a result of the marked behavioural changes accompanying rapid industrialisation and urbanisation. This has implications for the future cervical cancer burden and the priority to be given to preventing cervical cancer in China, especially, given the promising efficacy of prophylactic vaccines against HPV16 and 18.


Ptrend= 0.04). Women who smoked 6+ cigarettes/day had a RR for HSIL/CA of 2.7 (95% CI = 1.1–6.7) compared to non-smokers. Current use of barrier contraceptives was associated with a reduction in risk of HSIL/CA . Sexual behaviour and a self-reported history of sexually transmitted diseases (STDs) other than HPV were not associated with HSIL/CA. Oral contraceptive use was associated with HSIL/CA among women with <3 pregnancies. Effects were similar in analysis restricted to women positive for high-risk HPV types. Among women positive for high-risk HPV types, 44% of HSIL/CA could be attributed to multiparity (≥3 pregnancies) and/or smoking. Among HPV-positive women, multiparity and smoking are risk factors for HSIL/CA. Oral contraceptive use may be associated with HSIL/CA in subgroups of women. © 2001 Cancer Research Campaign http://www.bjcancer.com We examined factors associated with high-grade squamous intraepithelial lesions (HSIL) and cervical cancer among human papillomavirus (HPV)-infected women in a prevalent case–control study conducted within a population-based cohort of 10 077 women in Costa Rica. We compared 146 women with HPV-positive HSIL or cancer (HSIL/CA) against 843 HPV-positive women without evidence of HSIL/CA. Subjects completed a risk factor questionnaire. We evaluated the associations between exposures and HSIL/CA among women positive for any HPV and restricted to those positive for high-risk HPV types. Risk of HSIL/CA increased with increasing number of live births (


Human papillomavirus (HPV) testing is included in the cervical cancer screening program in the triage of women with equivocal (ASC-US) or low-grade (LSIL) cytological lesions. These women have an increased risk for developing high grade dysplasia and cancer (CIN2+) compared to women with normal cytology. However, in order to avoid unnecessary follow-up, as well as overtreatment, a high positive predictive value (PPV) of the triage test is important.The HPV test PreTect HPV-Proofer, detecting E6/E7 mRNA from the HPV types 16, 18, 31, 33 and 45, is used as triage test together with repeat cytology. PPV data for HPV E6/E7 mRNA testing during the period from January 2006 up to June 2009 are reported. In total, 406 of 2099 women (19.3%) had a positive HPV test result. Of the women with a positive test result and with a histological diagnosis (n = 347), 243 women had histological high-grade dysplasia or cancer (CIN2+), giving a PPV of 70.0% . For HPV 16 or HPV 33 positive women above 40 years of age, the PPV was 83.7%  and 84.6%  respectively. The PPV of test positive women with HSIL cytology was 94.2% .When the result in triage is HPV mRNA positive, our data suggest direct treatment for women above 40 years of age or for women with a concurrent cytological HSIL diagnosis, contributing to better clinical safety for these women. In addition, by decreasing the time to treatment, thereby reducing the number of recalls, the patient management algorithm will be considerably improved, in turn reducing follow-up costs as well as unnecessary psychological stress among patients. Cervical cancer can be prevented by early detection and treatment of precancerous lesions. In Norway, a cervical cancer screening program was introduced in 1995, recommending all women between 25 and 69 years of age to have a cytological cell sample (Pap-smear) every three years. Since the introduction of the program, the coverage of women taking a Pap-smear has increased and consequently, the rate of cervical cancer is reduced As a result of the finding that human papillomavirus (HPV) is a necessary cause of cervical cancer, HPV testing has been included in cervical cancer screening in several countries. In Norway, HPV testing has been included in secondary screening since 2005 : If the In Norway, several HPV tests for use in secondary screening are available. One of these tests is the PreTect HPV-Proofer assay , detecting HPV E6/E7 mRNA from the five most prevalent types causing cervical cancer. The University Hospital of North Norway has five years of experience with the use of this test. The argument for choosing this test in secondary screening was the need for a clinically specific test to find the women truly needing follow-up and essentially requiring referral to treatment. The HPV E6/E7 mRNA test has been shown to have a higher clinical specificity and positive predictive value (PPV) than HPV DNA tests The PPV reflects the proportion of patients with a positive test result who are correctly diagnosed and gives information about the accuracy of the test. At our hospital we have repeatedly observed that women with a cytological normal, ASC-US or LSIL lesion at triage, and who are HPV mRNA positive, actually have an underlying high-grade lesion or cancer which is revealed at colposcopy and biopsy. In addition, re-evaluation of the cytological or histological slides after a positive HPV test often reveals more severe cell-changes than first diagnosed. In a previous paper The Regional Committee for Research Ethics has approved the study. Written consent from the patients for their information to be stored in the hospital database and used for research was not needed because the data were obtained and analyzed anonymously.In the routine diagnostic practice at the University Hospital of North Norway, the HPV E6/E7 mRNA test PreTect HPV-Proofer  is used in the triage of women with an ASC-US or LSIL diagnosis for the detection of cervical dysplasia and cancer. The Department of Clinical Pathology receives cervical smears from the population of Troms and Finnmark County in Northern Norway. Approximately 23 000 cervical smears are analyzed each year and from January 2006 to June 2009, smears from 54 326 women aged 25–69 years were analyzed. A total of 2 858 women (5.3%) were diagnosed with ASC-US or LSIL. For these women, repeat cytology and the HPV mRNA test were recommended after six months. Liquid based cytology and HPV mRNA results were received from 2 099 women (73.4% of the 2 858 women). The reason for not obtaining HPV mRNA results for all the cases is the wide use of conventional Pap-smear rather than liquid based cytology, which does not allow for HPV analysis.Cells were extracted from the ThinPrep® 2000  for cytological examination. The HPV mRNA test uses a liquid based sample from the same material as cytology. The mRNA testing was performed according to the manufacturer's instructions  and in accordance with national guidelines for HPV testing .Cytological and histological diagnoses were obtained from the diagnostic database (SymPathy) at the Department of Clinical Pathology, University Hospital of North Norway. Biopsies with histological high-grade dysplasia or cancer (CIN2+) were evaluated by experienced pathologists. In Norway, the current clinical threshold for treatment is CIN2+; after histologically confirmed CIN2+, national guidelines recommend treatment by conization of the cervix. Women with benign or CIN1 histology are advised to be followed up with a new Pap-smear and HPV test after 6–12 months. Biopsies with uncertain cellular changes are immunostained with p16 in order to detect occult CIN lesions.It is important to note that in clinical practice, the guidelines are not consistently followed. In contrast to a well planned study, individual evaluations are frequently made and essentially the history of the patient is important in the assessment of whether or not she should be referred to treatment. Different aspects of deviations are included in the Numbers for PPV calculations are presented in For women being treated (n = 230), the diagnosis used for PPV calculations is the most high-grade histological diagnosis of the biopsy before treatment or of the cone after treatment; the biopsy before treatment may have therapeutic effect and therefore the diagnosis of the biopsy may be the correct one. The diagnosis of the biopsy is reported for 42 women; for 181 women, the diagnosis of the cone is reported. Seven women were referred to treatment directly after abnormal cytology and/or colposcopy and/or a persistent HPV result and for these women the diagnosis of the cone is reported.Of the total women with a positive HPV result and a histological diagnosis (n = 347), 243 women had histological CIN2+, giving a PPV of 70.0% . Of the The added value of the HPV mRNA test in detecting women with high-grade lesions is shown in In total, 13 women were found to have cancer , all of The main cause of invasive cervical cancer is the deregulated and persistent production of HPV E6 and E7 oncoproteins Our data show that when including all age groups, the HPV mRNA test has a PPV for CIN2+ of 70%. A previous data analysis The PPV of the diagnoses ASC-H and HSIL for CIN2+ are, according to Norwegian Cancer Registry data, 56.4% and 73.9% respectively Women with ASC-US or LSIL at repeat cytology and with a positive HPV mRNA test are referred directly to colposcopy and biopsy. When an HPV test is not used, women with ASC-US and LSIL are referred to colposcopy and biopsy after three times repetition of the diagnosis. This means that for women with an underlying high-grade lesion, the disclosure of their disease will be delayed with up to two years, which may be critical. The same applies to women with normal cytology at triage, for whom the PPV of HPV mRNA test positives for CIN2+ is 65.0%. Women with normal cytology (when the HPV test is not included) are referred back to the screening program, emphasizing the importance of an HPV test for these women. Of note is that the PPV for mRNA positive women with normal cytology is higher than the PPV for women with ASC-US . This maAn HPV mRNA positive HPV 16 result has a PPV for CIN2+ of 80.4% when including all age groups, representing a higher PPV than the cytological HSIL diagnosis. For the other HPV types, the PPV is somewhat lower. One explanation for the lower PPV of HPV 18 and HPV 45 may be the lower degree of noticeable cell changes related to these infections and the fact that lesions caused by these HPV-types often are located further up in the cervical canal (glandular lesions) The motivation for looking at the age group >40 years is related to the lower probability of children planned among women in this group. Given the impact of cervical treatment (such as LEEP conization) on pregnancy outcomes An added value of the HPV mRNA test in detecting women with high-grade lesions is presented in In total, 13 women  were diagnosed with cancer. Interestingly, the HPV test had an important role in detecting most of these women, explained by the knowledge that the cytological diagnosis is influenced by the HPV result and by the follow-up of women with normal or low-grade cytology due to a positive HPV result . ConsequTo conclude, our data suggest a clinical “test and treat” application of the HPV mRNA test: Direct treatment may contribute to a better clinical safety for test positive women above 40 years of age and for women with a concurrent cytological HSIL diagnosis. Consequently, by decreasing the time between testing and treatment, thereby reducing the number of recalls, the patient management algorithm will be considerably improved and will in turn reduce follow-up costs and more importantly, unnecessary psychological stress among patients will be avoided.


P=0.0001) compared to 30 years and above. There was no difference in HPV prevalence between different socioeconomic groups. The data presented suggest a different HPV type distribution in South Wales in comparison to that reported for other populations.The objective of this study was to describe human papillomavirus (HPV) prevalence in South Wales in relation to age, cytology and social deprivation. This was an unlinked, prospective, anonymous, population-based study. DNA was purified from 1911 liquid-based cytology samples  using quality assured techniques and the presence of virus determined by PCR-Enzyme Immuno Assay (PCR-EIA). 209 (10.9%) samples contained high-risk (HR) HPV infection of which 36.4% had multiple HR-HPV types. The most frequent HR types were HPV 16 (19.6%), HPV 35 (9.5%), HPV 66 (9.2%), HPV 59 (8.5%) and HPV 56 (7.6%). There was a strong association between HPV infection and cytological abnormality. Significantly more HR-HPV infections were detected in women under the age of 30 years (68.9% of all HR-HPV infections Fisher's exact test  Cervical cancer is the second most prevalent female cancer worldwide , over a 5-month period in 2004. Cervical Screening Wales manages an organised call–recall system inviting women aged 20–65 years for 3 yearly cervical screening. The residual material of liquid-based cytology (LBC) samples from women attending for routine cervical screening were used for this study. Inadequate cytology samples or those from colposcopy clinics were excluded. This study was approved by South East Wales Local Research Ethics Committee.M Tris-HCL (pH 7.4) and resuspended in 1 ml 10 mM Tris-HCL (pH 7.4) and stored at −80°C until required for further analysis.The LBC samples  were processed and analysed by the Cytology Laboratory at Llandough Hospital, Cardiff, Wales. The residual specimen was anonymised and transported to the HPV Laboratory, Wales College of Medicine, Cardiff University. Samples were centrifuged, washed with 10 m−1 proteinase K (Boehringer Mannheim) 10 μl was added to a 100 μl aliquot from each sample and incubated at 56°C for 2 h, followed by 100°C for 10 min. Samples were allowed to cool, then centrifuged at 13 000 r.p.m. for 10 min, and the supernatant transfered to an appropriately labelled tube.Of 10 mg mlet al  and negative (water) PCR/ELISA controls were included in every experiment, as were positive and negative DNA extraction controls. A standard PCR for the house-keeping gene β-globin was also performed on each sample to ensure PCR viability. 10% of samples analysed were repeated to determine reproducibility.Standard HPV typing of LBC samples was performed using the PCR-Enzyme Immuno Assay (PCR-EIA) method of Walboomers β-Globin PCR positive (96% extraction efficiency)Complete information available on age, cytology and social deprivation scoreWithin the target screening age group 20–65 yearsDetailed analysis was only performed on samples that conformed to the following criteria:This eliminated 112 of the original 2023 samples. Detailed analysis was performed on the remaining 1911 samples.Cytology results were reported according to the guidelines of the British Society of Cervical Cytology (BSCC) by the laboratory at Llandough working within the CSW programme.Si is the standard population sizes in the relevant age groups and ‘i’ and ‘ria’ are the age-specific rates in age groups i and area a . WIMD is a Welsh Assembly Government funded project, developed to describe levels of deprivation across Wales and support policy development and the targeting of resources. The index provides an estimate of social deprivation based on income, employment, health, education, housing, access to services and physical environment. Each area within Wales has been ranked according to social deprivation score; rank 1 being the most deprived area with the highest social deprivation score (78.9); the mid-range rank having a score of 17.9 and the lowest rank a social deprivation score of 1.4.Social deprivation was estimated by linking postcodes to the Welsh Index of Multiple Deprivation (WIMD) . The age standardised HR-HPV prevalence in the Welsh population was 14.6%.n=317) was as follows: HPV 16 (19.6%), HPV 35 (9.5%), HPV 66 (9.2%), HPV 59 (8.5%), HPV 56 (7.6%), HPV 58 (7.6%), HPV 18 (7.6%), HPV 31 (6.9%), HPV 45 (5.4%), HPV 39 (5.1%), HPV 33 (4.7%), HPV 52 (4.1%), HPV 51 (4.1%) and HPV 68 (0.3%).The distribution of HPV types is illustrated in Repeat experiments to validate the reproducibility of our results identified 96% consistency in HR-HPV detection and 92% in HR-HPV typing.n=1911) with those in the HR-HPV positive samples (n=209) (P=0.0112).Comparison of cytological grades in the whole data set ( (n=209) . A break (n=209)  identifiNegative and borderline cytology samples had a similar percentage of single  and multiple  HR-HPV infections. In dyskaryotic samples multiple HR-HPV infections were more prevalent in mild (42.4%) than in those with a moderate (12.5%) and severe cytological grading (21.4%), whereas single HR-HPV infections were predominant in the moderate (75%) and severe (57.1%) dyskarotic samples compared with those observed in the mild (33.3%).P=0.4000).In all, 68.9% of HR-HPV and 64% of LR-HPV infections were found in women aged under 30 years of age. The percentage of HR-HPV infections observed within each age group decreased progressively from 28% among 20–24 year olds, to 3% in those aged 45–49 years with between 0.6 and 2% positive in women aged 50 and 65 years . 75% of No correlation between HR-HPV prevalence and social deprivation score was observed . The perThe use of anonymous consecutive routine screening samples in this study limits population bias with no women excluded. Collection of the samples over a period of less than 6 months avoided testing of the same subjects twice due to recall for repeat smears. The Welsh population represents an ideal study cohort since it is demographically stable and socioeconomically well-defined.Variability between HPV prevalence in different populations has been highlighted in numerous studies but is complicated by differences in study design, sample collection and methods used for HPV detection and typing. A recent publication by et al. ). It would be interesting to study HPV infection in screening nonattendees but such a study would be logistically problematic, although possible using self-testing  to confirm HPV prevalence and the predominant HPV types within South Wales.In conclusion, HPV prevalence in South Wales is high, with HPV 16 and HPV 35 recognised as the two predominant circulating HR-HPV types. Future work will aim to investigate a larger sample set (


Cervical cancer is the most frequently diagnosed malignancy among women in southern Vietnam where its incidence is one of the highest observed worldwide.Cervical HPV DNA infection was measured in a cross-sectional sample of 282 female sex workers (FSW) in Soc Trang province in southern Vietnam. HPV DNA was detected in 85% of FSW and prevalence did not vary by age. Thirty-five HPV genotypes were detected; HPV 52 was the most common type. Half of HPV-positive women were infected with oncogenic types and 37% were infected with multiple genotypes. The prevalence of oncogenic HPV infection was lower among FSW with more formal education , those servicing 25 or more clients per month (adj. PR = 0.66 95% CI 0.48–0.92), and those engaging in withdrawal prior to ejaculation . Oncogenic HPV prevalence was higher among FSW with regular male partners who had other female partners  and FSW who were HIV+ .Our results demonstrate that although cervical HPV infection is extremely common among FSW in southern Vietnam, prevalence varies by education level, sexual activity, habits of regular partners, and HIV status. Cervical cancer is the most frequently diagnosed malignancy among women in southern Vietnam where its incidence is one of the highest observed worldwide ,2. ThereSubmitted.)Between April and August of 2003, 406 women were recruited. Of these women, interviews, physical exams, and cervical specimen collection were completed for 395. Following chlamydia and gonorrhea testing on 395 cervical DNA specimens, 300 specimens remained and were sent to the HPV testing lab. DNA was sufficient for 282 of the 300 specimens. Sexually transmitted infections other than HPV were evaluated in a recent report.  of women. HPV prevalence varied little by age and exceeded 80% for all age groups Figure . Thirty-The mean age of FSW was 25 years (range 16–47). The majority of FSW was of Kinh ethnicity and over half lived within the local province. Overall, 52% of women were single, 10% were married, 14% were cohabitating, 23% were divorced/separated, and 1% were widowed. Fifty-four percent of women had a current relationship with a regular male partner outside of their commercial sex work. Sixty-three percent of women had no more than a primary school education. Sixty-three percent of women had been a sex worker for less than 3 years. FSW were distinguished by the venues for selling sex. Forty-eight percent of women engaged in sex work from "direct" venues including the streets, parks, bus stops, boats, ferry piers, brothels, small cafés, and guesthouses; 52% worked out of "indirect" venues, that is, hotels, restaurants, massage parlors, karaoke lounges, bars, and barbershops. The mean number of clients seen per month was 18 (range 1–81). All women engaged in vaginal intercourse. Condom use with regular and irregular clients was reported by 84% and 85% of FSW, respectively. Prevalence of sexually transmitted infections other than HPV ranged from 2% for HIV to 43% for chlamydia.When adjusted for age alone, none of the variables were significant for any HPV infection, oncogenic HPV, or multiple HPV infection. Variables were then evaluated in models containing all 26 variables  Table . FSW witOur results demonstrate that cervical HPV infection is extremely common among southern Vietnamese sex workers with an overall prevalence nearly twice that of chlamydia. HPV prevalence in the present study was much higher than that observed in a population-based prevalence study of HPV in Vietnam . In Ho CThe basis for these differences in the prevalence of HPV and other sexually transmitted infections by geographic region is not completely understood. It may reflect differences in sexual practices including the pervasiveness of prostitution by region. Soc Trang province, where nearly 1/3 of the population is Khmer, is proximate to Kien Giang, An Giang and Dong Thap provinces which border Cambodia. Sex workers commonly traverse between the 2 countries through these areas. It is possible that these highly transient sex workers are at particularly high risk for HPV. The substantial proportions of multiple infections and untyped specimens are consistent with a high-risk population with exposure to many different partners.Oncogenic HPV 52 was more common than HPV 16 in this population of sex workers. HPV 52 is one of the most common types found among women in southeast Asia as well as eastern Asia including women with normal cervical cytology as well as those with SIL and carcinoma [The lack of variation of HPV prevalence with age among these sex workers is contrary to what has been observed in North American, European, and some Asian populations. The flat age curve in this population of sex workers is similar to that observed in high-risk populations in India and Nigeria characterized by high cervical cancer incidence and mortality .The observed association of education level with oncogenic and multiple-type HPV infection is consistent with studies in other countries demonstrating an inverse association of socioeconomic status and HPV ,9. EducaInterestingly, HPV infection (any and oncogenic types) were less prevalent among FSW servicing the most clients. Risk of cervical HPV infection has been consistently observed to increase with number of recent partners  and partThe lower prevalence of HPV among FSW engaging in withdrawal during intercourse is difficult to explain. Semen is not a major site of HPV infection in males compared to the external genitals . FurtherThe prevalence of oncogenic and multiple HPV was higher among the limited number of HIV-positive women in this population. This is consistent with studies of cervical HPV and HIV in other populations ,18 and mOur results demonstrate that even among a high-risk population such as commercial sex workers, the behavior of regular partners, including spouses and cohabitating partners, plays an important role in HPV acquisition. Sex workers with regular male partners who engaged in sexual relationships with other females were at increased risk of any, oncogenic, and multiple HPV infection. While other studies have demonstrated that the important role of men who are serviced by prostitutes in transmission of HPV to their wives ,19, the Interestingly, the relationship of partner's age and HPV prevalence contrasts with other sexually transmitted infections. A previous study of sex workers in Vietnam found that age of partners was inversely associated with risk of gonorrhea and chlamydia . It is pObservations of the role of condoms in HPV infection are inconsistent and conflicting ,21,22. TGiven the transient nature of most HPV infections, this cross-sectional study offers a limited perspective of the natural history of HPV in this high-risk population. The minority of sex workers who were negative for HPV in the present study were likely infected in the past and subsequently cleared these HPV infections. The HPV-positive sex workers observed in this study may disproportionately include those with persistent infections. The ability to distinguish factors associated with any, oncogenic, and multiple infection was limited as many women were positive for multiple HPV types including concurrent oncogenic and non-oncogenic types.The dynamics of HPV transmission are not well understood. Our study demonstrates that sex workers may be important reservoirs of HPV infection within southern Vietnam where the incidence of cervical cancer is one of the highest observed worldwide. Effective measures to reduce the incidence of invasive cervical cancer in the population will ideally incorporate both primary and secondary prevention efforts, including HPV vaccination and cervical screening.The study was approved by the Pasteur Institute, Ho Chi Minh City and the Standing Bureau for HIV/AIDS in Soc Trang province (currently known as the Soc Trang Center for HIV/AIDS Control and Prevention).Initially, a mapping process to identify local sites where FSW could be found and the numbers of FSW in each hot spot was conducted by meeting with various local provincial and district sector officials, including health workers, police, the women's union, the Department of Labor, Invalid and Social Affairs, and peer educators.Using the information from mapping, 406 FSW in Soc Trang province were identified and invited to participate in a cross-sectional study between May and August 2003. Because no lists of FSW were available, it was impossible to do systematic random sampling to recruit subjects in each hot spot. After obtaining agreement from the owners of establishments and FSW, subjects were recruited by convenience sampling. The number of refusals (FSW who avoided meeting with the interviewers) was not known. Verbal informed consent was obtained from all study subjects.Treponema pallidum hemagglutination assay (Bio-Rad) for syphilis.Blood specimens were obtained for serological measurement of syphilis  and HIV . Positive sera were first stored at -20°C, then batched and sent to the Pasteur Institute in Ho Chi Minh City every two weeks for confirmation with two ELISA tests for HIV  and the Vaginal fluid specimens were obtained for microscopic and clinical identification of trichomoniasis and candidiasis. Bacterial vaginosis was defined by Amsel criteria. Cervical secretions were collected and temporarily stored at -20 degrees C prior to transport to the Pasteur Institute in Ho Chi Minh City where they were stored at -70 degrees C. DNA was extracted from cervical specimens and used for PCR-based testing of chlamydia, gonorrhea, and HPV.Study subjects were interviewed by trained interviewers using a structured questionnaire. Social and demographic information and behavioral and sexual characteristics were queried.Frozen cervical DNA was sent to the Cancer Research Center of Hawaii in Hawaii, U.S.A. for HPV DNA testing and genotyping. The PCR reaction utilized PGMY09/PGMY11 primers  to ampliHPV-positive specimens were subsequently genotyped using a reverse line blot detection method   was used for all data analyses. The relationship of variables with HPV infection was evaluated using prevalence ratios (PRs). PRs and 95% confidence intervals (CI) were estimated using modified Poisson regression with robust error variance, which produces estimates with minimal bias and is particularly suited for outcomes of high prevalence . MultivaThe authors declare that they have no competing interests.All authors read and approved the final manuscript. Dr. Nguyen was responsible for the overall design and conduct of the study in Vietnam including staff training, study recruitment, data collection, laboratory testing, and data management. Dr. Hernandez was responsible for HPV testing and genotyping. Dr. Nguyen and Hernandez were both responsible for the statistical analysis of data and the authorship of this manuscript.


Human papillomavirus is the principal risk factor associated with cervical cancer, the most common malignancy among women in Colombia. We conducted a survey, aiming to report type specific prevalence and determinants of human papillomavirus infection in women with normal cytology. A total of 1859 women from Bogota, Colombia were interviewed and tested for human papillomavirus using a general primer GP5+/GP6+ mediated PCR–EIA. The overall HPV DNA prevalence was 14.8%; 9% of the women were infected by high risk types, 3.1% by low risk types, 2.3% by both high risk/low risk types and 0.4% by uncharacterized types (human papillomavirus X). Thirty-two different human papillomavirus types were detected, being human papillomavirus 16, 58, 56, 81(CP8304) and 18 the most common types. The human papillomavirus prevalence was 26.1% among women younger than 20 years, 2.3% in women aged 45–54 years, and 13.2% in women aged 55 years or more. For low risk types the highest peak of prevalence was observed in women aged 55 years or more. Compared to women aged 35–44 years, women aged less than 20 years had a 10-fold increased risk of having multiple infections. Besides age, there was a positive association between the risk of human papillomavirus infection and number of regular sexual partners and oral contraceptive use. In women aged below 25 years, high educational level and having had casual sexual partners predicted infection risk. In conclusion, there was a broad diversity of human papillomavirus infections with high risk types being the most common types detected. In this population multiplicity of sexual partners and, among young women, high educational level and casual sexual partners seem to determine risk.British Journal of Cancer (2002) 87, 324–333. doi:10.1038/sj.bjc.6600442www.bjcancer.comCancer Research UK© 2002  Cervical cancer is the most common cancer among women in developing countries, and the sixth most common cancer in women in developed countries .Infection with certain types of human papillomavirus (HPV) is the main cause of cervical cancer and its precursor lesions (On the basis of their main association with benign or (pre-) malignant lesions, HPVs can be subdivided into low risk (LR) and high-risk (HR) oncogenic types. Women with normal cervical cytology who are infected with HR HPV have an approximately 100-fold increased risk of developing CIN III compared to uninfected women  reported from some areas in China and Spain . The aim of this study was to investigate the natural history of HPV infection and CIN lesions among low-income Colombian women. We report here the results of a cross-sectional analysis of the cohort at enrolment, with focus on determinants of HPV infection among women with normal cervical cytology.Between November 1993 and November 1995 the Colombian National Cervical Cancer Control Program conducted a census in four health districts in Bogota, which had no previously implemented population-based cervical screening program. The first 2000 women aged 18–85 years identified in the census were invited to participate in the study. Additionally, 200 adolescents aged 13–17 years were invited to participate. They were identified consecutively from an adolescent clinic giving contraceptive counselling in the study area. At recruitment, all women were interviewed face-to-face by specially trained interviewers. They answered to a structured questionnaire on socio-demographic characteristics, lifelong sexual behaviour, reproductive and menstrual history, and smoking and dietary habits. After interview all women underwent a pelvic examination.From the 2200 invited women, 53 refused to participate, eight were considered ineligible  and 29 did not provide cell specimens for HPV DNA detection, so that 2110 women had cell specimens to be analysed. Of them 150 had abnormal cytology (according to the Bethesda system classification) and 101 of the women with normal cytology were beta-globin PCR negative . After these exclusions, 1859 women remained in the analysis presented here. In the multivariate analysis (see below) we further excluded 14 women who did not answer the questionnaire completely, resulting in 1845 women with normal cytology and risk factors analysis. Informed consent was obtained from all participants included in the study. The local ethical committee and the ethical committee at IARC approved the study protocol.g for 10 min. The cell pellet was resuspended in 1 ml buffer Tris-HCl 10 mM pH 8.3 and stored at −70°C until their use. For analysis, 100 μl aliquots were boiled for 10 min at 100°C, cooled on ice and centrifuged for 1 min at 3000×g. 10 μl of these pre-treated crude cell suspensions were used for PCR analysis +0.05% thiomersal. Cells were detached from the spatula and endocervical brush through vortex, and subsequently centrifuged at 3000 M Tris HCL pH 8.3, 50 mM KCl, 200 μM of each deoxynucleotide, 3.5 mM of MgCl2, 1 U of DNA polymerase  and 25 pmol of each of the GP5+ and biotinylated GP6+ primers : 40 cycles of amplification were carried out using a Perkin-Elmer 9600,USA thermocycler. Each cycle included a denaturation step at 95°C for 1 min, one annealing step at 40°C for 1 min, and a chain elongation step at 72°C for 1.5 min. The first step was preceded by a denaturation step of 4 min and the last step was followed by an elongation step of 10 min.HPV-DNA detection was performed by a standard GP5+/GP6+ PCR based assay, as described by 32P]dCTP labelled DNA fragments from cloned DNA of HPV6, 11, 16, 18, 31 and 33 under low stringent conditions  were used as positive control. As negative PCR controls, distilled water and processing blanks were used every 10 samples. HPV positivity was assessed by Southern blot hybridization of GP5+/GP6+ PCR products with a cocktail probe of specific [α-HPV positive samples were first subjected to HPV group-specific analysis using cocktail probes for HR and LR HPVs . The HR M NaOH and hybridised to digoxigenin-labelled type-specific oligoprobes. After several washings the hybrids were detected using anti-digoxigenin (Fab fragments) labelled with alkaline phosphatase  and paranitrophenyl phosphate  was used as substrate. The optical density (OD) was measured at 405 nm using a Labsystem Multiscan reader. In our assay a cut-off point was defined using three times mean OD of the negative controls.Briefly, in the enzyme immune assay (EIA), 5 μl of the biotinylated PCR products were captured in streptavidine-coated microtitle plates . Subsequently, the wells were washed three times with 1×SSC; the captured DNA was denatured by alkaline treatment with 0.1 The HPV positive samples were analysed successively in other specific EIA probe sub-cocktails and finally specific oligoprobes were used to identify each individual HPV type. Samples which were positive by Southern blot analyses and negative by HR and LR EIA, were considered as positive for HPV of undetermined type (HPV X).We computed odds ratios (ORs) and 95% confidence intervals (CI) using unconditional logistic regression models, considering HPV infections as dependent variables and several known or hypothesised risk factors for cervical cancer as independent variables . We performed both age adjusted  and multivariate analyses. The following variables were included in the models: age (as categorised above), educational level , number of regular  sexual partners, parity , age at first sexual intercourse , use of oral contraceptives (ever or never use), condoms (ever or never use), and smoking habits. The different age-adjusted and multivariate models did not differ materially from each other. Therefore we present in this report only results of the fully adjusted multivariate models.The characteristics of the study population are summarised in Table 1The overall HPV-DNA prevalence rate was 14.9% , and 32 HR HPV types were at least three times more prevalent than LR types in all age groups, except among women aged 55 or more years . SimilarFigure 1Single infections (infections with only one HPV type) were detected in 194 women . Among these women, the most common HPV HR types were 16 (16.3% of the women with single infections), 58 (6.2%), 56 (3.6%) and 18 and 51 (2.9%). The most frequent HPV LR types were HPV 81 (CP8304) (3.6%), 42 (2.5%), 40 (1.9%) and 70 (1.4%). The prevalence of single HPV infection decreased with age, the same HPV types being the commonest ones in all age groups (Table 2Multiple infections (infections with two or more HPV types) were detected in 82 women . Women aged less than 25 years had an almost five times higher prevalence rates of multiple infections (9.6%) than women aged 35 years or more (1.9%). Most of the multiple infections were caused by HR/LR types (53.7%) or HR/HR types (42.7%) and less (3.6%) by LR/LR types. Among women with multiple infections, HR types were present in 97.6% of those women aged less than 25 years, 100% among those aged 25–34 years, and 85.7% among those aged 35–54 years, and 83.3% among those aged 55 or more years. HPV 35, 43, 44 and CP6108 were detected only in multiple infections (data not shown).Besides age, number of regular sexual partners and OC use, no other risk factors were clearly associated with overall risk for HPV infections in our study population , and more than a single regular  or casual  sexual partner predicted infection risk . There wIn the age group 25–34 years, having had more than one regular sexual partner increased HPV infection risk   reactivation of latent HPV infections by decreased immune response. Some immunological studies show a decrease in circulating mature T cells in older people as a result of a decrease in CD8+ lymphocytes, a decline in the frequency of CD4+ T cells producing IL-2 and/or a decreased expression in IL-2 receptors , 51 and 18 were the most prevalent HPV types detected as single infections in all age groups. Although HPV16 is the predominant type detected in the majority of studies  was higher than previously observed among control subjects in the IARC studies done in Brazil (0%)  which were risk factors for HPV positivity, other reproductive and sexual behaviour factors considered by us were only weakly and inconsistently related to HPV infection. It might be explained by the relatively high frequency of HPV infections in the studied women and possibly the predominance of ‘male role’ in the transmission of HPV infections to women (particularly over age 35 years). Unfortunately, no information was available on the sexual behaviour of the partners in our study population. Our results suggest an age-dependent association between HPV infection and some risk factors. A possible explication of the highest prevalence of HPV infections among young, highly educated women and with more than one regular or casual sexual partner could reflect changes in lifestyle and sexual behaviour in younger generations (possibly reduced influence of religion and greater freedom).We observed an increase of HPV infections and particularly of LR types in women older than 55 years and we tried to analyse if these women were different in terms of exposure to risk factors. Due to the low number of women in this group we could not find a clear pattern of association. We found that use of oral contraceptives may be a risk factor for both HR and LR HPV infections. Use of exogenous hormones – as contraceptives or hormone replacement – could influence HPV infections in different ways. Results from laboratory work have indicated that the HPV genome contains a hormone-recognition segment, which might show an interactive effect of oral contraceptives and HPV (With respect to parity, in our study there was a trend of decreased risk of HR and multiple HPV infections with increase of number of births. Previous studies have presented conflicting results: an increase in risk with number of births (In conclusion, our results showed a broad diversity of HPV infections in women with normal cytology, with HR types being at least three times more common than LR types. Whereas young women were particularly at risk of HR and multiple HPV infections, post-menopausal women showed an increased frequency of LR HPV types. In this population, high educational level and multiplicity of sexual partners seem to determine risk among young women. No other hypothesized risk factor was clearly associated with the risk of HPV infection.


We evaluated two molecular methods of HPV detection and their correlation with cytological and histological diagnosis in a large sample of Greek women.All women with liquid-based cytology performed at a University Hospital between 2000 and 2003 were included. The Hybrid Capture 2 (HC2) kit and in house Polymerase Chain Reaction (PCR) were used for HPV DNA detection. Cervical biopsy was performed for women with ASCUS+ cytology, HPV detection, or abnormal colposcopy. Positive (PLR) and negative (NLR) likelihood ratios were calculated for cytology and HPV molecular testing for the prediction of CIN2 and greater histology.Of the 1270 women evaluated 241 (18.5%) had abnormal cytology. Cytology diagnosed high-grade squamous intraepithelial lesion (HSIL) or invasive carcinoma in 21(1.7%) cases whereas 26 (2%) women had CIN2+ or greater histology. PCR detected HPV in 397/1270 (31.3%) and HC2 in 260/1270 (20.4%) samples. Both molecular tests exhibited high reproducibility . Positive likelihood ratios (PLR) of 9.4, 3.8 and 3.4 and negative likelihood ratios of 0.13, 0.21, and 0 were noted for ≥ LSIL, any positive HC2 or any positive PCR-HPV testing, for predicting CIN2+ histology, respectively. All CIN 3+ lesions harbored high risk oncogenic HPV type infections.HPV infection was found in a large proportion of this population and was associated with CIN 2/3 lesions and infiltrating carcinomas. Thin prep testing and HPV detection by HC2 or PCR performed very well with regards to identifying high grade lesions in an environment with experienced examiners. Large epidemiological studies performed over the last two decades have identified infection with human papilloma virus (HPV) as a necessary cause for cervical cancer,2. FurthSpecific HPV testing may not be appropriate as a primary screening due to claims that it lacks specificity but it mThe purpose of the current study is to evaluate cytological findings from a large observational population sample in association with identification of HPV infection using newer molecular techniques, such as Hybrid Capture 2 and PCR. Furthermore, we correlate these findings with histological diagnosis.This is a cross-sectional study performed at all specimens sent for diagnostic cytology at the Departments of Histology and Embryology, and the Department of Cytopathology of the National and Capodistrian University of Athens Medical School. Samples are addressed to these departments every day from many community and hospital-based Gynecology clinics covering the metropolitan area of Athens (roughly a population of 3.8 million people). Informed consent was obtained from all women included in this study that was performed between January 2000 and December 2003.® vials  containing the cell samples were addressed to the aforementioned Departments for preparation of thin-layer slides using the ThinPrep 2000 Automated Slide Processor®  according to the manufacturer' instructions. Cytological findings were interpreted according to the Bethesda classification system [Samples for the ThinPrep Pap test were collected by means of a Brun's-like brush. The PreservCytn system  and wereA cervical biopsy was performed if ThinPrep testing revealed ASCUS and above cytological categories or there was positive HPV testing or there was a visible lesion upon colposcopy. Biopsy was performed by an experienced colposcopist (in practice for more than 10 years) as part of the study protocol. All women with indications consented to this procedure. The research was performed with the approval of the Institutional Review Board and in compliance with the Helsinki declaration. The three-tiered cervical intraepithelial neoplasia (CIN) grading system was used for histological diagnosis . All casTwo techniques were used simultaneously:a) The commercially available Hybrid Capture 2 (HC2) kit that was used according to the manufacturer's instructions . Briefly, HC2 is a signal amplification assay that uses a combination of antibody capture and chemiluminescent signal detection. An RNA probe cocktail (full genome probes) that detects 13 high-risk HPV types (16/18/31/33/35/39/45/51/52/56/58/59/68) and 5 low-risk (6/11/42/43/44) HPV types is used in the reaction with the target DNA. The RNA:DNA hybrids are captured onto a solid phase coated with universal capture antibodies specific for the RNA:DNA hybrids. Capture RNA:DNA hybrids are detected with multiple antibodies conjugated to alkaline phoshatase. The signal resulting from the chemiluminescent reaction is read and the results are interpreted. For each specimen relative light unit/cutoff values were calculated as the ratio of the specimen luminescence relative to the luminescence of the 1.0 pg/ml HPV-16 cut-off standard and reflect a semi-quantitative value of the cumulative viral burden from one or more of the examined genotypes. A relative light unit/cutoff value of ≥ 1 was considered as a positive result. Specimens testing positive for high-risk HPV types or low risk HPV types only were classified as HPV-high risk or HPV-low risk respectively, whereas specimens testing positive for both low and high risk HPV types were classified as HPV low-high risk.® 3730XL DNA Analyzers by Lark Technologies, Inc, UK) and the PCR products were confirmed.b) An in house Polymerase Chain Reaction (PCR) to detect HPV DNA presence. DNA was extracted and purified from 3 ml of residual ThinPrep samples using a commercially available kit according to the manufacturer's instructions . The quantity and integrity of the DNA extracts was monitored through spectrophotometer readings and amplification of β-globin gene (endogenous control). The extracted DNA was tested for the presence of HPV DNA by PCR using the consensus  primers GP5+/GP6+ following a previously published protocol. These pSensitivity, specificity, positive and negative predictive values were calculated for cytological results and molecular HPV testing against the histological diagnosis of CIN2 and above or CIN3 and above. More specifically, we calculated values considering all cytology results ≥ ASCUS as positive, or all ≥ LSIL as positive or all ≥ HSIL as positive separately. For HC2 we calculated values for any positive result and for positive high risk results . For PCR we used either any positive result or positive results for HPV types 16, 18, 31 and 33 only. Positive and negative likelihood ratios were also calculated : likelihDuring the 4 year period 1270 women were evaluated (mean age: 34.2 ± 12.1 years old). Table ThinPrep diagnosis in relation to HPV DNA detection by HC2 or PCR testing is depicted in Table HC2 detected infection with high risk or mixed low-high risk HPV types in 40/101(39.6%) of ASCUS cases. PCR detected HPV 16, 18, 31, or 33 (single or multiple infections) in 31/86 (36%) of ASCUS cases. For LSIL the corresponding figures were 77/119 (64.7%) and 63/105(60%) for HC2 and PCR respectively; for HSIL 6/10 (60%) by HC2 and 8/10 (80%) by PCR  with a biopsy diagnosis of CIN 2+ had a HC2 positive test for high risk viruses, whereas PCR detected HPV types 16, 18, 31, or 33 in 21/26 (80.8%) such cases  and high risk  HPV types ,16. On t results ,18. Alth results -20. It a results . Newer g results . CertainOur results confirm the higher prevalence of HPV infection in women with abnormal cytology, in concordance with most studies so far published, that have observed that the increase in HPV prevalence is related to the increasing grade of squamous intraepithelial lesions -26. RateSimilar to other observations, both hybrid capture and PCR HPV DNA testing showed a strong correlation with the diagnosis of CIN lesions or squamous cell carcinoma ,29. The Although none of the patients with normal cytology and an HPV infection had a biopsy proven lesion higher than CIN 1 in our study, these women should not be considered false-positive but as having a real risk for progression to abnormal cytological findings and cervical neoplasia -33. It iThe current observations further confirm the association of high risk HPV types with cytological detection of HSIL or invasive carcinoma but also with histologically confirmed premalignant or malignant lesions -41. All The rate of invasive carcinoma discovered in this study is indicative of a largely unscreened population. The reasons and possible solutions for this observation are an important public health issue and should be further investigated. Moreover the effect of the introduction of newer techniques in population screening is a matter of intense research. Despite the excellent results with cytology in this study, it is well known that screening for cytological changes may have limited sensitivity and findings are not always reproducible . In a coIn conclusion, the present study was more of a technical nature and focused on strengths and weakness of current screening methods in correlation with histological findings. HPV rates were high in high grade lesions in accordance to published literature however HPV was also identified in a large fraction of samples with normal cytology or in samples with normal biopsies. The best approach for such samples will be guided after careful identification of the local epidemiology of the transmission and risk factors for HPV acquisition. Newer methods assessing the integration of the virus may be more appropriate in the workup of such cases. In our study in an referral center with experienced doctors, thin prep cytology and molecular HPV tests performed equally well as screening tests in all scenarios and sometimes were complementary to each other. As newer methods to detect HPV continue to evolve it is important to recognize the clinicopathological correlates of such testing. This will lead to more appropriate screening strategies in the post-vaccine era.The authors declare that they have no competing interests.ST, AC, JG, and PK conceived and participated in the design and coordination of the study; ZV collected thin prep and histology samples; JG, AT and PK performed the thin prep evaluation; AC performed the molecular studies; JP and PK performed the pathological evaluation; ST, JP, AP and PK performed the statistical analysis and analyzed the data; ST, AC, JP and PK drafted the first draft; All authors reviewed and critically revised the first draft; All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/10/53/prepub