With major advances in understanding the infectious etiology of cervical cancer, preventive medicine has obtained highly promising new tools. Human papillomavirus (HPV) vaccines, together with a growing arsenal of HPV-based screening tests, have the potential to radically change public health but require diligent, large-scale implementation to reach the final goal: the elimination of cervical cancer. We reflect here upon the state of cervical cancer prevention globally as there have been several recent developments that will inform this implementation process. Karin Sundström and Miriam Elfström discuss prospects for and progress towards cervical cancer elimination. Currently, there are 3 commercially available HPV vaccines: the bivalent (targeting high-risk types HPV16 and 18), quadrivalent  and nonavalent (targeting HPV6/11/16/18 and a further 5 high-risk types), which have all shown excellent efficacy against cervical cancer precursor lesions and, in the case of the latter 2, against external genital warts. In the future, we are likely to observe efficacy against large portions of the burden of HPV16-dominated anal, oropharyngeal, and penile cancers as well. Early in 2019, the United States Centers for Disease Communication and Control (CDC) increased the recommended upper age limit through 26 years for women and men to receive prophylactic HPV vaccination [A growing body of population-based studies have been key in shaping the globally accepted view of HPV vaccine outcomes, in which evidence of efficacy from randomized clinical trials (reviewed in ) is gradSuch extended approaches would target the spread of the virus faster while at the same time providing direct cancer prevention in both women and men, and ambitions for disease prevention have grown accordingly. The growing evidence has suggested prospects for so-called disease elimination: when the rate of cervical cancer is reduced to a minimum and is no longer considered prevalent in the population—currently defined as a rate below 4 cases/100 000 woman-years . In 2018The foundation for cervical cancer elimination is a 2-pronged approach in which vaccination in adolescents is complemented by more widespread cervical screening in women, defined in the motto “90:70:90”—i.e., 90% vaccinated, 70% screened, and 90% of those with cervical disease being offered effective treatment. Today, however, few regions worldwide reach near the ideal level of vaccinated girls. Despite carrying 80% of the global cervical cancer disease burden, typically because of an absence of effective screening at the population level, low- and middle-income countries (LMIC) in 2014 only accounted for 1% of the vaccinated girls worldwide . For exaFurthermore, although the logistical issues of cold chain storage and vaccine cost have long been anticipated, the most recent challenge that has arisen is a global limitation in the number of HPV vaccine doses available . Timely By the same logic, it should be equally valuable to show 2-dose vaccine schedule effectiveness in individuals greater than 13 years at age of vaccination, which—if firmly established—could allow a reduction from 3 doses to 2 and ensure that the available doses went even further.Even in high-resource settings, elimination may prove a challenge, as exemplified by the situation in France, where HPV vaccine delivery has been challenging and uptake has remained low, at below 20% . ExperieAnother programmatic challenge will be how to integrate vaccine services with cervical screening delivery, possibly in the HPV-FASTER concept, which suggests also vaccinating adult women against HPV  . A furthThis is critical to achieve the greatest impact of prevention resources and reduce the burden on individuals of repeated vaccinations and screening rounds. Currently, the best evidence indicates that because the underlying probability of cervical lesions will diminish in vaccinated women, the positive predictive value of screening in such women will diminish as well ,19. It mAlthough efficacious strategies have been developed, several public health challenges remain in order to achieve effective global control of cancers driven by HPV. High-income countries should be able to achieve elimination more easily because of the presence of organized screening programs. Strengthening screening in LMIC will be paramount, e.g., through implementing primary HPV-based methods such as self-sampling and rapid HPV testing . When itThe recent announcements from the US CDC, UK NHS, and WHO constitute important but incremental steps on the way to reduce cervical cancer. We must also keep in mind the time frame required to show sizeable reductions in disease, reductions that will take more or less time depending, firstly, on the success of the screening component of the elimination strategy—which, if successful, could detect and treat a large proportion of cervical cancer precursors before they come invasive, thereby leading to an early reduction in incidence of invasive cervical cancers—and secondly, on the time lag required between mass vaccination being performed and a preventive effect to be observed. Although much work remains, if complementary and equally ambitious measures in prevention program accessibility and adaptability are implemented and sustained, we believe that elimination of cervical cancer could move from prospect to reality.


The most commonly found serotype was isolated HPV 18 or in combination with other serotypes , followed by HPV 6 with frequencies of 4.7% and 11%, respectively; however, lower frequencies were estimated for HPV 16  and isolated HPV 11, 4%. If a second set of cut-off points for seropositivity is applied, the overall prevalence for any serotype is reduced to 15.2%. As it appears that a significant sector of the study population has had basal contact with an HPV serotype, we recommend considering the possibility of vaccination against HPV at earlier ages.Data regarding humoral immunity against HPV infection are scarce. Most analyses focus on the identification of viruses on mucous membranes and primarily refer to women of reproductive age. The aim of this work was to estimate the seroprevalence of antibodies against HPV serotypes 6, 11, 16 and 18 among unvaccinated boys living in Mexico City. A cross-sectional study of 257 male students from 48 public primary schools in Mexico City, whose ages fluctuated between 9 and 14 years, was carried out. Immunological status was assessed by applying the competitive Luminex Immunoassay of HPV (cLIA). Among the study population, we initially found that 38.52% ( Human papillomavirus (HPV) is associated with skin and anogenital warts, as well as cervical, anogenital and oropharyngeal neoplasms , 2. ModeData regarding HPV infection due to HPV in children are generally scarce . Most anThis study is part of a clinical trial aimed at assessing the immunogenicity and safety of the quadrivalent HPV vaccine , comparing boys and girls to young women. Two serum samples were obtained for the trial; the first sample was drawn prior to vaccination and the second, 1 month after the second dose in the two-dose vaccination scheme. For the purposes of this study, we used only the first sample; that is the one drawn prior to vaccination. The 257 boys participating in this analysis were fifth-graders, enrolled at 54 public primary schools, located in nine of the 16 municipalities that comprise Mexico City. All of the primary caregivers who participated declared that their children had not received any previous HPV vaccination.Initially, we obtained parental consent and children participating in the study also agreed. Structured interviews in the form of a standardised questionnaire were applied to procure demographic data and weight and height were also measured using standardised procedures and scales. Finally, 5 ml blood samples were obtained, and one serum aliquot was sent to the FOCUS Central Labs Merck, in California, USA, to be processed using the competitive Luminex Immunoassay. This assay measures virus-like particles that indicate antibody concentrations against HPV 6, HPV 11, HPV16 and HPV18 serotypes .We applied the 41, 24, 34 and 39 mMU/ml cut-off points to establish seropositivity, for HPV6, HPV 11, HPV16 and HPV18, respectively. This first set of values was sent to us by the laboratory once sample processing had been accomplished; at that time, we noticed that these values were higher than the cut-off points cited in other studies published previously (see Appendix 1) –19. SubsHence, We also estimated geometric means for the antibody titres, along with their corresponding 95% confidence intervals . FinallyThe 257 boys who participated ranged in age from 9 to 14 years; the mean age was 10.4 (95% CI 10.3–10.5) years, and the median age was 10 (IQR 10–11) years.The geometric means  of the antibodies against HPV 6, 11, 16, 18 were 20.3 mMU/ml , 12.5 mMU/ml , 13.1 mMU/ml  and 32.5 mMU/ml , respectively . Figure Overall, using the first set of cut-off points previously mentioned, we estimated that 38.5% of the children presented humoral evidence of contact with any of the following serotypes: HPV 6, 11, 16 or 18. The most common serotype identified was HPV-18, accounting for about a third of the population affected (31.1%), followed by serotype 6 with 10.9% and lower frequencies were observed for serotypes 16 and 11 with 6.2% and 3.9%, respectively . In TablThese measurements were also apt for identifying single or multiple infections . We deteAntibody reactivity to more than one HPV serotype was less frequent (9.8%), while the presence of a single infection was 28.8%. Unexpectedly, no individual manifested isolated HPV11. Again, when we applied the second set of cut-off points, results changed significantly, and the overall figure of 38.5% of subjects with some evidence of contact with one or more VPH serotypes was reduced to 15.2%.To our knowledge, this is the first serological survey of HPV infection in boys to be performed in Mexico. The main result was an overall prevalence of 38.5%, indicating contact with any serotype of HPV contained in the quadrivalent vaccine, either alone or in combination . In our An unexpected line of discussion has to do with the cut-off points being applied to estimate the prevalence. In this regard, the gold standard used to measure antibodies is the technique known as competitive Luminex Immunoassay, but the cut-off points for establishing seropositivity have changed over time. Initially, published studies used cut-off points of 11, 8, 11 and 10 for VPH serotypes 6, 11, 16 and 18, respectively. Later the cut-off points were raised to the values 20, 16, 20 and 24 for the same order of serotypes.In 2010, Opalka and coworkers reported that the assay had an overall >99% specificity and tested three different methods for establishing cut-off points; for their data. The only dramatic change referred to the serotype 6, which ranged from 0.8 to 114 mMU/ml, but all the rest of the values that could be used for assessing serological status were below 10 mMU/ml, for the serotypes included in the quadrivalent vaccine. Subsequently, they modified the cut-off points, altering them to 30, 16, 20 and 24 for the same order of serotypes [As previously stated, we received an initial set of cut-off points from the MSD central laboratory, which were 41, 24, 34 and 39 for the same order of serotypes; it is important to note that all these values are higher than those used in the past. Later, we received a second set of values, which were 50, 29, 41 and 59, respectively. We have no explanation as to how these sets of cut-off points were determined by the laboratory. However, considering that the initial set of values were higher than any previously used set of values, we decided to report using the first set provided by the laboratory. Obviously, the estimated prevalence for each serotype diminishes when the second set is applied.Correspondingly, we consider that the most relevant issue is to reach a cogent agreement in terms of a set of values that are most appropriate for estimating seropositivity, either for vaccinated and/or unvaccinated populations. It is essential to take into account that comparisons of population prevalence across locations or over time also depend on the validity of the cut-off points and the methodology employed for measuring antibody levels.Vaccination against HPV was initiated in Mexico in 2008 and is restricted to girls who are either in fifth-grade at school or 11 years old, as part of a strategy to prevent cervical cancer . Boys haHowever, the Mexico City government presented an initiative to include males in the public vaccination programme. In this context, the Mexican Ministry of Health suggested implementing a trial focused on the vaccination of males, with the same characteristics of the girls, who comprise the target group of the National Program. Previous studies performed in Mexico included only girls and had the purpose of demonstrating non-inferiority when reducing the vaccination scheme from three to two doses. None of those studies collected serum samples prior to vaccination, assuming that the target group had a negligible prevalence of infection.Our study was designed to demonstrate non-inferiority of vaccination results among boys using as reference the results of vaccination among young females and that is the subject of another report. However, since we took serum samples prior to vaccination, we were able to estimate the seroprevalences of antibodies against the serotypes included in the quadrivalent HPV vaccine, among the boys in our study population at that very moment.Findings from our study indicate that an important number of boys may present evidence of contact with HPV, prior to vaccination. It is uncertain whether this infection originated from some type of sexual contact or not, and we attained no information in this regard, as parents had to consent to this type of inquiry. There is evidence suggesting the possible transmission of HPV through asexual routes, either vertical  or horizontal  , 24; howIn serological studies with age-matched participants of both genders prior to vaccination, women consistently had similar or higher HPV seroprevalences for all serotypes, suggesting that women may have a higher risk of acquiring HPV infection than men . Thus, iA study carried out in Germany, with a sample drawn from the general population, observed that the group under 15 years of age had a prevalence of antibodies against serotypes 16 and 18 of <3% for both genders . A studyet al. serology in isolation tends to underestimate cumulative HPV exposure [We wish to emphasise that the prevalence of antibodies among the children participating in our study may be considerably higher than values reported elsewhere , 28. Alsexposure . Hence, It is unclear what the presence of HPV antibodies at early ages in life signifies. For example, we cannot tell whether these boys are at risk of developing diseases such as genital warts or suffering other consequences from HPV infection. We consider our findings very relevant to decisions that ponder the apt time to initiate HPV vaccination during infancy. Finally, this study contributes to understanding the natural history of HPV infection and provides a baseline assessment which will elicit discussions about the possible incorporation of boys into the national HPV vaccination programme.


Clinical trials registration: NCT01381575 and NCT00541970.This analysis focused on long-term cross-reactive immunogenicity against nonvaccine human papillomavirus (HPV) types 31 and 45 following 2 doses of AS04-adjuvanted HPV-16/18 vaccine in girls aged 9–14 years or following 3 doses in women aged 15–25 years, for up to 3 years (HPV-070 study) and up to 5 years (HPV-048 study) after the first vaccination. Both schedules elicited antibodies against HPV-31 and HPV-45 up to 5 years after first dose. The antibody concentration was similar in young girls as compared to women. Specific CD4 The AS04-adjuvanted human papillomavirus type 16/18 (HPV-16/18) vaccine showed sustained cross-reactivity against nonvaccine HPV types 31 and 45 for up to 5 years, whether administered as a 2-dose schedule in girls aged 9–14 years or as a 3-dose schedule in women aged 15–25 years. The high immunogenicity of the vaccine observed after 3 doses in girls aged 9–14 years led to the investigation and eventual licensure of a 2-dose schedule, at months 0 and 6, in this age group. The aim of the exploratory phase 1/2 HPV-048 study  was to investigate alternative schedules of AS04–HPV-16/18 in subjects aged 9–25 years [The AS04-adjuvanted human papillomavirus (HPV) types 16 and 18 vaccine  was developed and initially licensed for delivery on a 3-dose schedule, at months 0, 1, and 6. AS04 is an adjuvant system containing 3-O-desacyl-4’-monophosphoryl lipid A  adsorbed on aluminum salt  study was a phase 1/2, partially blinded, controlled, randomized (1:1:1:1), parallel group trial conducted at 21 centers in Canada and Germany between October 2007 and March 2013. Study HPV-070  was a phase 3b, multicenter, open-label, randomized trial conducted in 5 countries  between June 2011 and November 2014.The methods of these studies have been described and published previously , 2. A suBoth primary studies were approved by an appropriate independent ethics committee or institutional review board and conducted according to the principles of the Declaration of Helsinki, good clinical practice guidelines, and all other regulatory requirements. Written informed consent was obtained from all participants and/or parents or legal representatives prior the start of the study.Blood samples for antibody determination were collected from all subjects before the first vaccination (at month 0); at months 7, 12, 18, 24, and 36; and at months 48 and 60 (in the HPV-048 study only). Antibodies to HPV-31 and HPV-45 were assessed by an enzyme-linked immunosorbent assay (ELISA) as previously described [+ T-cell responses specific to HPV-31 and HPV-45 were determined by intracellular cytokine staining, as described elsewhere [In the HPV-070 study, CD4lsewhere .The descriptive primary analyses were performed on the initially seronegative participants in the month 36 (for the HPV-070 study) and month 60 (for the HPV-048 study) according-to-protocol (ATP) cohorts for immunogenicity (ATP-I); secondary immunogenicity analyses based on the total vaccinated cohort (TVC) were performed to complement the ATP analyses. The analysis was exploratory for the HPV-070 study, and testing and analysis were conducted in a post hoc fashion for the HPV-048 study. The ATP-I included all evaluable participants who met all eligibility criteria, who complied with the study procedures, and for whom data concerning immunogenicity end point measures were available.Geometric mean concentration (GMC) calculations were performed by taking the antilog of the mean of the log concentration transformations. Seroconversion rates for each antigen and GMC were calculated with exact 95% confidence intervals (CIs) before and after vaccination. An arbitrary value of half the cutoff for the GMC calculation was given to antibody concentrations below the assay cutoff.In the HPV-048 study, 960 participants received at least 1 vaccine dose and were included in the TVC. Among them, AS04–HPV-16/18 was administered to 157 participants aged 15–25 years (and 82 participants aged 9–14 years) via the standard 3-dose schedule and to 78 participants aged 9–14 years (and 162 participants aged 15–25 years) via the 2-dose schedule. The other participants (n = 481) received a different vaccine formulation. There were 91 participants aged 15–25 years in the 3-dose group and 46 participants aged 9–14 years in the 2-dose group who were included in the month 60 ATP-I; of these, 37 and 33 participants, respectively, were considered for the HPV-31 and HPV-45 subset analysis [Overall, 967 participants in the HPV-070 TVC (93.7%) received AS04–HPV-16/18 and completed the month 36 visit. Among them, 907 (93.8%) were included in the month 36 ATP-I cohort: 401 were aged 15–25 years and in the 3-dose group, and 506 were aged 9–14 years and in the 2-dose group [Demographic characteristics and baseline serostatus, stratified by age and study, are shown for both groups in All seronegative participants from the HPV-048 study and all but 1 (in the 3-dose group) from the HPV-070 study in the ATP-I seroconverted to HPV-31 and HPV-45 one month after the last vaccine dose .HPV-31– and HPV-45–specific memory B-cell and T-cell responses were detected following vaccination and were similar across groups . SimilarIn both studies, similar anti–HPV-31 and anti–HPV-45 GMCs and seroconversion rates were observed in young girls receiving the 2-dose schedule as compared to young adult women receiving the 3-dose schedule, with >80.0% of subjects who were initially seronegative seroconverting following vaccination, irrespective of the schedule received. The kinetics of antibodies against nonvaccine HPV types 31 and 45 observed in both trials were similar to that observed against HPV-16 and HPV-18 : there w+ T cells and memory B-cell responses were detected until the end of the HPV-070 study, at month 36, and in similar range across groups. This suggests the ability to produce antibodies against HPV-31 and HPV-45 after challenge or natural infection years after primary vaccination with either a 2-dose or 3-dose schedule. These findings were not surprising, because HPV-31 is closely related to HPV-16 and HPV-45 is closely related to HPV-18. However, in a different study, in which AS04–HPV-16/18 was compared to an aluminum-only adjuvanted HPV vaccine, the amplitude of cross-reactivity was much bigger with the AS04-adjuvanted vaccine. We hypothesize that the adjuvant plays a major role in the production of nonvaccine-type anti-HPV antibodies [HPV-31– and HPV-45–specific CD4Overall, these results provide additional evidence that the cross-protection against HPV-31 and HPV-45 after vaccination with either 2 doses or 3 doses of AS04–HPV-16/18 is likely to be sustained whether the vaccine is given as a 2-dose or a 3-dose schedule.Our present work has the limitation that no efficacy end points were assessed along with the immunogenicity assessment, owing to the young age of the population studied. However, long-term cross-protection after 3 doses of AS04–HPV-16/18 against HPV-31 and HPV-45, as well as other HPV types, was shown in clinical trials . Our resIn summary, cross-reactivity against HPV-31 and HPV-45 is maintained over time and is similar following either 2 doses of AS04–HPV-16/18 in girls or 3 doses in women. The GMC plateau phase observed up to 5 years after vaccination and the presence of memory B cells bring additional evidence that the cross-protection offered by 2 doses of the AS04–HPV-16/18 against nonvaccine types 31 and 45 is long-lasting.The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at jiy743_suppl_Supplementary_Tables_1-5Click here for additional data file.jiy743_suppl_Supplementary_materialsClick here for additional data file.


In ASCC samples, the HPV genome more frequently remained in episomal form (45.2%). The most common signature of HPV insertion was MJ-SC (26.9%), i.e., HPV–chromosomal junctions scattered at different loci. Functionally, HPV integration signatures were not associated with survival or response to treatment, but were associated with viral load (p = 0.022) and PIK3CA mutation (p = 0.0069). High viral load was associated with longer survival in both univariate (p = 0.044) and multivariate (p = 0.011) analyses. Finally, HPV integration occurred on most human chromosomes, but intragenic integration into the NFIX gene was recurrently observed (n = 4/51 tumors). Overall, the distribution of mechanistic signatures of HPV insertions in ASCC was different from that observed in cervical carcinoma and was associated with viral load and PIK3CA mutation. We confirmed recurrent targeting of NFIX by HPV integration, suggesting a role for this gene in ASCC carcinogenesis.The role of human papillomavirus (HPV) in anal squamous cell carcinoma (ASCC) carcinogenesis has been clearly established, involving the expression of viral oncoproteins and optional viral DNA integration into the host genome. In this article, we describe the various mechanisms and sites of HPV DNA insertion and assess their prognostic and predictive value in a large series of patients with HPV-positive ASCC with long-term follow-up. We retrospectively analyzed 96 tumor samples from 93 HPV-positive ASCC patients using the Capture-HPV method followed by Next-Generation Sequencing, allowing determination of HPV genotype and identification of the mechanisms and sites of viral genome integration. We identified five different mechanistic signatures of HPV insertions. The distribution of HPV signatures differed from that previously described in HPV-positive cervical carcinoma ( Anal squamous cell carcinoma (ASCC) accounts for about 2.5% of all gastrointestinal malignancies . It is mRadiotherapy (RT) alone or in combination with chemotherapy  is the standard first-line treatment for nonmetastatic ASCC ,8. LocalThe role of HPV in tumor initiation and progression of cervical, anal canal, oropharynx, vulva, and penis carcinomas has been clearly established . HPV is We have recently developed a sensitive HPV double capture method (Capt-HPV) followed by Next-Generation Sequencing (NGS) in order to precisely and robustly determine HPV genotype, status , viral load as well as the integration sites in the human genome . This coThe aim of this study was to describe and characterize the HPV integration signatures using our Capt-HPV method in a large, single-institution, clinically annotated cohort of 93 patients with HPV-positive ASCC. We report the mechanistic HPV insertion signatures, assess their prognostic and predictive value and compare the HPV features of anal vs. cervical cancers.Ninety-six cryopreserved HPV-positive tumor biopsy specimens from 93 patients treated for ASCC at the Institut Curie Hospital between 1993 and 2017 were retrospectively retrieved from the institutional tissue bank. Matched initial diagnostic biopsy and recurrence biopsy samples were available for three patients.In accordance with French regulations and ethical requirements, patients were informed about the research performed on tissue specimens and did not express their opposition. The study protocol was approved by French Ethical Committee  and the ethics committee of the Institut Curie (Agreement number C75-05-18). Clinical data were collected retrospectively from electronic patient files.Tumor DNA was extracted from frozen tumor samples using previously published procedures . Sampleshttp://blast.ncbi.nlm.nih.gov/Blast.cgi).HPV detection and genotyping were first performed using Real-Time PCR as previously described . From 19The DNA libraries were prepared using 500 ng of genomic DNA, starting with ultrasonication  to produce double-strand DNA fragments with an average length of 280 bp. End-Repair and A-tailing were then applied to facilitate ligation of the adapters, containing unique barcodes for each sample, specific to the Illumina technology for amplification and sequencing. KAPA Hyper Prep kit was used for these steps, according to the manufacturer’s instructions.Capt-HPV was performed as previously described . BrieflyKLK3 gene used as a control. All probes were included in the capture set. The optimal cut-off was defined as 12 based on the ROC (receiver operating characteristic) curve .Viral load was estimated by the ratio of the number of reads mapped to HPV over the number of reads mapped to the human We used an automated alignment tool  allowing HPV genotyping and viral–human DNA junction identification using specific filters. The insertion site was analyzed using reads containing both HPV and non-HPV sequences. The non-HPV sequence was aligned on GRCh37-hg19 (BLAT tool).n = 3) were excluded from survival analyses. Survival curves were estimated by the Kaplan–Meier method, and compared using the Log-Rank test. The Cox proportional hazards regression model was used to assess prognostic significance and the results are presented as hazard ratios and 95% confidence intervals (CIs). For all statistical tests, the limit of significance was defined as p < 0.05.Correlations between HPV integration signatures and clinical, laboratory and molecular features were analyzed using Chi-square tests, Chi-square tests with Yates’ correction or Fisher’s exact tests, as appropriate. Given the small sample size, 2J-COL and 2J-NL simple junctions and MJ-CL and MJ-SC multiple junctions were pooled for analyses. To visualize the efficacy of a molecular marker  to discriminate two populations (patients who died/did not die) in the absence of an arbitrary cut-off value, data were summarized in an ROC curve . The AUCNinety-three HPV-positive ASCC patients were included. Patient characteristics are presented in n = 3), HPV18 (n = 2), HPV33 (n = 1), HPV35 (n = 1), and HPV67 (n = 1). Previous mutational analysis of the PIK3CA gene performed on all tumor samples demonstrated that 22 patients (23.7%) harbored a PIK3CA hot spot mutation in exon 9 (n = 21) or exon 20 (n = 1) [HPV genotype determined by PCR was confirmed by NGS, as seen in n = 41) vs. high viral load , determined as described in “Statistical analysis” section. No association was observed between HPV viral load and clinicopathological features, as seen in Patients were classified as low , MJ-CL , 2J-COL , 2J-NL , and a few other cases  in which a single HPV-chromosomal junction was observed. The mechanistic distribution of HPV signatures was therefore markedly different from that observed in cervical carcinoma (p = 0.0000012), as seen in Bioinformatics analysis of Capt-HPV reads allowed complete identification of HPV genome status. In the absence of integration , no HPV breakpoint or HPV–chromosomal junction reads were identified, indicating that the viral genome was maintained in its episomal form (EPI). In the presence of integration, the viral genome and its breakpoints as well as the coordinates of the integration sites in the human genome were identified by pure HPV reads and junction reads. All patients displaying HPV integration  exhibited partial and variable integration of the viral genome, albeit systematically retaining the HPV E6 and E7 oncogenes. The mechanistic integration signatures were distributed as follows: MJ-SC  switched from EPI to 2J insertion signature, indicating that HPV integration status may change over time.NFIX gene (19p13.2) that was targeted in four tumors (two in intron 1 and two in intron 2), as seen in NFIX gene but nonintragenic, of unknown significance, as seen in Multiple integration regions in the human genome were observed. We identified more than 90 HPV–chromosomal junction regions (intergenic or intragenic) in the 51 tumors with HPV integration, as seen in p = 0.93), as well as according to treatment type , and in HIV-positive vs. negative groups (p = 0.92), as seen in The distribution of HPV status and integration signatures  according to the patients’ clinical, laboratory, and pathological characteristics is presented in p = 0.022). Moreover, samples with viral integration (2J or MJ) more frequently harbored PIK3CA activating mutations  than those harboring episomal HPV  (p = 0.0069).Of note, samples with 2J insertion displayed low viral load, while MJ insertion was associated with high viral load (p = 0.36), as seen in p = 0.53) and CRT subgroups (p = 0.47), and in the HIV-negative subgroup (p = 0.70).No significant association was observed between HPV integration signatures and response to RT/CRT , HPV16 genotype (p = 0.005), and CR after RT/CRT (p < 0.001) were significantly associated with OS in univariate analysis; in multivariate analysis, HPV16 genotype (p = 0.008), tumor stage (p = 0.048), and complete response after RT/CRT (p = 0.001) were independent prognostic factors, as seen in p = 0.044, p = 0.011) analyses, as seen in p = 0.50; p = 0.038 for viral load, p = 0.70 for integration signature). The association between viral load and OS was stronger in the RT subgroup  vs. the CRT subgroup , and in the CR subgroup  vs. the non-CR subgroup .Ninety patients were evaluable for survival (follow-up > 30 days). Median follow-up was 46.2 months (range: 7.0–277.0 months). Tumor differentiation . These patients had more advanced tumor stage  and more frequently displayed MJ-SC or MJ-CL integration signatures (p = 0.036), but no correlation was observed with viral load (p = 0.63), as seen in p = 0.093 and p = 0.051 in the whole cohort and in the subgroup of 50 patients with HPV integration evaluable for survival, respectively; Remarkably, four patients harbored HPV integration in the PIK3CA mutation (p = 0.0069) and viral load (p = 0.022). HPV integration signatures also had no impact on OS or response to RT/CRT.In this study, we analyzed a large clinically annotated cohort of 93 HPV-positive ASCC patients for their HPV status and integration signatures using our Capt-HPV double capture method followed by NGS . This HPp < 0.001) from that observed in cervical squamous cell carcinoma, with a higher proportion of EPI in ASCC  [Our analysis of HPV integration signatures in ASCC revealed the predominance of EPI  over MJ  and 2J  insertions. This distribution was statistically different (rcinoma) . In oroprcinoma)  reportedrcinoma) . Twenty-rcinoma) . The ovep = 0.022), suggesting that viral load is linked to the alternative mechanistic mode of HPV insertion proposed by Holmes et al. [p = 0.011). Similar findings have been reported in cervical cancer, where low HPV viral load is associated with shorter survival and poor prognosis features including with poorly differentiated tumors and metastatic lymph node metastasis [Of note, samples with 2J insertions were associated with low viral load, while MJ samples were associated with high viral load , while tastasis . TherefoWe also observed that HPV16 is an independent predictor of survival in our patient cohort. HPV-16 is the most frequent genotype found in ASCC, and HPV-positivity is associated with longer survival and response to RT/CRT, similar to HNSCC ,5,6,29. PIK3CA-activating mutations than those harboring episomal HPV (p = 0.0069). It has been suggested that HPV creates a selective pressure that promotes the emergence of tumors with APOBEC-mediated driver mutations in HNSCC [PIK3CA gene mutation across multiple cancers, which may explain the positive association between HPV integration and PIK3CA mutation in our series [Interestingly, samples with viral integration (2J and MJ) more frequently harbored in HNSCC . The APOr series . In addir series .KLF5/KLF12 gene and adjacent to the MYC gene locus [NFIX gene was observed in four cases, confirming the results from the recent study by Jeannot et al. [NFIX gene but nonintragenic, of unknown significance. NFIX belongs to the NFI gene family, consisting of four transcription factors , involved in the regulation of cell proliferation and differentiation. The C-termini of the NFI protein family diverge due to the existence of multiple splicing sites. Each NFI transcription factor encodes multiple splicing variants, the function of which remains unknown in many cases. NFI transcription factors have both oncogenic and tumor suppressor potential, depending on the primary tumor site [NFIX induced a decrease in IL6ST, TIMP1, and ITGB1 gene expression and reduced cell proliferation, migration, and invasion processes [NFIX gene was associated with a trend towards longer OS in patients with HPV-positive ASCC (p = 0.05). We could not assess the effect of HPV integration on NFIX expression and function. The favorable survival trend that we observed may be due to the fact that these all of these patients achieved complete response after RT/CRT and none of them developed metastasis, both of which are favorable prognostic factors. This result, obtained on a small number of patients (4/51), needs to be validated in larger series, and further exploration of the underlying molecular and biological mechanisms is warranted.We observed that HPV insertion occurred in both intergenic regions and in repeated sequences, as well as in intragenic regions. In HPV-positive cervical cancer, viral genome integrations occur on all chromosomes, with no detectable hot spots, except for the ne locus . These rt et al. , along wmor site . In lungrocesses . In colorocesses . In controcesses . In our PIK3CA mutation [NFIX by HPV insertion in ASCC, a potential favorable prognostic factor [In conclusion, the present study validates the robustness of our method of double capture followed by NGS for comprehensive one-step analysis of tumor HPV status. The distribution of the various HPV integration signatures differed between ASCC and cervical cancers and was associated with viral load and mutation . The smac factor . Further


Fewer studies have been done over the years to establish the association of human papillomavirus (HPV) with head and neck squamous cell carcinoma (HNSSC) within the subregions of sub-Saharan Africa, and thus this study was designed to investigate the presence of HPV in HNSCC at a tertiary hospital in Ghana, providing additional evidence on the need to explore similar studies in other subregions. A retrospective cross-sectional study was employed to investigate the presence of the DNA of HPV genotypes in HNSCC archived tissue. A total of 100 HNSCC cases were classified as suitable for HPV genotyping. HPV-DNA was detected in 18% of the HNSCC cases, with 17 being HPV-16 and 1 dual infection with HPV-16 and HPV-18. HPV was prevalent in 50% of oropharyngeal cancers, 27% of laryngeal cancers, and 23% of oral cavity cancers. HPV E6/E7 oncogenic DNA was found in 18% of the HNSCC cases, with HPV-16 being the predominant genotype present. The pattern of HPV association was similar to earlier reported studies, recording a higher prevalence in oropharyngeal cancers, followed by laryngeal cancers and oral cavity cancers. Head and neck cancers comprise a broad range of tumors that have been grouped as an entity, based on common etiology, anatomy, and sensitivity to treatment . These mAccording to the Global Cancer Statistics 2018 (GLOBOCAN 2018) , the numHPV transmission in head and neck cancer has been linked primarily to oral sexual behaviors –15. SincThe implication of HPV in HNCs has led to the creation of a new subject profile in the hospital, as noted in a study by Goon et al.,  that subA retrospective cross-sectional study was employed to investigate the existence of the DNA of HPV genotypes in head and neck squamous cell carcinoma (HNSCC) archived tissue samples retrieved from the Department of Pathology at our study site, from January 2007 to December 2016.CHRPE/AP/438/17). The study was conducted within the period of October 2016 to July 2018.Approval for the study was obtained from the Committee on Human Research, Publications and Ethics of our study site  were included in the study. Specimens were essentially excluded from the study for any of the following reasons: (i) no consensus in diagnosis; (ii) unavailability of tissue block; (iii) insufficient DNA for analysis as determined using Nanodrop spectrophotometer ; and (iv) negative beta-globin amplification by PCR technique.Data regarding age, sex, site, and histological diagnosis on HNSCCs were extracted from the surgical day book of the Department of Pathology.μm section of each selected tissue block was taken twice. For each tissue block, the microtome was thoroughly wiped and a fresh microtome blade was used. In case of suboptimal information, the additional section of a block was stained with H&E and assessed again by the pathologists. The tumors were then graded according to recommended guidelines of the American Joint Commission on Cancer [In consecutive order (from 2007-2016), archived, formalin-fixed paraffin embedded (FFPE) HNSCC tissue block and slides of selected cases were retrieved from the archives of the Pathology Department. The hematoxylin and eosin (H&E)-stained slides of the selected cases were then reviewed independently by two pathologists to confirm the diagnosis. With the aid of a microtome, 10n Cancer .μm FFPE tissue section using the Quick-DNA™ FFPE Kit  according to the manufacturer's instructions. There was deparaffinization of the FFPE tissue using a deparaffinization solution. This was followed by digestion using proteinase K and RNase A, and finally purification of the tissue using genomic lysis buffer, isopropanol and genomic DNA wash. The extracted DNA was quantified using a Nanodrop spectrophotometer  and stored at -20°C for future use. The DNA lysate prepared was quality controlled using human beta-globulin DNA polymerase chain reaction (PCR) as described by de Roda Husman et al., [μl, 4μl of the DNA lysate and 25pmol of each human beta-globulin consensus primers PCO3+ and PCO4+  were used.Genomic DNA was prepared from a 10 et al., . For a PThe HPV-DNA amplification and detection were performed using nested multiplex PCR as described by Sotlar et al. . Generalμg/ml ethidium bromide. Ten microlitres of each sample were added to 2μl of either blue or purple (6X) gel loading dye for the electrophoresis. Fifty bp DNA molecular weight marker (New England Biolabs® Inc.) was run alongside the PCR products. The gel was prepared and electrophoresed in 1X TAE buffer using a mini gel system at 100 volts for one hour and the gel photographed over UV transilluminator [Gel electrophoresis was employed in the analysis of the amplified products, using 2% agarose gel and 0.5uminator  to generWithin the period of January 2007 to December 2016, a total of 100 head and neck squamous cell carcinoma (HNSCC) cases were classified as suitable for HPV testing and genotyping. The mean age of the patients was 52.36 years . Majority of the patients were >56 years (51%). The distribution is shown in Majority of the samples were from the larynx, followed by oral cavity with hypopharynx being the least represented. Eighteen (18) out of the 100 HNSCC samples were positive for HPV-DNA. Out of the 18, 15 (83.3%) were males while 3 (16.7%) were females. The males were thus more likely to have HPV-positive HNSCC compared to the females . The patients were again stratified into young (<56 years) and old (≥56 years) based upon the median age of the study group. The results showed that there was a trend towards patients ≥56 years being more likely to have HPV-positive tumors , but this difference was not statistically significant. The distribution of the 18 HPV-positive cases according to location showed that HPV was prevalent in 50% (6 out 12) of oropharyngeal cancers, 27% (7 out of 26) of laryngeal cancers, and 22% (5 out of 23) of oral cavity cancers. Majority of the HPV-positive tumors were found in moderately differentiated samples , followed by well differentiated samples . The distribution is shown in The most common genotype found was HPV-16, present as a single infection in 17 out of the 18 cases, with one case of HPV-16 and HPV-18 coinfection, found in laryngeal cancer. None of the other 13 HPV genotypes tested for in the study was observed . The distribution is shown in The study employed a nested multiplex PCR (NMPCR) technique as described by Sotlar et al.  for HPV INK4a which have been associated with HPV-induced carcinogenesis. Since the current study did not explore any biomarker associated with HPV, we could not conclude with certainty that the HNC samples that harbored HPV-DNA were actually caused by the HPV virus.HR-HPV type 16 and type 18 were the only HPV genotypes detected in this study, although HPV-6, HPV-11, and HPV-33 have been reported in other studies of HNSCCs albeit rarely , 30. MorThe clinical and prognostic implication of HPV-positive HNSCCs have been established, and there is a general consensus among the scientific community that it is distinct from those of conventional, alcohol- and tobacco-related HNSCCs . MajoritThe study has shown a prevalence of HPV-positive DNA rate of 18% in 100 cases of HNSCC, revealing a preponderance in males. The study also affirmed the dominance of HPV-16 and the relative rarity of HPV-18 in HPV-positive HNSCC as reported by other studies. The observed pattern of HPV association in our study population was similar to earlier reported studies, recording a higher prevalence in oropharyngeal cancers, followed by laryngeal cancers and oral cavity cancers. However, this was a small study and therefore requires a large scale population studies in sub-Saharan Africa to confirm our findings.


Qualitative detection and quantification of HPV was performed by PCR-Real time method based on the Russian equipment and test systems . The DNA of low-risk  and possibly / potentially / high carcinogenic risk , a total of 21 types, were detected. X 2 15.9). Average viral load in patients with CaCx was 6.9±4.0 . A reliable relationship between the cancer staging and the viral load was found . Domination of type 16 calls for urgent need the transition to HPV primary screening and resumption of immunization program discontinued in 2014. The study is registered in ISRCTN registry, No. ISRCTN71514910 (01.02.2018). During the period of 2014-2017 total 1,166 clinically healthy women were tested for HPV, as well as 73 women diagnosed with CaCx. Overall prevalence of HPV in female population was determined as 25.0% . Top-5 leading HPV types: 16 (26.4%); 31 (10.1%); 51 (9.4%); 52 (9.0%); 6 (7.9%). Average viral load was 5.5±3.8 . In women diagnosed with CaCx ranking was as follows – 16 (54.1%), 31 (11.2%), 18 / 58 (5.1% each), 33 / 45 (4.1% each). Type 16 appeared to be one of the most significant risk factors of the CaCx development (p=0.00007, phi 0.35, Pierson’s  The human papillomaviruses (HPVs) is a large diverse group of viruses of about 190 fully characterized types. In total, 4 groups are currently classified, including group 1, containing types of highly carcinogenic risk (HR-HPV); probably carcinogenic, such as type 68 (group 2a); possibly carcinogenic, such as 26, 53, 66, 67, 70, 73 and 82 types, considered potential carcinogens, with an arguable and still not thoroughly defined role in carcinogenesis (group 2b); not classified (group 3); and, possibly not carcinogenic types (group 4) . Aggregated damage caused by papillomaviruses is estimated about 5% of all cancers of the human body . Growing number of proofs on the HPV continuous evolution resulted in clear molecular-biological evidence of the uniquely high carcinogenicity of types currently classified as probably / possibly carcinogenic . Leading researchers suggested that for these types of HPV, previous classification should be revised, although there is no need to include them in routine screening tests . For activity towards classification revision, foremost the entire body of information on prevalence and leading types causing cervical cancer (CaCx) across all areas of the world is needed. Meanwhile, data on HPV leading types across Kazakhstan still are limited with a few publications . At the same time, situation with the incidence and prevention of CaCx still remains strained in Kazakhstan, despite the existing nationwide screening program. Experts from the Information Center on HPV and Cancer (ICO) stated in 2015 that cervical cancer in Kazakhstan was the second most prevalent among women and ranked first in frequency in the 15-44 age group, with rough incidence rate 32.8 . Therefore, making a nationwide map of the HPV prevalence along with identifying the most dangerous types in regard to the cervical cancer is the foreground task for domestic researchers. Thus, the present study aims to determine the overall HPV prevalence and types distribution both in general female population and in women with first diagnosed cervical cancer. The study has also provided obtaining findings on HPV viral load, which is well-known predictor of the infection severity, eventually leading to invasive cancer development . MethodsStudy settingThe present study constitutes a part of large multipurpose research on the scope of HPV infection which was held in western region of the country during 2014-2017. Full Protocol of the research has been published upon registration in the ISRCTN registry . The design and Protocol of the study were approved by the University’s Institutional Review Board (09.10.2014). The work was carried out in accordance with the Helsinki Declaration principles. All participants who signed the informed consent form were fully informed on the objectives of this analysis. PopulationWhen determining the Sample size for general female population, the previous study’s findings mattered - total HPV prevalence 26.04%, p≤0.043, N 1,098 . In total, N was counted as 1,152, of which 417 in Aktobe, 253 in Uralsk, 237 in Atyrau, 245 in Mangystau. Data on adult (18+) female population of the republic, along with the age-ajusted incidence of cervical cancer in Kazakhstan were applied to calculate the sample size for having CaCx patients, and the number of 67-80 enrolled was determined. Data were collected in medical settings in cities of regional importance, including the nearest vicinities. To reach maximally possible scope of female population and avoid possible bias, all kinds of outpatient clinics were involved: state-sponsored, insurance and private ones. Enrollment of women was held either during their routine visit to the gynecologist, or by ads placed in the clinics lobby, or by the invitation of sentinel specialists. Randomization was not required due to the screening type of study. Inclusion criteria for general sample were the following: age 18-60+ years; resident of western Kazakhstan of any ethnicity; no vaccination history.Exclusion criteria were: non-residents of Kazakhstan; vaccination history. HIV status and pregnancy of I trimester were not Exclusion criteria. Inclusion criteria for having CaCx: any age; any stage of the cancer process; histological verification of the diagnosis. Exclusion criteria: non-residents of the Western Kazakhstan; presence of previous medical intervention - radiotherapy, chemotherapy, surgical treatment.Qualitative detection and quantification of Human papillomavirus was performed by PCR-Real time method based on the Russian test systems and equipment . Production of the company “DNA-technology” was certified (ISO 13485: 2012) and registered in the Republic of Kazakhstan . Test systems used in this study3 to 105 GE as “moderate”, and 105 GE and higher as “high” respectively. Kit of the HPV reagents Quantum-21 is designed for identifying, typing and quantifying the DNA of low-risk human papillomavirus  and possibly / potentially / high carcinogenic risk , total 21 types. To isolate the viral DNA, we used sets of reagents PROBA-NK-PLUS, of the same production. Type of analysis is absolute, that is, a certain number of copies of the virus per sample, measured in genomic equivalents (GE) with a logarithmic calculus. The viral load of up to 103 GE HPV per 100,000 human cells was regarded as “small,” from 10Besides, all assays taken in having CaCx women were subjected to HPV DNA sequencing according to commonly accepted methods . DNA isolation for sequencing was performed using a DNA extraction kit Qiagen according to the Manufacturer’s protocol (Spin Protocol). For amplification, the nested PCR method with two pairs of primers was used: the first pair as MY09 / MY11 (Sigma-Aldrich), and the second pair as GP05 + / GP06 + (Sigma-Aldrich). Sequencing of the samples was carried out using the BigDye v3.1 Cycle Sequencing terminator kit.Results processingX 2, Cramer’s V). All calculations were carried out in the program Statistica.10 . For all tests a two side type I error of p=0.05 or less at 95% CI was assumed statistical significant. Non-parametric operational tests were used in this paper due to a priori missing a normal distribution. Analysis to measure the strength of associations between the variables was performed when appropriate During the period of 2014-2017 total 1,166 clinically healthy women were tested for HPV with “Quantum-21” test system. Age/ethnic attributes of the general female population are summarized in Overall prevalence of HPV infection was determined as 25.0% , or total 291 infected with HPV out of 1,166. Types distribution is summarized in Top-5 leading HPV types were identified: 16 (26.4%); 31 (10.1%); 51 (9.4%); 52 (9.0%); 6 (7.9%). Of these, only type 6 refers to weakly carcinogenic, the rest are of the HR group. Type 6 matters as a causative factor for fast growing number of laryngeal cancers in Kazakhstan . 236 HPV positive women out of 291 in total (81.2%) were infected with types of the HR group . The highest prevalence of HPV was traced in the 18-29 years old group (42.9%), and decreased with age, that was a commonplace in all reports on the topic. Ratio of the HR group to non-HR by age categories increased from 1.6/1 in the youngest group up to 2.3/1 in the group of 40-49 years. Viral load for each HPV positive assay  was determined. Average viral load across the region appeared to be 5.5±3.8  with a range of 0.9 to 22.3, Me 5.2 (3.1-8.4 by 25/75 quartile), and considered high for the general sample. Analysis of viral load by age groups revealed a weak inverse correlation . However, relationship of this index and the age of HPV infected appeared not to be linear. Distribution of viral load by age categories is summarized in The graph demonstrates that the amount of abnormally high values is the greatest in the group of 30-39 years, when, according to body of numerous evidences, the viral persistence and the CIN process is initiated .Whilst data collecting by provinces (oblasts), differences in the HPV prevalence were revealed, with a magnitude of 19.3% in Mangystau up to 29.5% in Uralsk. To determine the differences, a general sample is analyzed in the context of provinces. Data on the HPV infection by sites, including leading types and an average viral load are summarized in As follows from the - 3.6% of the Caucasian ethnicity representatives in Mangystau vs. 0% in Uralsk;- 19.3% of Slavic representatives in Uralsk vs. 11.6-12.0% in other areas.In fact, differences in the ethnic composition of the study participants are inherent for these sites: proportion of the Slavic population in Uralsk or the Caucasians in Mangystau is traditionally higher due to the borderline nature of mentioned areas. Contingency analysis did not reveal associations whatever significant, but confirmed the sites heterogeneity . Yet, a weak trend towards relationship between ethnicity and a specific type of HPV was established in the Mangystau , confirming the data of the aforementioned pilot project of 2014, when quite a robust correlation had been found between Caucasian ethnicity and HPV 33 . No correlations were established in other areas, though previous project revealed a relationship between Slavic ethnicity and type 45 in Uralsk . Associations between specific HPV types were found in multipositive assays: two times more frequent between 16 and 31 types .CaCx sampleIn total, 73 women with the first time diagnosed cervical cancer were tested: 7 from Mangystau; 3 - from Atyrau; 8 - from Uralsk and 55 from the Aktobe province (oblast). Besides, their allocation by the cancer stages was also extremely uneven – 15 of Tis, 25 of StI (a/b), 27 of StII (a/b) and 6 of StIII respectively. This circumstance was related to difficulties in arranging the data collecting on sites. As such, contingency analysis by sites and CaCx stages was not performed due to uneven amount of samples. Average age of the tested was 49.0±12.4 , Me 47.5 . Distribution of HPV genotypes in patients with cervical cancer is shown in X2 15.9).One type of the virus was detected in 68.2%; 2 types – in 15.9%; 3 – in 9.1%; 4 – in 2.3% respectively. Ranking by all 98 identified types was as follows – 16 (54.1%), 31 (11.2%), 18 / 58 (5.1% each), 33 / 45 (4.1% each). In the context of types identified in each patient, the proportion of type 16 reached 72.6%, or otherwise, type 16 served as the cause for cancer development in more than 7/10 of all cases . Besides, this type operated as single infection in 77.4% of cases. The most frequent associations were the following: type 16 / 31 (4 cases) and type 16 / 52 (3 cases). Type 16 appeared to be one of the most significant risk factor of the CaCx development , and exceeded the average in the general sample . The range of the HPV viral load in CaCx patients appeared to be very variable (3.1-19.5). To clarify relationship between the cancer staging and the viral load, the stages by TNM / FIGO (The American Joint Committee on Cancer (AJCC) TNM / FIGO Classifications for Cervical Cancer, 2015) were converted into ordinal scale, with digital values ranging from 1 - Tis to 4 - St IIIab. A reliable relationship between the process staging and the viral load was found . The largest contribution to Pierson’s The viral load increased from the Tis to St IIab, demonstrating the largest extent in the Tis stage and the maximum number of emissions and extreme points in the St IIab stage. Given relatively small number of observations, rational explanation for such a distribution of the viral load has not been found, but it is quite reasonable to assume that the greatest extent in the Tis stage occurs due to the need to break a basal membrane, whereupon immune mechanisms are no longer able to restrain the replication of the virus. It is natural that as the process progresses towards St IIIab, the viral load decreases, since the macroorganism is no longer able to maintain adequate metabolism necessary for reproduction of the viral mass. Our limited observations on the behavior of the viral load depending on the degree of the oncological process have partially been confirmed by other researchers , who had showed that in persons with cervical cancer, the viral load was no longer to serve a predictor of the process progression like in CIN-II +, and did not depend directly on the process stage. To date, it has not been proven reliably that a lower viral load inevitably excludes the progressive disease . 3 / per sample; a 72-year-old woman from the Martuk district of the Aktobe province who was diagnosed with StIIb (T2bNxM0) cervical cancer, also caused by type 53 as a single infection, with viral load of 6.6 GE*103 / per sample; a woman 80 years old from the Aktobe with identified type 73 and StIIb (T2bNxM0) stage of the process with viral load 7.3 GE*103 / per sample. A high viral load, sole type of HPV of non-HR group, the estimated long exposure period given the age of these women were inherent to all of them. HPV types identification was confirmed by gene L1 sequencing in two cases - type 53 from Uralsk and type 73 from Aktobe. As to the third case, sequencing was failed. In fact, our report may be confirmed by the results of Korean researchers , who have found 2.4% HSIL with uncommon HPV genotypes  among 3,164 HPV-positive cases. We are prone to agree with the Chinese scientists reporting the CaCx mortality trends reaching a peak in the >85 yr age group , and likely, the oldest age group will be the most vulnerable in future due to the cancers caused by 2b group (possibly / probably carcinogenic types).3 cases of cervical cancer detected at different stages and caused by types from the group 2b (possibly / probably carcinogenic) solely, are of the particular interest. A woman 60 years old from the Ural province with identified type 53, in the Tis stage and viral load of 6.0 GE*10Findings on undoubtedly high HPV prevalence among female population in the region (25.0%) with overwhelming majority of HR-HPVs were supported by other domestic researchers , who found 25.1% HR-HPV positive results at N 2,408. The distribution diagram clearly indicates unconditional leading the most carcinogenic HPV type 16. Moreover, type 16 is the most prevailing in the group of having CaCx. Confirmed by other local scientists, domination of type 16  calls for urgent need in revision of the current screening design. Accepted in the country cervical screening is featured by cytological methods only, whereas necessity to practice primary HPV screening has been evidenced worldwide, being to-date global trend . Potential to implement HPV primary screening scenario even in low-resource settings has been proved in a large-scale population-based the IARC’s project . To our knowledge, vaccination is the only method aimed to prevent cervical cancer that proved its efficacy . However, wide availability and acceptability of vaccination is still an unresolved issue for developing countries . We believe that obtained results evidencing the role of type 16 as one of the most significant risk factors in CaCx development, convincingly substantiate the need to restore the adolescent girls vaccination program discontinued in the country in 2014. Even more so that a new nonavalent vaccine Gardasil-9 has come into a practice, being approved by FDA . It operates against 9 types of HPV . First publications appeared in 2015, where the potential effect of the new vaccine was highly appreciated . Along with, there are also categorically negative reviews that warn against the use of Gardasil-9 in teenage children . On obtaining data on clear presence of malignant neoplasms caused by probably / possibly carcinogenic HPV types (type 53 - 2 cases and type 73 – 1 case), we have received a certain though insufficient evidence allowing to agree with Arbyn et al., that the need to reassess the carcinogenic potential of known types of HPV is coming up. The HR-HPV group will likely be increased in future from 13-14 known today up to 20.Basing on the results on high HPV prevalence, unconditional domination of type 16 among the CaCx patients, we believe that the current situation calls for reassessing approaches to the CaCx prevention in the country. The present study allows for making a nationwide map on types distribution in the country, and thus contributes to the rational decision making in regard to transition towards HPV primary screening of cervical cancer. Our aforementioned previous research of 2014 had a lot of limitations, and the first was its targeted group, as the HR-HPV suspected individuals only were tested. The present study, as being screening-like by its type, was designed to avoid such a bias, and its results quite met requirements relating to generalizability. Of limitations, the most serious is relatively low translatability of the study results due to restricted number of HPV types which are detectable by the Russian test systems (21 type) vs. HC-II or Inno Lipa systems (up to 44 types) mostly applying in similar researches. This research was performed in frames of the scientific Project “Epidemiological analysis of Human Papillomavirus in Western Kazakhstan in relation to HPV-attributable cervical pathology - social, clinical and genetic aspects”, funded by the Committee of Science of the Ministry of Education and Science of the Republic of Kazakhstan .SB and AT were responsible for general editing of the manuscript and key issues of the research design. SB was major contributor to writing all sections of the manuscript. AK, SU and OU were responsible for editing the “Background” and “Methods” section. DZ and KS were responsible for selection of references and participated in writing the “Results” sections. All authors read and approved the final manuscript.


Most of human papillomavirus (HPV) infections are “cleared” by the immune system; however, in cases of immune system suppression, infections could lead to development of malignancies. The aim of this study was to find out the frequency of HR-HPV infection in early period after renal transplantation in recipients receiving immunosuppressive therapy and to follow the progression of the infection up to one year. 43 female renal transplant recipients and 79 healthy female individuals as a control group were enrolled in this investigation. For the detection of HPV infection, patients' samples  were collected two weeks after transplantation with following collection of six months and one year. Different polymerase chain reactions for HR-HPV genomic sequences detection and ELISA kit for detection of anti-HPV IgG antibodies were used. In this study, we show that frequency rate of HR-HPV infection has increased in the first year after transplantation from early stage of immunosuppressive therapy (from 24% to 36%). Also an increase of HR-HPV load was detected over time, showing the highest median viral load at sixth month after transplantation. From the obtained data, it follows that it is very important to carefully monitor patients receiving immunosuppression therapy on progression of HR-HPV. Human papillomavirus (HPV) infections remain one of the major global burdens even despite the very active use of vaccination. Prevalence rate of HPV in East Europe is about 21.4% which is much higher in comparison with the global prevalence of 11.7% .Based on association with cervical cancer and precursor lesions, HPV can be classified as high-risk (HR-HPV) and low-risk (LR-HPV) oncogenic types , 5. LR-HMost of HPV infections are “cleared” by the immune system and do not result in clinical diseases in healthy individuals; however, in cases of immune system suppression, infections could lead to development of malignancies .Although immunosuppressive therapy has improved long-term graft and patient survival after renal transplantation, it increases the cumulative occurrence of (pre)malignancies, especially those associated with viral infections –10. DeclThe objective of this study was to find out the frequency of HR-HPV infection in early period after renal transplantation in Latvian recipients and to follow the progression of the infection up to one year.43 female renal recipients , who received kidney allograft during 2013-2015, and 79 healthy female individuals , who were visiting gynaecologist for preventive examination, as a control group were enrolled in this investigation. For the early detection of HPV infection, patients' samples  were collected two weeks after transplantation with following collection of six months and one year after the transplantation to receive data on later periods. Chronic glomerulonephritis (7%), hypertensive nephropathy (21%), chronic interstitial nephritis (26%), and polycystic kidney disease (26%) were the most common reasons for the subsequent transplantation. All patients had received induction immunosuppression therapy with monoclonal or polyclonal antibodies and steroid bolus course. Initially immunosuppressive therapy consisted of glucocorticoids (Prednisolone tapered down to 5 mg per day during study period), antiproliferative drugs , and calcineurin inhibitors (once per day tacrolimus with trough level of 7-10 ng/ml during first 3 months after surgery and 5-8 ng/ml thereafter or microemulsified formulation of cyclosporine with trough level of 150-250 ng/ml during first 3 months after surgery and thereafter 100-200 ng/ml for patients transplanted in 2013).μl blood plasma were collected from EDTA peripheral blood samples for further serological tests. Blood plasma samples and cervical swab samples were stored at -70°C.Aliquots of 200 DNA from cervical swab samples was extracted using phenol-chloroform method.β-) globin PCR with appropriate primers was used to determine the quality of isolated DNA , and 3rd recipient: HPV-16+HPV-56; 7.48 log copies/105 cells)  in one recipient was detected on the second week after transplantation. After six months, two more recipients had developed CIN I, and after one year, one of the three recipients with CIN I cytology results were normal. In all DNA samples obtained from cervical swabs of recipients with CIN high HR-HPV loads were detected and in two of them coinfection with several HPV types was found  . Antibod5 cells) .Cytology results of other recipients had shown normal epithelium or such pathologies like atrophy, colpitis, and cervicitis.Among control group individuals, no CIN cases were detected; however, one individual with very high HPV-16 load had atypical squamous cells of unknown significance (A2-ASCUS).HPV persistent infection is strongly associated with development of cervical cancer . Despite5 cells, resp.).The HPV clearance from host's organism requires an adequate immune response; therefore, immunocompromised individuals could be in the risk group of HPV persistent infection development . BecauseAnother recent study showed that papillomatous lesions in the oral cavity occurred in 36.1% of kidney allograft recipients within 2 years after transplantation, where 25% of recipients were positive on HPV-16 DNA sequence. More than half of the studied group were male recipients [That means a broader study on different HPV associated cancer type developments, including anal cancer development, whose incidence has been rising in the last few years, is needed . Such reAnother crucial factor that has an effect on the HPV infection is the median age, 48, IQR= 39-58, of enrolled recipients. This means that they were not vaccinated, because, as was written above, HPV vaccination was included in Latvian National Health Care Program in 2010 and should be done before the age of 15. Preventive vaccination against HPV could help decrease HPV related cancer development in the future; however, vaccination in adulthood is not very efficient, especially in the case of immunosuppressant, due to the fact that, after the first infection, HPV may persist or be integrated in the hosts' genome and therefore escape from humoral immune response. Therefore, recipients, who missed vaccination or were not able to be vaccinated during childhood, are in the highest risk group of developing HPV associated cancers. New ways to manage HPV infection should be found.The results of this research show a significantly higher frequency rate of HR-HPV infection in renal transplant recipients even in the early period after transplantation  in comparison with control group (8%). These results show the growing tendency of HR-HPV infection frequency over the time in female recipients receiving immunosuppressive therapy which indicates they are in the risk group for HPV persistent infection development and possible development of cervical cancer.5 cells, IQR: 1.10-6.66 against 2.01 log copies/105 cells, IQR: 0.88-4.43) is another evidence showing immunosuppression as a high-risk factor of development of HPV persistent infection. The increase of HR-HPV viral load detected in recipients' samples from two weeks to six months  could be related to the deepening of immune system suppression because the mean CD4/CD8 ratio dropped from 1.95±1.07 till 1.51±0.87. However, it is not clear why median viral load has started to decrease in the one-year period after transplantation . It may be related to the lowering of immunosuppressive drug dosages as significant decrease of tacrolimus in recipients' peripheral blood one year after transplantation in comparison to 2 weeks and 6 months after transplantation    was founSignificant correlation between the age of recipients and HR-HPV load was found only in the period of six months and one year after transplantation . This agHigher frequency rate of IgG antibodies against HR-HPV L1 capsid protein in control group rather than in recipients' group  is another evidence that immunosuppression plays an important role in the development of persistent HR-HPV infection. Also, in some recipients who had received Rituximab, which inhibits B lymphocytes' activity, no detectable antibodies against HR-HPV in the early period after transplantation were found. This could indicate the crucial role of immunosuppressive therapy, including Rituximab, in suppression of humoral immune response against HPV infection.Interestingly, 14% of recipients who were previously negative for the presence of HR-HPV genomic sequences but positive for the presence of antibodies against HR-HPV L1 protein became positive for viral sequences in the next observation period after transplantation . This co5 cells). In these cases, two facts should be pointed out: (1) in one recipient with high HPV load (9.6 log copies/105 cells) six months after transplantation clearance of CIN I followed with viral load decrease to 2.7 log copies/105 cells was found after the one-year period; (2) another recipient showed presence of CIN I during all three testing points with low viral load  and was also positive for antibodies against HR-HPV. The first fact shows that HR-HPV load could potentially be a useful marker in the progression of HPV associated CIN development. The second fact points out the presence of antibodies as a positive marker which indicates HPV load decrease.Presence of cervical intraepithelial neoplasia is detected only in recipients' group and in all three cases HR-HPV infection was found. Also, high viral loads were detected in those patients , these results indicate that female renal transplant recipients are at high risk of developing HPV associated cervical intraepithelial neoplasia of different grade and possibly even cervical cancer. Therefore, all female recipients need to be more carefully monitored (twice a year during the first two years after surgery) for HPV infection and development of CIN from the beginning of immunosuppressive treatment application. The presence of several cases of CIN I in recipients' group but not in control group could support this statement. Early detection of HR-HPV infection in female renal transplant recipients could help prevent development of cervical cancer in the future.In this study, we show that frequency rate of HR-HPV infection has increased in the first year after transplantation from early stage of immunosuppressive therapy (from 24% to 36%). Together with increase in viral load (highest median is detected on sixth month after transplantation, 3.98 log copies/10


The World Health Organization has recommended the introduction of HPV vaccines into national immunization programme (NIP), but vaccination coverage remains low worldwide. We assessed the coverage and the parental acceptance of female and male HPV vaccination in Brazil after its introduction into the NIP.We conducted a random-digit-dial survey of parents in seven major Brazilian cities from July-2015 to October-2016. A knowledge, attitude and practices questionnaire was developed and validated by expert analysis, semantic analysis, and pre-testing.826 out of 2,324 (35.5%) eligible parents completed the interview. Parental acceptance of the HPV vaccine for daughters and sons 18 years of age or less was high . Parents refusing vaccination were less likely to know that: HPV is sexually transmitted and causes genital warts, HPV vaccination is more beneficial before sexual debut, and HPV vaccine reactions are minor, and they were more likely to believe HPV vaccination can cause severe adverse events. Parents accepting HPV vaccine for daughters but not forsons were more likely to ignore that the vaccine is recommended for boys. Attitudes associated with HPV vaccine acceptance included: general belief in vaccines, trust in the NIP and in the HPV vaccine efficacy. Among girls eligible for HPV vaccination through the NIP, 58.4% had received a two-dose scheme and 71.1% at least one dose. “No vaccination/missed vaccination at school” was the most common reason for missed HPV vaccination in theNIP.One year after introduction in the NIP, most parents surveyed in Brazil accepted HPV vaccination for their daughters and sons. Low coverage in the NIP seemed to be due to challenges in adolescent vaccine delivery and HPV vaccination barriers at health-care centers, rather than to vaccine refusal. In Brazin Brazil.There are currently three highly effective and safe licensed vaccines against HPV. The World Health Organization has recommended the introduction of HPV vaccines into immunization programme for children and young adults. NeverthThe quadrivalent HPV vaccine was introduced into the National Immunization Programme (NIP) in Brazil in 2014, targeting girls 9 to 13 year of age. Initially, the vaccination was school-based and the schedule included two doses 6 months apart followed by a third dose 60 months later. Later in the first year, a reduced two-dose schedule was adopted and the vaccination delivery changed to a health-clinic based strategy. The programme was extended to boys 11 to 13 years old in 2017. According to NIP data for 2014 to 2017, the cumulative vaccine coverage for the two-dose course in girls was 45.1%, and 72.4% of the targeted female population received at least one dose–12.The aim of this study was to assess coverage and parental acceptance of the HPV vaccine for adolescent daughters and sons in Brazil after its introduction into the NIP. In addition, we sought to determine factors associated with parental intentions for female and male HPV vaccination.We conducted a cross-sectional study in seven Brazilian cities . All five Brazilian regions were included. The interviews were conducted by telephone from July/2015 to October/2016. All participants gave verbal consent prior to commencing the interviews. This study was approved by the Ethics Committee of the Gonçalo Moniz Research Center—CPqGM / FIOCRUZ-BA.Our sample size was estimated at 801, based on an estimate of parental acceptance of the HPV vaccine of 75%, the population size of the 7 cities 29,298,142, a 95% confidence interval and 3% margin of error.Participants were selected by random-digit-dialing. Briefly, we sampled from a computer-generated list of all published telephone numbers in each city selected. Parents in households with children aged 18 years or younger were identified and invited to participate. When an eligible parent was not immediately available, a follow-up appointment was scheduled. If the selected person was unwilling to participate, no substitution was made in that household. Up to 10 callbacks were made to repeated no-answers, busy phone numbers, and answering machines.All interviewers were trained and certified before study enrollment. A round of pilot testing was conducted prior to data collection to assess and improve question wording. We developed and validated aknowledge, attitude and practices (KAP) question2) or Fisher’s exact testfor categorical variables. For each assessment about HPV or HPV vaccine, parents’ knowledge was arbitrarily classified as “adequate” if 70% or more of the answers were correct, otherwise, knowledge was considered “inadequate”.All statistical analyses were performed using Stata Statistical Software . The dataset is available  was assessed by the Chi-square , with a mean age of 43.8 years (range 18 to 82). At the time of the study interview, 37%had at least one daughter/son in the age range for HPV vaccination (9 to 14years).The parental acceptance of HPV vaccine for daughters or sons less than 18 years of age was high , and did not differ significantly in the different cities surveyed . VaccineParents’ knowledge about HPV and HPV vaccine was considered adequate for 10 of 21 items assessed (47.6%). Less than one third of parents (30%) knew that there was a vaccine to prevent genital warts, and 37% acknowledged that condoms are not fully protective against HPV infection . ParentsParental attitudes significantly associated with HPV vaccine acceptance included: beliefs in vaccines in general, trust in the NIP, belief in the efficacy of HPV vaccine, and willingness to receive the HPV vaccine if recommended. In contrast, parents were more likely to refuse HPV vaccination if they believed that: HPV vaccine is not safe or can cause severe reactions, girls age 9 to 13 years are too young to get HPV vaccine, and HPV vaccination can cause girls to become sexually active earlier. Parents refusing HPV vaccine for boys were less likely to perceive their sons as being at risk of getting HPV infection .Knowing other parents who had their children vaccinated against HPV was associated with accepting HPV vaccination. Most mothers in our survey have had a cervical cancer-screening test performed at least once in their lifetime (92%) or in the past three years (83%). A full course of diphtheria, tetanus and pertussis vaccine or hepatitis B vaccine was reported by 69% and 66% of the study participants, respectively . None ofThe reasons for parental acceptance or refusal of human papillomavirus (HPV) vaccination, using open-ended questions to elicit spontaneous responses, are presented in The most common reason for refusing HPV vaccination for both children was “fear of reactions or adverse events” reported as the primary reason by 51% of the parents, and as one of them by 61%. Among parents refusing HPV vaccination for sons (but accepting it for daughters), the reason most commonly reported was “the HPV vaccine is not recommended for boys” (74% as the primary reason and 78% as one of them).Out of 291 parents with a daughter eligible to receive the HPV vaccine through the NIP (9 to 14 years of age),170 (58.4%) reported their daughter had completed the two-dose schedule, and 207 (71.1%) had received at least one dose . The mosOne year after the inclusion of HPV vaccine in the Brazilian NIP, most parents surveyed were accepting of the HPV vaccination for their daughters (92%) or sons 86%) at the recommended age. Despite the high parental acceptance of HPV vaccine for both daughters and sons, HPV vaccination coverage in Brazil remains only modest for girls (45.1%) and quite poor for boys (16.5%)[% at the Acceptance of the HPV vaccine for girls was also high among parents in Indonesia (96%) and in tHPV vaccine acceptance did not differ substantially by sex of child in two large reviews, although a preference of parents and health care providers to vaccinate females over males was reported in the majority of studies reviewed,24. NeveKnowledge about HPV and HPV vaccine was fair in our study population. Although most parents knew about HPV and its association with cervical cancer in women and other cancers in men, this knowledge was not associated with acceptance of HPV vaccination for daughters or sons. Some studies have suggested that parents accept the value of HPV vaccine’s role in cancer prevention,26. In aIn our study, parents who knew that HPV vaccine is more beneficial when given before sexual debut were more likely to accept HPV vaccination (as well as parents who agreed to give their child a vaccine against a STI). Some studies have suggested that parents’ concerns about offering their child a vaccine to prevent sexually transmitted infections and parents’ beliefs that HPV vaccine would promote promiscuity as reasons for not vaccinating–30. TherIn our survey, parents who knew that HPV vaccine is effective and generally safe were more likely to accept vaccination, as shown in previous studies,26,32. AGeneral belief in vaccination was the primary reason for parental acceptance of HPV vaccine in our survey. In contrast, a study of a representative sample of parents in the State of California found a much smaller proportion (4.9%) reporting a general belief in recommended vaccinations as one of the reasons for being likely to vaccinate. In our As far as we know, this is the first population-based survey of HPV vaccine coverage in Brazil since its introduction in the NIP. Our estimates of vaccine coverage for the two-dose course (58%) and for at least one dose 71%) were similar to the ones provided by the NIP, 45% and 72%, respectively. The pro1% were sOur study had several strengths, including the use of a national sample, and refining our survey instrument extensively through cognitive testing and pretesting. In addition, we did not inform parents about the vaccine’s potential health benefits for females and males before asking them about their views on HPV vaccination (which could have affected vaccine acceptability among study participants). Finally, most studies of attitudes about HPV vaccination come out of high-income countries. We provided much needed research examining HPV vaccination in general and opinions about male vaccination in a middle-income country.There are many limitations to this study. First, we reported on individual items and have not attempted to combine items in subscales to examine each construct impacted on decision making. Also, one cannot be sure about how the results obtained via a telephone interview might translate into real-life decisions, where medical information and conversation with family will influence parents’ decision process. The response rate (35%) is low and may not seem sufficient to generalize the results to the target population, however, this number is relatively high for a telephone survey. According to the American Association for Public Opinion Research the average telephone response rate in 2015 for the U.S.A was 9.3%. MoreoveOur study shows that most parents in Brazil are interested in vaccinating their daughters and sons against HPV. Nevertheless, HPV vaccination coverage in the NIP remains low. Barriers to access to vaccination in health care settings are likely the main reason for low HPV vaccine uptake, therefore changing back to a school-based vaccine delivery would likely improve vaccine coverage. Regardless of the vaccination strategies adopted, more efforts should be made to educate parents and adolescents about HPV infection and its implications for male and female health,38,39. AS1 Dataset(SAV)Click here for additional data file.S1 Questionnaire(DOCX)Click here for additional data file.S2 Questionnaire(DOCX)Click here for additional data file.


Alcohol use disorder (AUD) and unhealthy drinking are prevalent among women involved in the criminal justice system and women military veterans. Pharmacotherapy—including naltrexone, topiramate, acamprosate, and disulfiram—for AUD is one form of effective treatment that is associated with better health and criminal justice outcomes. The current study examined the association of justice involvement with receipt of pharmacotherapy for AUD, as well as other patient factors that may explain variation in receipt of pharmacotherapy for AUD among women veterans who receive care at Veterans Health Administration (VHA) facilities.Using national VHA clinical records, we examined all women VHA patients who received an AUD diagnosis during an outpatient or inpatient visit in fiscal years (FY) 2014–2017. We compared patient characteristics by justice status, defined as contact with one of the VHA’s justice outreach programs, and used a mixed-effects logistic regression model to test whether justice involvement was independently associated with odds of receiving pharmacotherapy for AUD.Of 10,511 women veterans diagnosed with AUD in FY2017, 852 (8%) met our definition of justice-involved. Since FY2014, the percentage of women veterans who received pharmacotherapy for AUD increased (14–21%). Women justice-involved veterans and those who were homeless had higher odds of receiving pharmacotherapy for AUD . Women veterans age 55 or older or who were African-American had lower odds of receiving pharmacotherapy .While women involved in the criminal justice system face many barriers to accessing health and social services, women justice-involved veterans had higher odds of receiving pharmacotherapy for AUD at VHA facilities compared to women veterans with no justice involvement. Legal mandates and supportive programming directed towards veterans in the criminal justice system may explain the higher rate of receipt of pharmacotherapy observed among justice-involved women veterans. Women veterans who are homeless may also have more opportunities to access and use pharmacotherapy for AUD compared to their housed counterparts. Alcohol use can contribute to women becoming involved in the criminal justice system. Women under the influence of alcohol are at greater risk for committing a violent crime , and aboUnhealthy alcohol use is also prevalent among women veterans, putting them at risk of criminal justice involvement. Past research found the prevalence for alcohol misuse among women Department of Veterans Affairs (VA) patients to be 27%, and 32% among women veteran non-VA users . AdditioPharmacotherapy for AUD (i.e. medications) is one form of effective treatment that has been associated with a decrease in health care costs, alcohol use, and recidivism –16. The While access to pharmacotherapy for AUD is a consensus standard of care, women with criminal justice contact face many barriers to accessing this substance use disorder (SUD) treatment modality. Past research found that women in jail who had a SUD were more likely to report a need for housing, mental health counseling, job training, medical care, and parenting assistance which could limit their ability to access and attend SUD treatment . AdditioUsing national VHA clinical records and administrative data, we conducted an observational study of all women VHA patients who received an AUD diagnosis (excluding in remission) during an outpatient or inpatient visit in fiscal years (FY) 2014–2017. AUD diagnosis was determined using International Classifications of Diseases (ICD)-9th and 10th Edition-CM codes, based on the American Society of Addiction Medicine specifications . This stgender, age, ethnicity/race , marital status , urban or rural residence , and homeless status . Military characteristics included service-connected disability rating, which reflects a VHA-determined percent coverage for disabilities caused by illness or injury occurring during or aggravated by military service. The higher the service-connected disability rating percentage, the more compensation the veteran receives. Demographic and military characteristics were coded from records collected the same day the veteran received her AUD diagnosis during the FYs of interest, or from the next available record. Patient health characteristics included co-occurring psychiatric disorder , co-occurring substance use disorder  and the Charlson-Deyo Comorbidity Index, a sum of up to 17 comorbid medical diagnoses, such as HIV, liver disease, diabetes, and congestive heart failure [Demographic variables included  failure . These hA veteran was considered justice-involved if she had a clinic code indicating contact with the Health Care for Reentry Veterans (HCRV) program (591 code), which provides outreach to veterans exiting prison, or the Veterans Justice Outreach (VJO) program (592 code), which provides outreach in other justice system settings, primarily jails and courts, in the year prior to or during any of the FYs between 2014 and 2017 . Women wReceipt of pharmacotherapy for AUD was defined as filling at least one prescription for naltrexone, acamprosate, topiramate, or disulfiram as indicated in VHA pharmacy records during the FY period they received an AUD diagnosis. Receipt of pharmacotherapy for AUD is a performance measure endorsed by the American Society of Addiction Medicine [Medicine .For FY 2017, we examined descriptive statistics of women veterans’ characteristics, stratified by justice-involved status, and tested for group differences using Chi square analyses. Cases with missing data  were excluded from the Chi square analyses. The rate of receipt of pharmacotherapy for AUD was calculated separately for each FY as the number of women veterans who received pharmacotherapy for AUD within 1-year of diagnosis divided by number of women veterans diagnosed with AUD overall and by medication type. A mixed-effects logistic regression model using SAS PROC GLIMMIX was used to test the association between justice-involved status and receipt of pharmacotherapy for AUD across all FYs examined. All women veterans’ characteristics and FY indicators were simultaneously entered in the model as main effects to account for the demographic and time trend adjustments. Nested random effects were used to model a three-level hierarchical data structure: patients within years within facilities. Cases with missing data  were excluded from the mixed-effects model.Of 10,511 VHA women patients diagnosed with AUD in FY2017, 852 (8%) had contact with one of the VHA’s justice outreach programs for individuals in the criminal justice system. Characteristics of women veterans with AUD in FY2017 are displayed by justice-involved status in Table The percentage of women veterans, both justice- and non-justice-involved, who received pharmacotherapy for AUD increased from 14% in FY2014 to 21% in FY2017 (p < .0001). Additionally, of women veterans who had contact with a VHA justice outreach program, 20% received pharmacotherapy for AUD in FY2014 compared to 31% in FY2017 (p < .0001). The mixed-effects logistic regression model indicated that women veterans with justice involvement had higher odds of receiving pharmacotherapy for AUD compared to women veterans not justice-involved (p < .0001, Table The primary aims of this study were to examine the association of justice involvement with receipt of pharmacotherapy for AUD and examine other patient factors that may explain variation in receipt of pharmacotherapy for AUD among women veterans who receive care at VHA facilities. We found that women veterans who had contact with a VHA justice outreach program had higher odds of receiving pharmacotherapy for AUD compared to women veterans with no known justice involvement, even after adjusting for other patient characteristics. Programming and legal mandates for veterans with criminal justice system contact may partially explain the higher rate of pharmacotherapy receipt. Some veterans with criminal justice involvement participate in treatment courts and others are on probation or parole. Through those systems, they may have a requirement to seek AUD treatment which could include pharmacotherapy. Although we could not identify which veterans in our sample had a legal mandate for treatment, prior work with the general population exiting prison found that legal supervision and court mandates were associated with participation and adherence in SUD treatment, including pharmacotherapy , 29.The VHA’s justice outreach programs, which are designed to assess the treatment needs of veterans with criminal justice involvement and connect them with appropriate services, may also explain the higher rate of receipt of pharmacotherapy for AUD. Outreach workers from these programs support veterans with tasks as diverse as helping them complete benefits paperwork, find housing, and schedule health care appointments. Connecting justice-involved veterans with SUD treatment, which may include pharmacotherapy, is one of the priorities of the program, and most participants enter and engage in SUD treatment . JusticeOther characteristics of women veterans were also associated with receipt of pharmacotherapy for AUD. Women veterans who were homeless had increased odds of receiving pharmacotherapy for AUD. One possible explanation for the higher rate of receipt may be VHA’s homeless veterans’ initiatives. Similar to the VHA’s justice outreach programs, VHA’s homeless initiatives and supported housing programs help connect homeless veterans to housing solutions and medical, mental health, and SUD treatment which can include pharmacotherapy for AUD. Prior research showed homeless women veterans were more likely than men to enter a VHA supported housing program, and reported less substance use over the subsequent year , suggestAfrican-American women veterans were less likely to receive pharmacotherapy for AUD, consistent with prior research indicating that African-American VHA patients overall are less likely to receive pharmacotherapy for AUD compared to White patients . AdditioWomen veterans age 55 and older were less likely to receive pharmacotherapy for AUD than younger women. In contrast, past research has found that older adult women veterans use VHA mental health and SUD outpatient care more frequently than their younger counterparts . One posThere are several limitations to our study, particularly because we examined secondary data. First, as our sample was limited to women veterans using VHA-services, women veterans receiving pharmacotherapy for AUD outside of VHA were not covered by the dataset. Second, due to our definition of justice involvement, there may have been veterans with criminal justice contact that were misclassified as non-justice-involved in this study. However, across the general population of veterans, less than 3% are justice involved , and it This study found that receipt of pharmacotherapy for AUD is increasing among women veterans generally, and among women veterans who have had contact with the VHA’s justice outreach programs specifically. Many barriers to AUD care experienced by justice-involved women are being addressed by the VHA’s integrated health care system, which helps to explain the higher odds of receiving pharmacotherapy for AUD among the women justice-involved veterans compared to their non-justice-involved counterparts. Women veterans experiencing homelessness were also more likely to receive pharmacotherapy for AUD; this finding may also be partially explained by the VHA’s integrated care model and support provided to homeless veterans. Generally, African-American and older women veterans had lower odds of receiving pharmacotherapy for AUD, suggesting that these women may have unique barriers to accessing or utilizing this effective treatment.Legal mandates and supportive programming targeting veterans with criminal justice system contact may explain the higher rate of receipt of pharmacotherapy for AUD observed among justice-involved women veterans in our study. To better improve receipt and use of pharmacotherapy for AUD among women veterans with criminal justice involvement, we need to better understand their general treatment and service access and use. In the criminal justice and health field, future research, such as qualitative studies examining treatment and service access, preference, and entry among women veterans with criminal justice involvement may help identify barriers to and facilitators of accessing pharmacotherapy for AUD. Additionally, research with health care providers and facilities offering pharmacotherapy for AUD may help shed light on implementation strategies and facilitators that increase use of these medications among women veterans with criminal justice contact, and women veterans generally, who are interested in this treatment option.