Human papillomavirus (HPV) induce many cancer conditions and cause cervical cancer, second in frequency of malignant disease in women.The aim was to develop biomarker panel for HPV-induced cervical precancerous diseases in patients infected with herpes simplex virus (HSV).The study involved 71 women with cervical precancerous diseases (mean age 26 ± 5 years) revealed by colposcopic, cytomorphological, and ultrasound signs which were assessed according to the following: first group, 44 patients infected with HPV; second group, 27 HPV-negative patients; and third group, 30 healthy patients (controls). In cervical specimen, we identified HPV DNA of different oncogenic risk types by polymerase chain reaction (PCR). Enzyme-linked immunosorbent assay (ELISA) kits (JSC SPC ‘DiaprofMed’) were used for detecting antibodies to HSV1 and/or HSV2 and for determining the avidity index. The production of pro-inflammatory cytokines, interferon-γ (IFN-γ), IFN-α, TNF-α, and interleukin-1β (IL-1β), and anti-inflammatory cytokines, IL-4, IL-10, and transforming growth factor-β1 (TGF-β1), were studied by ELISA.In HPV-induced cervix precancerous diseases, we identified low-avidity IgG antibodies to HSV serum of 20 patients; in the serum of 17 patients, we identified average-avidity antibodies, and high-avidity antibodies were found in 2 patients only. In 14 HPV-negative patients, we found low-avidity IgG antibodies to HSV; in 10 patients, medium avidity. Patients with low-avidity IgG antibodies to herpes virus showed high and medium oncogenic risk HPV types and a decrease of IFN-γ compared to patients with medium-avidity IgG antibodies. Production of IFN-γ was suppressed also in HPV-negative patients with cervical precancers, but we found low- and medium-avidity IgG antibodies to herpes virus. In patients with low-avidity antibodies, we observed increased level of IL-10. Level of IFN-α, IL-1β, IL-2, and IL-4 did not change in patients of all groups, but TGF-β1 increased.In HPV-positive patients, those with low-avidity IgG antibodies to HSV had immunosuppression, confirmed by increased TGF-β1 and violation of IFN-γ production. Therefore, in pro- and anti-inflammatory cytokines and IgG antibodies to HSV, their avidity is an important diagnostic biomarker of HPV-induced precancerous cervical diseases. Low-avidity IgG antibodies may be an indication for treatment with immunomodulators and antiviral drugs. Cancer of the cervix  is the second most common cancer in women worldwide, with about 500,000 new cases and 250,000 deaths each year [Women health and gender-related pathology is among the priorities for predictive, preventive, personalized medicine (PPPM) -4 - an iHuman papillomavirus (HPV), which induces a wide range of diseases and precancerous tumor genesis, is the most important risk factor for cervical cancer. The interaction of oncoproteins E6 and E7 of high oncogenic risk with intracellular factors is a key stage for induction of malignant transformation. These factors play an important role in the regulation of growth, differentiation and apoptosis, which may lead to instability of the genome and malignant transformation [ormation .The risk co-factors of HPV-induced cancer are as follows:• Patients infected by other sexually transmitted pathogens, especially viruses like herpes simplex virus (HSV) ;• The violation of a specific cellular immune response -11 and p• HPV type, especially in the case of cervical infection;• Frequent multiple full-term pregnancies and birth giving before 16 years;• Congenital and/or acquired immunosuppression;• Patients infected with HSV-2;• Use of steroids , oral contraceptives;• Genetic factors - polymorphism of the E2 protein gene of HPV and molecules of the major histocompatibility complex (MHC), interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β);• Smoking, lack of antioxidants in the body or folic acid due to low socio-economic standard of living, etc.It was noted that E6 and E7 oncoproteins of high oncogenic risk HPV have immunosuppressive activity directed primarily to the inhibition of gene expression of IFN and IFN-induced genes, as well as decrease in the production of IL-18, which directly regulates γ-interferonogenesis. This in turn affects the balance of cytokines Th1 and Th2 type and thus determines the main path of development of the immune response - either by Th1 or by Th2 type ,18,19. Tin vitro[The role of pro-inflammatory cytokines is ambiguous, which can affect both the formation of the body’s immune defence in the HPV ,22-24 anin vitro. We havein vitro. PossiblThe issue of the role of HSV-1 and HSV-2 as co-factors of HPV-induced carcinogenesis was debated for a long time since 1982 . HSV canThe results of epidemiological studies ,28 also We have previously reported  that in The aim was to assess the production of pro- and anti-inflammatory cytokines in HPV-induced cervical precancerous diseases in patients infected with HSV-1 and/or HSV-2 in serum IgG, identified with varying degrees of avidity, specific to these HSV.The study involved 71 women with cervical precancerous diseases (mean age 26 ± 5 years). Human papillomavirus infection and cervical precancerous diseases were diagnosed on the basis of colposcopic  and cytoAll patients underwent general clinical examination, which included clinical and biochemical blood tests, blood tests for HIV, RW, HBS-Ag and HCV-Ag, clinical urine tests, ECG, ultrasound, chest X-rays and a study of vaginal biotope (microflora), according to the protocols of the Ministry of Health of Ukraine.According to the nature of the pathological process in cervix, we formed the following groups of patients with cervix precancerous diseases: 1) 44 patients identified HPV DNA in cervical specimen with colposcopic, cytomorphological  was taken to obtain the serum.DNA HPV detected by polymerase chain reaction (PCR) in cervical specimen. The HPV DNA of different oncogenic types: high , medium  and low .For screening the sera for IgG for presence of HSV, we used the test system ‘DIA-HSV-1/-2-IgG’, constructed in the form of indirect solid phase enzyme immunoassay (ELISA). The solid phase polystyrene plates PolySorp  were used, which adsorbed the mixture of recombinant proteins gG1 and 2 gG . Murine monoclonal antibodies to human IgG labelled with horseradish peroxidase were used as a conjugate. TMB reaction, diluted in citrate buffer containing hydrogen peroxide, was used as a developer.Differential diagnosis for HSV-1 and HSV-2 was performed using kits manufactured in the same format as above. However, in the immunosorbent, only the recombinant proteins gG1 or gG2 were used respectively. Based on the last test, the system was designed such that it enables not only to detect IgG to HSV but also to determine the degree of avidity.The avidity index was calculated as the percentage of absorbance obtained in the test sample in the presence of a dissociating agent; the absorbance was obtained in its analysis as usual regimen. Thus, if avidity index was less than 30%, we supposed that serum contains low-avidity antibodies, in the range of 30% to 60%, it contains medium-avidity antibodies, and if more than 60%, high avidity. The setting reaction was conducted according to the manufacturer’s instructions for these kits (JSC SPC ‘DiaprofMed’).The production of pro-inflammatory cytokines, IFN-γ, IFN-α, TNF-α, IL-1β and anti-inflammatory cytokines, IL-4, IL-10, TGF-β1, in determining the levels of these cytokines in serum of patients was studied by ELISA. To determine the serum TGF-β1, we used test production system User’s Manual . The levels of IFN-γ, IFN-α, TNF-α, IL-1β, IL-4 and IL-10 in serum were determined using appropriate ELISA test kits of Vector-Best (Russian Federation). Setting ELISA was performed according to the manufacturer’s instructions specified test systems.p = 0.05).These data were processed by a computer program STATISTICA. The null hypothesis for the control and experimental groups tested using non-parametric Kolmorogov-Smirnov test. Data was presented as M ± SEM. Some experimental results are presented as median and interquartile range MAE (LQ − UQ), where Me is the median, LQ and UQ are the lower and upper quartiles, respectively. The significance level for all tests was 5%  biomarkers were assessed on small group of patients. For this reason, biomarker specificity/sensitivity was not evaluated as well as the measurements of individual outcomes were not sufficiently assessed according to the findings of the study.In HPV-induced cervical precancerous diseases, we identified IgG antibodies to HSV-1 and/or HSV-2 with low avidity in serum of 20 patients; in serum of 17 patients, we identified IgG antibodies to HSV-1 and/or HSV-2 with average avidity, and high-avidity IgG antibodies to these HVS were found in serum of 2 patients only. Antibodies to HSV-1 and/or HSV-2 were not found in serum of two HPV-positive patients.In the serum of 14 HPV-negative patients, we revealed IgG antibodies to HSV-1 and/or HSV-2 with low avidity, and serum of 11 patients in this group had IgG antibodies to HSV-1 and/or HSV-2 with a medium avidity; high-avidity IgG antibodies to these HVS were found in serum of 1 patient only. Antibodies to HSV-1 and/or HSV-2 were not found in the serum of two HPV-negative patients.In HPV-induced cervical precancerous diseases, we detected HPV of high oncogenic risk , medium  and low   with medium-avidity antibodies to HSV-1 and/or HSV-2, high-risk HPV types were identified . In 3 patients (17.6% cases) with medium-avidity antibodies to HSV-1 and/or HSV-2, medium-risk HPV types were detected. Low-risk HPV types was identified in four HPV-positive patients (23.5% cases) with low avidity antibodies to HSV-1 and/or HSV-2.Thus, high- and medium-risk HPV types were more common in patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 (95.0% of cases) than in patients with medium-avidity IgG antibodies to HSV (76.5% of cases) in serum.Two patients with high-avidity antibodies to HSV were infected with high-risk HPV types.The study of production of pro-inflammatory cytokines IFN-α, IFN-γ, IL-1β, IL-2, and TNF-α in patients with cervical precancerous diseases with low or medium-avidity serum IgG antibodies to HSV-1 and/or HSV-2 is presented in Table We found that IFN-α and IL-1β, IL-2 and TNF-α production at the system level was not changed in HPV-positive and HPV-negative patients with cervical precancerous diseases, who had low or medium-avidity IgG antibodies in serum to HSV-1 and/or HSV-2. Thus, in these patients, the serum levels of these cytokines were similar to that of the control group .However, serum level of IFN-γ significantly decreased in HPV-positive patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 comparing to controls as well as HPV-positive patients with medium-avidity IgG antibodies to HSV-1 and/or HSV-2. It should be noted that serum level of IFN-γ decreased slightly in HPV-positive patients with medium-avidity IgG antibodies to HSV-1 and/or HSV-2, but the difference compared with the controls was not statistical.Serum IFN-γ was also significantly lower in HPV-negative patients with cervical precancerous diseases with both low and medium-avidity IgG antibodies to HSV-1 and/or HSV-2 than in controls.These data suggest that production of IFN-γ was suppressed in HPV-positive patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 as well as in HPV-negative patients with cervical precancerous conditions of low or medium-avidity antibodies to these herpes virus. However, there are no dependencies between the level of serum IFN-α, IL-1β, IL-2 and IL-4 in the two groups of patients in comparing the presence of serum with low- and medium-avidity or IgG antibodies to HSV-1 and/or HSV-2.It is shown that the median serum IL-4 levels in HPV-positive patients with cervical precancerous conditions of low- or medium-avidity IgG antibodies to HSV-1 and/or HSV-2 was respectively 3.6 pg/ml (0 to 6.8) and 3.2 pg/ml (5 to 0.1). In the control median serum, IL-4 levels were 0.1 pg/ml (0 to 0.305). Although we observed a trend towards increased IL-4 in the serum of patients relative to controls, the difference between all these parameters was not statistical.The median serum IL-10 levels in HPV-infected patients with low- or medium-avidity IgG antibodies to HSV-1 and/or HSV-2 was respectively 7.6 pg/ml (0.1 to 44.8) and 2.2 pg/ml (0 to 50.3). In the control median serum, IL-10 levels in serum was 11.2 pg/ml (2.5 to 36.9). The difference between all these parameters was also not statistically significant.There was no statistical difference between the levels of IL-4 in the serum of HPV-negative patients with cervical precancerous conditions of low- or medium-avidity IgG antibodies to HSV and that in the control. The median serum IL-4 levels in those patients with low- or medium-avidity IgG antibodies to HSV-1 and/or HSV-2 was respectively 1.8 pg/ml (0 to 16.0) and 1.0 pg/ml (0 to 6.4).p < 0.05). The level of serum IL-10 in HPV-negative patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 was also statistically higher than the level of this cytokine in serum HPV-infected patients both with low- and medium-avidity IgG antibodies to HSV-1 and/or HSV-2 as well as in the control (p < 0.05).In HPV-negative patients with low- and medium-avidity IgG antibodies to HSV, the median serum IL-4 levels were respectively 253.8 pg/ml (62.1 to 533.9) and 31.0 pg/ml (7.2 to 52. 1). The difference between these figures is statistically significant (p < 0.001)  and second (HPV-negative) groups.P > 0.05).In patients of both first and second groups, we registered the changes of structure of the cervix on ultrasound as follows: cervical canal thickening over 5 mm ; hydrocerix, fluid in cervical canal in ovulatory phase ; nabothian cysts in cervix ; local stiff cervical lesions, fibrosis (hyperechoic bands) in cervical tissue ; deformation of structure, rough boundary between the mucosa and muscle layer ; cervicosis, including stiff areas on sonoelastography of hyperechoic inclusions (fibrosis/petrifications) ; cervical canal polyps ; increased vascularization in endocervix ; extensive fibrosis (hyperechoic bands) in cervical tissue ; cervical solid nodules; stiff in sonoelastography  and increased vascularization in endocervix and stroma . At sonography, mean cervical length before treatment was 26.7 ± 6.9 mm and 21.2 ± 4.5 in controls  ; for mild cervical dysplasia (CIN grade I), data were insignificant (P > 0.05) due to small number of patients.For all US symptoms inherent to ) Figure , we obtaDiagnostic evaluation of ultrasound for revealing cervical dysplasia and staging was as follows: the sensitivity was 97.18% ; specificity was 83.33% ; positive predictive value was 93.24%  and negative predictive value was 92.59% .The ultrasound findings are presented on Figure Today, it is known that in the development of HPV-induced cervical dysplastic lesions, the key impact has a specific cellular immune reactivity to HPV, especially the Th1-type response of T helper cells, that develops by balancing various opposition groups of cytokine, in particular, pro- and anti-inflammatory cytokines ,14,35,36It is known that suppression influenced oncoproteins E6 and E7 of HPV high-risk oncogenic gene expression of interferon, interferon genes and IL-18 production, which directly regulates the γ-interferonogenesis, as well as increased production of immunosuppressive cytokines that inhibit the development of T helper cells of Th1-type and the production of interferon-γ and IL-2, which is one of the most important evolutionary mechanisms against HPV immune factors ,18,19.It is believed that another important co-factor in HPV-induced neoplastic lesions is HSV infection ,25-30,37we hypothesized that the results of our study may have important diagnostic and predictive clinical value, contributing to the predictive diagnosis of herpetic infections in HPV-induced cervical precancerous diseases, determining besides the presence of antibodies to HSV-1 and HSV-2 in serum, the avidity of specific IgG antibodies to these herpes virus. Determination of avidity of specific IgG is important for the diagnosis of various stages of HSV infection and its development is characterized by the presence of antibodies with different  avidity. We have previously shown [Assessment of cytokine production was performed by determining their concentration in serum, since such studies are widely used in laboratory practice to diagnose the state of immunity. Therefore, ly shown  that in In this study, we have shown that there is a relationship between infection patients with cervical precancerous conditions HPV and/or HSV-1 and HSV-2 suppression γ-interferonogenesis. The important role is played by the degree of avidity of IgG antibodies to HSV-1 and/or HSV-2. In HPV-infected patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2, level of IFN-γ in serum was significantly lower than in patients with medium-avidity IgG antibodies to these herpes virus and in controls. HPV-infected patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 often showed HPV oncogenic high and medium risk oncoproteins E6 and E7 which are known to suppress γ-interferonogenesis ,18,19.in situ, the production of IFN-γ was inhibited more clearly than in CIN I and in benign cervical processes [Previously, we have reported that in severe HPV-induced cervical precancerous diseases, as CIN-II and CIN III, it was observed that there is a more common incidence of HPV-positive patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 compared to the patients whose blood serum contained medium-avidity IgG antibodies to HSV-1 and/or HSV-2 . In patirocesses .Whereas, among patients with cervical precancerous diseases without herpetic infection in clinical form, the IgM antibodies to HSV-1 and/or HSV-2  were absStill, it is not clear whether infected patients with high- or medium-risk HPV types lead to reactivation of HSV-1 or HSV-2 genome in the case of chronic process.The analysis of our data may argue that HPV and HSV-1 or HSV-2 suppressing of γ-interferonogenesis may contribute to the development of HPV-induced cervical cancer, since this cytokine is known  to contrWe have previously shown that the HPV induced cervical dysplasia in patients with decreased serum levels of IFN-γ and IFN-α while increasing the levels of pro-inflammatory cytokines, TNF-α and IL-1β, and cytokine Th-2 type, IL-4 ,15. AccoIn patients with cervical precancerous diseases with different avidity IgG antibodies to HSV-1 and/or HSV-2, we have not observed the development of an active inflammatory response, as the content of pro-inflammatory cytokines like IFN-α, IL-1β, IL-2 and TNF-α maintained at level of controls.However, in HPV-infected and HPV-negative patients with cervical precancerous disease with low- or medium-avidity antibodies to HSV-1 or HSV-2, the concentration of serum TGF-β 1 was significantly increased. It was reported  that TGFTherefore, the increase of TGF-β1 production was registered in the present study in all compared groups, which is probably the result of precancerous processes of cervix than the result of HPV infection and/or HSV-1 and HSV-2 and therefore should be considered as unfavorable predictive sign for these diseases.Thus, our findings showed that HPV-positive patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 as well as HPV-negative patients with low- and medium-avidity IgG antibodies to HSV-1 and/or HSV-2 showed the violation of production of IFN-γ, confirming the immunosuppressive state. However, the level of TGF-β significantly increased in the serum of HPV-positive as well as HPV-negative patients of all groups.While for HPV-negative patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2, the production of IL-10 increased. The level of IL-10 in serum also increased in HPV-positive patients with CIN III according to other studies .predictive biomarker for unfavorable prognosis in some forms of HPV-induced cancers as a shift from Th-1 to Th-2 cytokines observed in metastases and in later stages of carcinogenesis [According to the literature data, the reduction of IFN-γ and IL-2 and increased levels of IL-4 and IL-10 in serum may be considered as a ogenesis ,43.Therefore, the presence of low-avidity IgG antibodies to HSV-1 and/or HSV-2 in the serum of patients with HPV-induced cervix precancerous diseases does not depend on the reactivation of HSV genome  which may be an indication for treatment as immunomodulators and antiviral (antiherpetic) drugs.HPV-positive patients with low-avidity IgG antibodies to HSV-1 and/or HSV-2 in the serum showed the violation of production of IFN-γ, confirming the immunosuppressive state. Therefore, the presence of low-avidity IgG antibodies to HSV-1 and/or HSV-2 in the serum of patients with HPV-induced cervix precancerous diseases does not depend on the reactivation of HSV genome  which may be an indication for treatment as immunomodulators and antiviral (antiherpetic) drugs. The level of TGF-β significantly increased in the serum of HPV-positive as well as HPV-negative patients with low- and medium-avidity IgG antibodies to HSV-1 and/or HSV-2. Ultrasound was used for the diagnosis of cervical dysplasia, and it showed the sensitivity 97.18%, specificity 83.33%, positive predictive value 93.24%, and negative predictive value 92.59%.Considering the limitations of the current research, more studies on larger cohorts using extensive technological platform with the translational research approach are required for the assessment of different constitutional types, collateral diseases, etc. with biomarker specificity/sensitivity calculations to formulate valid panel aiming for implementation for PPPM in complex women health. We suggest also the further studies regarding virus infections, human microbiota, immune response and gene associations and interactions with promising substances in nanoscale  for complex impact for female health considering wide spectrum of comorbidities and related pathologies to initiate comparative studies to establish science-based treatment algorithms and update screening programs. After approval, develop safe and effective person-related treatments beneficial for individual outcomes.Integrative women health care includes multimodal approach for gynaecologic pathology management with PPPM paradigm including the assessment in the following: breast , endometIt was acknowledged that more than 15% of viral infections are able to cause cancer in humans ,46. ThusSchiffman et al.  describe1. Infection of metaplastic epithelium at the cervical transformation zone, viral persistence, progression of persistently infected epithelium to cervical precancer and invasion through the basement membrane of the epithelium;2. Infection is extremely common in young women in their first decade of sexual activity;3. Persistent infections and precancer, typically within 5 to 10 years, from less than 10% of new infections;4. And finally, the invasive cancer that arises over many years, even decades, in a minority of women with precancer, with a peak or plateau in risk at about 35 to 55 years of age.Each genotype of HPV acts as an independent infection, with differing carcinogenic risks linked to evolutionary species.Metabolic disturbances in obesity causes a number of diseases, namely cardiovascular system, number of tumor sites, including lung cancer, breast cancer, uterine and ovarian cancer; in women, there is a violation of ovarian-menstrual cycle, local and systemic immunity and dyslipidemia. The recent data, regarding women’s differential responses to lifestyle changes, support another branch of research with a gender nutrition emphasis within predictive, preventive, and personalized medicine . There wIn immunology, the signal pathways are still not studied for gynecology cancers, promising is the ability of group of factors considered, namely, probiotics, which affect the relevant Toll-like receptors (TLRs) that promote effective immune response and the initiation of an effective immune defence. Application of probiotics/immunobiotics might be a promising and integrative personalized use.Oxidative stress (OS) induced by reactive oxygen species (ROS) is one of the main factors in cellular aging, and many cellular disorders cause extensive damage to DNA and also in mitochondria [chondria . OS is achondria . While ttheranostic, has received increasing attention in biomedicine [oxidative stress has been postulated as one of the main physiopathological hallmarks of most of chronic diseases, the nanoparticles of gold [cerium dioxide considering its UV-shielding effect, antiviral, antibacterial and antifungal activity, cardioprotective, neurotrophic, hepato- and nephroprotective and anti-aging effect have potential for various biomedical applications.Advances in nanoscience, nanotechnology and nanomedicine lead to the construction of new materials and devices for various scientific and therapeutic purposes, which are applicable in molecular diagnostics, nanodiagnostics, and improvements in the discovery, design and delivery of drugs, including nanopharmaceuticals. The application of nanoparticles allowing the combination of therapy and diagnosis, known as medicine . Pharmac of gold ,54 and c of gold  were repantiviral activity of nanocrystalline cerium dioxide were reported [universal nature action and can be directed to different targets in a cycle of virus reproduction . Due to fluctuations of the electromagnetic field, interaction between the nanoparticles with sufficiently large values of the non-linear polar leads to capacity building, which causes attraction at large distances, and at distances of the order of particle sizes - repulsion.The antiviral activity mechanisms of nanoceria that we discovered are of particular interest and are for further study because these open the prospect of using biosafe and biocompatible nanoconstructions to perform beneficial prevention and treatment of viral diseases for patients.Treatment with nanoceria has supplementary perspectives in gynecology and reproductive medicine as it results in the increase in the number of oocytes in follicles, increase in the number of oocytes at metaphase I and metaphase II, increase in the number of living granulosa cells and decrease in the number of necrotic and apoptotic cells .synthesis of virus-like nanoparticles is promising for designing safe and effective personalized vaccines, and that in combination with anticancer theranostic application, it is a significant impact in order to develop in PPPM in women health and reproductive medicine. Nanosensors could be used for screening the affinity between the identified proteins and the immunological synapses; protein arrays can be used to discover new antigenic determinants for vaccine development.Developing the technological platform for Vaccines offer a safe and cost-effective prevention; on the other hand, disappointing results of vaccine-related disorders require the shift of the ‘risk curve’ in order to better select cheap, efficacious and well-tolerated vaccine candidates. Vaccines do not eliminate the risk of HPV-induced cervical cancer; cervical screening programs will still be required to minimize cancer incidence. Thus, to develop innovative HPV vaccines and in order for the vaccines to reach populations in greatest need, financing mechanisms and multidisciplinary partnerships is essential [personalized treatment, prospective to promote effective immune response to infectious and related diseases, depends on the early detection of the etiological agent and any antibiotic resistances in a point of view of individual predisposition.ssential ,57. The We suggest to follow up this study in regards to profound assessment of all the panel of biomarker information using advanced biostatistics and bioinformatics techniques. We can suggest a mathematical model that integrates those multiparameter data, according to which the medical process is perceived as a complex system like ‘black box’ ,59 and cHPV-oriented model of cervical carcinogenesis should update and gradually replace older morphological models based only on cytology and histology [Several biologic markers or indexes have been studied as potential tools to determine the prognosis and biological behavior of cervical cancer . It was istology . It can Phenotypic  and genotypic biomarkers are potential surrogate end points for cancer incidence [ncidence . This wophenotypic surrogate end point. Promising are the biomarkers measuring specific and general genotypic changes correlating to the carcinogenesis . Thus, virus induce the activation of c-MYC protein suppressing the cell cycle controlling activity of P53 and allows, therefore, the development of new tumorigenic phenotype of transformed human cells. In consensus, the activated synthesis of HPV proteins E6, E7, E1 and E2 has been shown to be involved in the induction of malignant cell transformation [Precancer  has been considered the primary ormation ,48, a keTherefore, violation of interferon production may underlie relapse HPVI and be a risk factor for the development of HPV-induced malignant tumors.Integration of HPV DNA of high oncogenic risk to the host cell genome is undoubtedly a major factor in the persistence of the virus and its carcinogenic potential. However, there was an obtained evidence of other risk factors for HPVI and malignant transformation of HPV-infected cells . In partBiomarkers of immunosuppression may be considered as follows[various cytokines, namely IFN-γ, IL-2 and IL-12; cytotoxic T-lymphocyte antigen 4 (CD4), glucocorticoid-induced tumor necrosis factor receptor (TNFR)-related protein and programd cell death protein 1; natural killer (NK) cell biomarkers (receptors located on the surface of NK), namely levels of NKG2D and NKp46 and the expression levels of tumor necrosis factor-α, IL-4 and IL-10. Increased expression of MyD88 and TLRs is likely to enhance immunosuppression of Tregs, leading to the imbalance of Th1/Th2 and cytotoxic T cell type 1 (Tc1)/Tc2 cells. Our results illustrated that the presence of low-avidity IgG antibodies to HSV-1 and/or HSV-2 is the biomarker of immunosuppressive state.s follows,9,38: thproliferation and differentiation indices, specific gene and general chromosome damage, cell growth regulatory molecules and biochemical activities ; Ki67, a nuclear proliferation associated antigen is expressed in the growth and synthesis phases of the cell cycle . Serum biomarkers also may be monitored because of their accessibility [Other potential surrogate end points that may occur earlier in carcinogenesis may include sibility .INK4A, CDC6, and MCM5, was discussed and compared in [p16INK4A expression is closely associated with high-risk HPV infection; MCM5 staining intensity is independent of high-risk HPV infection, highlighting its potential as a biomarker in both HPV dependent and independent cervical dysplasia, and CDC6 may be a biomarker of high-grade and invasive lesions of the cervix, with limited use in low-grade dysplasia. Thus, p16INK4A may be suggested as the most reliable marker of cervical dysplasia among dysplastic group [The expression patterns of three potential dysplastic biomarkers, p16pared in  to evaluic group .oral contraceptive use with cervical adenocarcinomas in situ; however, no other evidence was found that oral contraceptives independently increase the risk of cervical carcinomas [Current data support the association of rcinomas .insulin-like growth factor (IGF) system is organized in a complex regulatory network at the cellular and subcellular levels. The IGF system has a key physiological role in the development of the organism and maintenance of normal cellular function during fetal and postnatal life and plays a central role in many aspects of the development and progression of cervical cancer. The IGF system consists of three ligands, IGF-I, IGF-II and insulin; three cell membrane receptors, IGF-I receptor (IGF-IR), insulin receptor (IR) and IGF-II receptor (IGF-IIR); and six high-affinity IGF binding proteins, IGFBP − 1 through −6, their specific proteases (IGFBP proteases) and membrane receptors (IGFBP-R). IGF-I is a potent mitogenic growth factor that plays a critical role in cancergenesis [The rgenesis .the most common diagnostic pitfalls and helpful morphologic and immunohistochemical markers[.Immunohistochemistry (IHC) is probably the most affordable and simple technology to detect many biomarkers . The difl markers.Elevated CA 125 levels are detectable in 20% to 75% of patients with cervical adenocarcinoma and have been associated with advanced tumor stage, large tumor size, high histological grade, lymph node involvement and status .Vieira et al.  proposedProteomics is a powerful tool for the development of molecular biomarkers in the postgenomic era and provides the hope of discovering novel biological markers for use in the screening, early diagnosis and prediction of response to therapy . ProteomProteomic studies of membrane proteins are an analytical challenge due to their dynamic physicochemical characteristics, hydrophobicity and heterogeneity. Differences in the membrane proteomes of two cervical cancer cell lines may correlate with the invasive potential . The resink4A-dependent pathway that limits cellular proliferation in epithelial cells [Human papillomavirus oncogenic proteins E6 and E7 were suggested to target the p53 and Rb pathways; E6 can enhance telomerase activity, whereas E7 inhibits a p16al cells . Thus, Hal cells . Only a al cells , includicervical vaginal fluid (CVF) is potentially an ideal sample to screen for biomarkers for early detection of cervical cancer. A recent study identified 151 new proteins that included proteins present in the lower female genital tract, such as HBD-2 and cathelicidin, two proteins that play an important role in the innate cervicovaginal immunity [Cervical mucous or immunity .Magnetic resonance imaging (MRI) is the most effective technique to assess the type, degree of differentiation, presence or absence of lymphovascular invasion, lymph node involvement, etc. Magnetic resonance spectroscopy (MRS) may support additional characteristics, namely ADC and total choline, that may be suggested in a role of predictive biomarkers. Thus, ADC coefficients were reported to be lower in cancer compared to normal cervical tissue, with degree of tumor differentiation contributing to this difference . BaselinPositron emission tomography-computed tomography (PET-CT) has higher sensitivity and specificity than do conventional anatomic modalities and is valuable in determining the extent of disease and detecting recurrent or residual tumor [18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) has become important in the initial evaluation of disease extent. 64Cu-labelled diacetyl-di(N(4)-methylthiosemicarbazone) is taken up by hypoxic tissues, which may be valuable for prognostication and radiation treatment planning [For these reasons, actually, we still cannot consider PET as a perspective screening tool for cervical cancer.al tumor . In locaplanning . Howeverplanning . For theSchöder and Gönen  investigDopplerography of the cervix revealed significant differences in all existing indices studied between women with cervical precancerous lesions or cancer and healthy women. In women with cervical cancer, an advanced stage is associated with higher velocity indices [Laboratory biomarkers representing vascularization may be conjoined with imaging data[in particular for vasospasm assessment. indices ,83. High indices . Pelvic  indices . Laboratging data,67in parThe most specific colposcopic signs of PVI are acetowhite epithelium, positive iodine punctuation and mosaic, and atypical transformation zone .Numeral challenges for optical imaging optimization were suggested, e.g., enhancing techniques with use of quantum dots that provide a promising alternative to conventional organic dyes for biological imaging, that when combined with optical imaging technologies can help visualize malignant changes in cervix at the molecular level [ar level .panel of biomarkers  for cervical carcinogenesis based on the currently available HPV-oriented model, leading to improve prevention and clinical management strategies, including improved screening tests and vaccines, reliably diagnosing that can help in the choice of multiple therapeutic alternatives most likely to benefit the patients [Thus, here, we suggest the patients , and to The following are the panel of biomarkers:1. Phenotypic Proteomic biomarkers  [• m, etc.) ;proliferation and differentiation ; Ki67, a nuclear proliferation associated antigen);• Serum biomarkers of histological biomarkers of cervical HPVI: exophytic and typical flat warts, mild changes of plane and metaplastic epithelium (single koilocytes) condylomatosis cervicitis, CIN of varying grades with/without koilocytes, and cervical cancer[• The al cancer;Dysplastic biomarkers: p16INK4A, CDC6 and MCM5 [• and MCM5 ;Viral biomarkers: virus herpes, HPV-related biomarkers ;• Receptors (ER) and PR, AR, PA);• The insulin-like growth factor (IGF) system receptors , the peptides , six high affinity IGFBPs (−1 to −6), IGFBP proteases and IGFBP receptors (IGFBP-R);• Cancer antigen (biomolecules) based biomarkers: cancer antigen 125 (CA125);• Receptors of the diffuse neuroendocrine system ;• Apoptosis biomarkers ;• • CVF samples for HBD-2 and cathelicidin testing;Oxidative stress biomarkers: DNA oxidation biomarkers , lipid oxidation , protein oxidation (protein carbonyls) [• rbonyls) ,88;Nitrosative stress biomarkers: NO, nitrite, peroxynitrite, and inducible NO synthase (iNOS) expression, modificated proteins, nitrosothiols, 8-nitroguanine (a marker of nitrative DNA damage), etc. [• e), etc. ,89,90;Vasospasm biomarkers  [• O, etc.) ,92.2. Genotypic biomarkers  ,94,etc.)4. Imaging biomarkersMR imaging/MR sprectroscopy: metabolic biomarkers, diffusion-weighted imaging, etc.;• Ultrasound ;• PET-CT ;• Colposcopy: specific colposcopic signs of PVI are acetowhite epithelium, positive iodine punctuation and mosaic, atypical transformation zone [in vivo subcellular imaging, enhancing optical imaging techniques as quantum dots [• ion zone , developtum dots ;Pathology, immunohistochemistry ;• Cellular, subcellular imaging.• 4. Immunological biomarkersBiomarkers of immunosuppression: immunosuppressive acidic protein (IAP); low-avidity IgG antibodies to HSV in HPV-positive patients leading violation of production of IFN-γ; various cytokines in the peripheral blood that IL-2, IL-12 and interferon-γ; cytotoxic T-lymphocyte antigen 4, glucocorticoid-induced TNFR-related protein and programd cell death protein 1 [• rotein 1 ; NK cell5. Biomarkers in pregnant women ;6. Patients profile including history of collateral diseases , HPV infection and sexual history data from properly constructed questionnaires, and cytological screening .Educational programs and individual preventive facilities for sexually active persons are important tasks for PPPM. The material for dissemination and lecturing should be standardized  in order to facilitate the work. Disseminate information and perform campaign for organization of free health check up available in low cost  and vaccination in childhood, especially in developing countries, and in time implementation of novel scientific findings in the field. Support preventive educational activity with long-term commitment of private and public funding programs.Cancer of the cervix accounts for over 60% of the gynecological cancer burden in developing countries which causes about 500,000 new cases and 250,000 deaths each year [ach year . The cosach year .The impact of HPV is not just clinical. The evaluation and treatment of the clinical manifestations of HPV also have an enormous monetary impact on the health care system . The ecoThus, our analysis of assessment of biomarker panel including current research of pro- and anti-inflammatory cytokines in patients with papillomavirus and herpes simplex virus infections allows to conclude as follows:Each individual pathological pattern of the production of pro- and anti-inflammatory cytokines in HPV-induced cervical precancerous diseases in patients infected with HSV1 and/or HSV2 in serum IgG, identified with varying degrees of avidity, specific to these herpes virus are promising biomarkers that defines further personalized tactics of comprehensive treatment using immunomodulators and antiviral drugs. The combination of diagnostic modalities such as imaging, serum and CVF biomarkers should help in the choice of multiple therapeutic alternatives as currently available integrative treatment  that is beneficial to the patients.HPV-oriented model should minimize the incidence of cervical cancer, and the morbidity and mortality it causes, even in low-cost settings, leading to improved prevention and clinical management strategies, including improved screening tests and vaccines. Persistent herpes virus, HPV infections have a high-risk for development of a number of collateral/infection-induced chronic diseases, namely cancer, cardiovascular, endocrine, autoimmune, metabolic, neurological diseases, that require research programs to support high levels of scientific and technological development for novel predictive programs. Levels of pro- and anti-inflammatory cytokines in papillomavirus and herpes simplex virus infections in patients have strong predictive value which has potential for development of predictive biomarkers for personalized treatment and tailored prevention of cervical precancerous lesions. Possibly, an imbalance of cytokine production Th1, 2, 3-type and anti-inflammatory cytokines may underlie CC relapse in HPVI and be a risk factor for HPV-induced malignancies. Expand biomarkers panel and proceed in the validation of new biomarkers in the shortest terms.Assessment of extensive biomarkers panel for cervical carcinogenesis based on Our results may lead to initiate the programs for women at risk to prevent cervical cancer and improve quality of life. In parallel with extensive biomarker panel develop preventive programs adapted for developing countries, namely campaigns for vaccination at schools, suggesting valid and simple diagnostic tests with self sampling and treatment with basic medicines. It is recommended to promote programs for introduction of ambulatory (‘office’) integrative women health care to a new level of efficiency and safety of the method.With the concluding points, we can formulate the following proposals (expert recommendations):1. For the European Union (EU): create an international research project to study integrative diagnosis and treatment towards women health improvement with regards to preserve the reproductive function. Perform sufficient evidence studies to determine relationships in virus, genetics, immune pathways, receptor system, to expand biomarkers panel that will allow and develop novel treatments and to complement the diagnostic algorithm.2. For Ukraine: it is recommended to promote programs of routine screening of preinvasive disease with HPV and HSV detection and assessment immunity status; introduction of personalized outpatient gynecological care with high level of efficiency and patient safety; the introduction of ambulatory (‘office’) care as the patient-centered medical home (PCMH) model for health care delivery; to participate in project and in partnership with EU to follow up experimental and clinical trials and involve related institutions and centers to the study.Cervical vaginal fluid; ER: Estrogen receptor; HPV: Human papillomavirus; MRI: Magnetic resonance imaging; MRS: Magnetic resonance spectroscopy; PA: Progesterone receptor antagonists; PET-CT: Positron emission tomography-computed tomography; PPPM: Predictive preventive, and personalized medicine; PR: Progesterone receptor; US: Ultrasound.AR: Androgen receptor; CC: Cervical cancer; CVF: The authors declare that they have no competing interests.LML did the planning of the research, study of pro- and anti-inflammatory cytokines, data analysis, statistical data processing and prepared the article. OEN did the collection and analysis of clinical material and determination of cytokine production. EVN did the collection and analysis of clinical material and the types of papillomaviruses. OMD did the collection and analysis of clinical material of colposcopic examination of patients. GVK participated in the creation of test systems for the determination of the avidity of the IgG antibodies. LOG participated in the creation of test systems for the determination of IgG and IgM antibodies in the serum of patients. RVB did the ultrasound survey, performed and did the analysis of the study and the literature review in part of the biomarker panel development, formulated prospects and performed the final article drafting. VOS determined the presence of IgM and IgG antibodies in the serum of patients. NMN did the collection and analysis of clinical material of cytomorphological study of the cervical material. VVB did the collection and analysis of clinical material and diagnosis of genital herpes infection. MYS did the organization and analysis of the study, planning studies, analysis of data, and prepared the article. All authors read and approved the final manuscript.LLM, Ph.D., D.Sci. Professor is a researcher in the Inteferon Department of Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine. OEN, M.D., is a medical doctor and fellow in the Odessa National Medical University. OMD, M.D., Ph.D., is a medical doctor in the Kyiv Perinatal Center. EVN, M.D., D.Sc., Professor, Department of Infectious Diseases Epidemiology Course Odessa National Medical University. EVN, Ph.D., is a medical doctor in the Kyiv Perinatal Center. GVK, M.S., fellow JSC SPC ‘DiaprofMed’. LOG, Ph.D., is a researcher of the Inteferon Department of Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine. RVB, M.D., Ph.D., is a researcher of the Inteferon Department of Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine and a medical doctor in the Clinical Hospital ‘Pheophania’ of the State Affairs Department, National Representative of the European Association for Predictive, Preventive and Personalised Medicine (EPMA) in Ukraine. VOS is a researcher of the Inteferon Department of Zabolotny Institute of Microbiology and Virology, National Academy of Sciences of Ukraine. NMN, M.D., is a medical doctor and fellow in the Odessa National Medical University. VVB, M.D., Ph.D., director of the Kyiv Perinatal Center. MYS, Ph.D., D.Sci., Professor is a corresponding member of the National Academy of Sciences of Ukraine and the director of the Inteferon Department of Zabolotny Institute of Microbiology and Virology, NAS of Ukraine, Kyiv, Ukraine.


The aims of this study were to measure the pre-vaccination prevalence of oncogenic HPV infection in women aged 20–69 years who were participating in the New Zealand National Cervical Screening Programme (NZ-NCSP) and who were: (1) referred with high grade cytology with a subsequent histologically-confirmed high grade cervical intraepithelial neoplasia (CIN2/3) or adenocarcinoma Women aged 20–69 years appearing on the NZ-NCSP register between August 2009-February 2011 with a cytology record of ASC-H/HSIL+/AGC/AIS were invited to participate in the study. Liquid-based cytology specimens were tested for 37 HPV types using Linear Array genotyping. The prevalence of type-specific HPV infection was reported within women with histologically-confirmed CIN 2/3 and within the wider group with ASC-H/HSIL+/AGC/AIS cytology. Age-specific trends for the relative proportion of HPV 16/18 vs. other oncogenic types in CIN2/3 were assessed.A total of 594 women with ASC-H/HSIL+/AGC/AIS cytology and a valid HPV test were recruited; of these 356 (60%) had confirmed CIN2/3 and 6 (1%) had confirmed AIS or glandular dysplasia. Positivity rates for any oncogenic HPV infection and for HPV16 and/or 18 within confirmed CIN2/3-AIS were 95% (95%CI: 92-97%) and 60% (54-65%) respectively; in all women with ASC-H/HSIL+/AGC/AIS cytology it was 87% (84-89%) and 53% (49-57%), respectively. The most common reported HPV types in women with CIN 2/3 were 16 (51%), 52 (19%), 31 (17%), 33 (13%) and 18 (12%). A trend for higher rates of HPV 16/18 infection compared to other oncogenic types was observed in younger women (p=0.0006).The prevalence of HPV 16/18 in confirmed high grade disease in New Zealand is comparable to that observed in Australia and European countries. Test positivity rates for type 52 appear higher than in comparable studies in other developed countries. A greater proportion of high grade lesions in younger women appear to be associated with HPV 16/18 infection. Infection with the oncogenic types of human papillomavirus has been associated with a higher cumulative risk over time of developing histologically-confirmed high grade cervical precancerous disease  ,2. A recGiven the geographic proximity of Australia to New Zealand, a previously used working assumption has been that the two countries have similar HPV infection patterns . In pracFor countries implementing HPV vaccination programs, a baseline measure of oncogenic HPV infection in high grade disease provides the capacity to estimate the potential burden of precancerous disease which may be avertable via vaccination. Ongoing surveillance will then provide an opportunity to monitor vaccine effectiveness. In September 2008, New Zealand commenced implementation of a national HPV immunization program using the Gardasil™ vaccine  . The vacand who had a histologically-confirmed high grade CIN lesion or adenocarcinoma in situ; and (2) among all women with a cytological prediction of high grade squamous disease or glandular abnormality (ASC-H/HSIL+/AGC/AIS) who were participating in the New Zealand National Cervical Screening Programme (NZ-NCSP). The secondary aim of the analysis was to compare oncogenic HPV prevalence in women with high grade disease in New Zealand with prior estimates from Australia and from other regions.The primary aims of the current study were to provide a baseline measure of oncogenic HPV infection in women aged 20–69 years among: (1) a potentially ‘enriched’ population of women with high grade cervical lesions, defined as a those referred with a high grade cytology report We used a cross-sectional design for the study. Eligible participants, defined as women aged 20–69 years with a high grade cytology result notified to the New Zealand National Cervical Screening Programme Register (NCSP-R) between August 2009 and February 2011, were invited to participate. Established in 1990, the NCSP-R is a country-wide national register that is used to monitor New Zealand’s cervical screening participation, compliance with recommended management, laboratory and colposcopy standards and cervical abnormality rates. The representativeness of the NCSP-R of the cervical screening population is underpinned by legislation that requires all cervical specimens in New Zealand to be sent to the NCSP-R . The regWomen on the NSCP-R with a notified high grade cytology result were invited to participate in the study. A recruitment flowchart is provided in Figures A1 and A2 in the Additional file Follow-up with colposcopy with or without biopsy proceeded accorded to standard clinical referral protocols. For each woman, the most severe disease ranking in the SNOMED diagnostic (morphology M) category observed over the 6 month period following the high grade cytology report was used to classify histology grade. Because the current study included only women referred with a high grade cytological result, the sub-group with confirmed high grade disease can be considered an ‘enriched’ population with respect to other studies of HPV in high grade CIN, since the majority of other studies have enrolled women referred with a smear showing any grade of abnormality.Depending on the usual practice at each collection site, either SurePath™  or ThinPrep™  liquid-based cytology (LBC) collection systems were used. Both cytology collection systems have been validated for use for HPV detection using Linear Array® HPV Genotyping Test  . LBC samThe Linear Array genotyping system uses polymerase chain reaction (PCR) amplification of DNA, followed by a reverse line blot hybridization assay to detect amplified DNA products (amplicons). The reaction volume consists of 50μl of Linear Array-HPV master mix and 50 μl of DNA. The PCR amplification reaction involved an initial activation step at 95°C for 9 minutes, followed by 40 cycles of denaturation at 95°C for 30 seconds) annealing at 55°C for 1 minute, extension at 72°C for 1 minute, with a final extension at 72°C for 5 minutes . The reaWe classified HPV types according to the International Agency for Research on Cancer 2009 assessment of biological agents . HPV typThe representativeness of the study sample in relation to all women in New Zealand with a high grade cytology report was assessed by comparing age and ethnicity distribution with data from the NCSP for all women with a high grade cytology report . The preThe prevalence of oncogenic HPV observed in confirmed CIN 2+ in New Zealand was compared with the findings of a prior study conducted in Melbourne . This stIn addition, study findings for the type-specific prevalence of oncogenic HPV in histological CIN 2/3 (excluding AIS) were compared with results for histologically-confirmed CIN derived from a worldwide meta-analysis of HPV prevalence in high grade disease . The oriAnalyses were undertaken using SAS V9.2 statistical software . Ethical approval for the study was obtained from the National New Zealand Ethics Committee, Cancer Council NSW Human Research Ethics Committee, Australia, and the University of Sydney Human Research Ethics Committee, Australia.A total of 2170 women were notified to the NCSP-R as having a high grade cytology report (ASC-H/HSIL+/AGC/AIS) over the recruitment period  of 594 women with a high grade cytology report and a valid HPV test Table . This prThe combined prevalence of oncogenic HPV types 16 and 18 was 52.9% among women with a high grade cytology report, 52.6% in women with histologically-confirmed CIN 2, and 66.4% in confirmed CIN3; whereas for other oncogenic types it was 33.8%, 42.8% and 28.3%, respectively    but was The study has also provided new more detailed information than has been reported to date on the pattern of the relative prevalence of HPV 16 and 18 infections in high grade lesions by age. For HPV type 16/18, prevalence peaked among women aged 20–29 years and fell with increasing age. Conversely, for the OHR HPV types, prevalence was lowest among women aged 20–29 years, and increased with increasing age to a peak among women aged 40–69 years. This observation is broadly consistent with patterns observed in the Guanacaste, Costa Rica cohort, which highlighted a similar pattern for HPV 16 and OHR types . It is aAn important strength of the study is that we recruited from the population-based National Cervical Screening Program register. A total of 27% of the population initially identified as potentially eligible were included in the final analysis, after taking into account exclusions, the ability to contact women, consent and HPV test success rates. However, of the women who could be approached a relatively high consent rate was obtained, and the observed distributions of age and ethnicity in the study population were very similar to that in the broader screening population of women aged 20–69 years with a reported high grade cytology result in New Zealand  and the inclusion of an AmpliTaqGold polymerase. PGMY09/11 primers were designed using DNA sequence homology for various HPV types indicated within the highly conserved region of the L1 region. In contrast to this method of designing primers, the original ‘manos’ MY09/11 primers used in previous prevalence studies were ‘degenerate’, which meant they did not necessarily provide reproducible estimates of HPV types detectable in samples . The impIn the current study it was assumed that samples positive for type 52 alone represented true type 52 infection, but that samples testing positive for 52 and also for at least one of types 33, 35 and 58 were not truly positive for type 52 (i.e. it was assumed apparent type 52 reactivity represented cross-reactivity). Dedicated probes are required for accurate detection of HPV type 52 in the presence of multiple infections . HoweverThis study provides a baseline measure of oncogenic HPV prevalence in a population of women in New Zealand, and provides a baseline for future similar surveys to assess the impact of HPV vaccination. Genotyping studies for high grade lesions have previously been included in a list of key recommendations to monitor the effect of HPV vaccination . Our finThe baseline assessment of oncogenic HPV prevalence in New Zealand women with high grade disease provides insight into the potential burden of disease avertable with HPV vaccination. The combined prevalence of oncogenic HPV 16 and 18 in New Zealand was found to be approximately 62% in confirmed high grade lesions. Ongoing surveillance of the prevalence of oncogenic HPV in high grade disease will allow future assessment of the impact of the national HPV immunization program in New Zealand.KC is co-PI of a new trial of primary HPV screening in Australia that is partially supported by Roche Molecular Diagnostics, Pleasanton, CA, USA. Other authors have no competing interests to declare. This study was funded by the New Zealand Ministry of Health.LS participated in the development of the study protocol, undertook the analysis of the data and participated in drafting the manuscript. HL participated in the development of the study protocol, co-ordinated the study in New Zealand and participated in drafting the manuscript. MS participated in the development of study protocol and drafting of the manuscript. HN participated in the development of the study protocol, setting up the study at various sites and participated in the drafting of the manuscript. CB undertook the HPV genotyping and participated in the drafting of the manuscript. KC participated in the development of study protocol, participated in drafting the manuscript, and supervised the analysis and drafting of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/114/prepubFigure 2A. Recruitment process for women approached to provide consent to test after a high grade cytology result used to notify NCSP-R. Table 1A. Oncogenic HPV prevalence by age in high grade cytology and in histologically-confirmed CIN 2/3. Table 2A. Oncogenic HPV prevalence by age in histologically-confirmed disease, by subcategory . Table 3A. Type-specific prevalence of oncogenic HPV in histologically-confirmed CIN2+ by sample collection method†.Recruitment process for women who provided a sample during colposcopy. Click here for file


Human papillomavirus (HPV) infection is highly prevalent in women migrating from countries where cervical screening is not implemented. The variety of HPV genotypes, their prevalence and the association with cervical abnormalities has been investigated by several groups in women moving mainly from Eastern Europe, Africa, and Southern Asia to Italy. All studies are concordant on the elevated rate of HPV infection among immigrants, which is four times higher than that observed among age-matched Italian women. The HPV prevalence among short-term migrants and characterization of viral variants showed that the high prevalence of HPV reflects either individual lifestyle or high prevalence of HPV in the country of origin. The high burden of HPV infection correlates very well with the high incidence of cervical cancer in migrant women. In fact, during the years 2000–2004 the cervical cancer incidence in women from Central and Eastern Europe and living in Central Italy was 38.3 per 100,000, which is statistically significant higher than that of native Italian women . In this study, we pooled together the results of three independent studies originally designed to assess the distribution and the prevalence of HPV genotypes among 499 immigrant women living in Southern Italy. A total of 39 mucosal HPV genotypes were identified. The 12 genotypes  classified as carcinogenic to humans (group 1) accounted for >80% of all infections. HPV16 was the most common viral type in all groups with frequency rates ranging from 15.4% in Africa to 51.1% in Eastern and Southern European HPV-positive women. The high prevalence of oncogenic HPVs and cervical cancer risk among migrant women, together with the lower participation in screening programs, demands for an urgent implementation of preventive strategies to increase screening and vaccine coverage and viral monitoring of uncommon HPV genotypes potential spreading in settled population. Cervical cancer is the third most common cancer in women worldwide with an estimated 530,000 new cases in 2008 . More thGenital HPV infections are highly prevalent among sexually active men and women worldwide . The IARMigrant women originating from low- and middle-income developing countries with limited resources in their health services and lack of cervical cytology screening programs have an increased risk of sexual transmitted diseases and HPV-related neoplasia –16. FurtThe aim of the current study was to describe the prevalence of HPV infection and the distribution of oncogenic genotypes in migrant women living in Italy along with the prevalence of HPV-related cervical neoplasia. The analysis was based on the three prospective studies including migrant women enrolled in Apulia, Campania, and Sicily –25 and oPublished data on the analysis of HPV type distribution in migrant women living in Italy were searched in Medline using the terms [“HPV” OR (“human” AND “Papillomavirus”)] AND (“migrant” OR “immigrant” OR “foreign” OR “asylum”) AND . When data were published more than once, only the publication with the largest sample size was included. Additional relevant references cited in retrieved articles were also evaluated. For the studies including women originating from more than one geographic location, the data were divided into components for each continent. The review was limited to studies that (1) included the analysis of cytological samples or paraffin embedded cancer tissues obtained from migrant women living in Italy; (2) provided cytological/histological grading; and (3) used broad spectrum HPV–DNA-based PCR assays able to detect and genotype at least the 12 high-risk HPVs included in the group 1. The search was updated on 15 November 2013.Four studies fulfilled the inclusion criteria. (1) The study by Chironna et al.  analyzed2 test, 1 degree of freedom.The frequency of each HPV genotype in cancer cases from Italian women (expected) was compared with the frequency of the corresponding genotype in cancers from born abroad women (observed). Ratios of observed and expected frequencies were calculated for each genotype and contingency tables were used to test for statistical significance with χn = 2; low SIL n = 12; high SIL n = 3). The prevalence rates of HPV infection were 57.9 and 94.1% among women with normal and abnormal cytology, respectively. In Sicily foreign women, enrolled among those self-referring for gynecologic care, the median age was 31.2 years (range 22–55) and the frequency of cases with abnormal cytology was 23.5% (27 out of 115). HPV prevalence was 42% (37 out of 88) and 66.7% (18 out of 27) in women with normal and abnormal cytology, respectively. Age-stratified HPV prevalence in the three regions showed a higher infection rate at younger ages with peaks of 53.1% among women ≤20 years old in Apulia and 70 and 68.3% in women aged 21–24 and 25–29, respectively, in Campania region, and 72.4% among women aged 22–27 in Sicily (Table p = 0.0049).A total of 499 cervical cytology samples and 46 cancer biopsies from foreign women living in Italy were included from the original studies Table . The oveThirty-nine different genotypes have been identified and among them the overall prevalence of group 1 HPVs , was 31.2, 48.9, and 43.5% in women from Apulia, Campania, and Sicily, respectively. The most common viral genotypes were HPV16 and HPV31 representing 27 and 8.5% of all infections, respectively. The relative frequencies of specific genotypes in migrant women from Apulia, Campania, and Sicily were quite comparable except for HPV59 representing 8.5% of infections in Apulia women and absent in other groups, and HPV16, highly prevalent in Campania  compared to Apulia (11.9%) and Sicily (16.4%) migrant women .The pooled analysis of three large studies on HPV prevalence in cervical cancer in Italy included 526 cases from women born in Italy and 48 cases from women born abroad. HPV sequences were detected in 95.8% of cases in both cancer groups  and HPV16 was the most common genotype representing 67.5% (340 out of 504) and 71.7% (33 out of 46) of all infections in native Italian and born abroad women, respectively. The distribution of HPV genotypes did not differ significantly between Italian and born abroad women  . The relin situ cervical cancer, during the years 2000–2004, among women aged 25–59 who were born in different countries but residing in central Italy. The incidence of invasive cervical cancer among women born in Central and South America and the Caribbean  and in Central and Eastern Europe  was statistically significant higher than that of Italian born women   , 42. Acc100,000)  recently100,000) .In Italy immigration is a relatively recent phenomenon: the proportion of immigrants was less than 0.6% in 1990, 2.3% in 2001 and reached the 6.8% in 2011Several studies have shown that the higher cancer incidence among migrant women living in Italy may be explained either by the higher HPV infection prevalence or the lower uptake of Pap test in the country of origin , 45. NotA limitation of the present pooled analysis includes a possible variation in the HPV genotype-specific sensitivity of different PCR assays used in the different studies. In fact, in the meta analysis including more than one million women with normal cytology, it was shown that the adjusted HPV prevalence for the MY09/11-based consensus PCR primers was significantly higher than that observed for GP5/6 or GP5+/6 + oligonucleotides, and that the PCR SPF10 primer system presented the better sensitivity and the highest HPV detection rate . The thrOn the other hand, a strength of the present study was represented by the relatively large population sampled in three Italian regions receiving highest immigration flows from low- and middle-income countries.The high prevalence of oncogenic HPVs and cervical cancer risk among migrant women, together with the lower participation in screening programs, demands for an urgent implementation of preventive strategies to increase screening and vaccine coverage and viral monitoring of uncommon HPV genotypes potential spreading in settled population.Dr. Paolo Giorgi Rossi is Principal Investigator of a project sponsored by the Italian Ministry of Health (data owner) and is in contact for reagents at a reduced price or free of cost from Roche Diagnostics, Hologic Gen-Probe, Abbott, and Qiagen. The other authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


High-risk (HR) HPV genotypes other than 16 and 18 have been detected in a significant proportion of immunocompromised females. We aim to evaluate the frequency of HR HPV genotypes in a population of HIV-positive Caribbean women.One hundred sixty-seven consecutive, non-pregnant, HIV-positive females ≥18 years were recruited in this study. Each participant received a vaginal examination, PAP smear, and completed a questionnaire. DNA was extracted for HPV testing in 86 patients.P value  = 0.040). 78% (130/167) of the women had HR HPV infections; the prevalence of abnormal cervical cytology was 38% among women who were HR HPV-positive compared to women who were HR HPV-negative (22%). Fifty-one percent of the 86 women with available genotype carried infections with HPV 16 and/or HPV 18; genotypes of unknown risk were also frequently observed. Women who had a CD4+ count of ≤200 had 7 times increased odds of carrying HR HPV infection in comparison to women with CD4+>200.Mean age was 39.1 years for women positive for HR HPV and 43.1 years for women negative for HR HPV (HR HPV infections in HIV infected females may consist of more than just HPV 16 and 18, but also HPV 52 and 58. Further studies are needed to determine whether HPV 52 and 58 play a significant role in the development of cervical cytological abnormalities in HIV+ women. Human Immunodeficiency Virus (HIV) infection leads to a decline in both the number and function of CD4+ T cells. This deficiency in the immune system places the infected person at risk for other infections. For example, Human papillomavirus (HPV) is the most common sexually transmitted virus that infects the cervix and is the major etiologic agent for cervical cancer. Studies show that immunodeficiency increases HPV persistence thus increasing the risk of cervical cytology abnormalities and invasive cervical cancer High-risk (HR) HPV types 16 and 18 account for the majority of all invasive cervical cancers worldwide , while HPV 58, 33, 45, 31, 52, 35, 59, 39, 51 and 56 in order of decreasing prevalence account for the other 27.4% of all invasive cancers worldwide et alHIV-positive persons treated with highly active anti-retroviral therapy (HAART) have reconstitution of the immune system following a successful lowering of HIV viral load and an increase in CD4+ T cell counts. These patients are no longer dying predominantly from opportunistic infections, but may be affected by other chronic medical illnesses and malignancies. A recent review by Adler In this study, the objectives are to evaluate the frequency and distribution of HR HPV genotypes in a population of HIV-positive Caribbean women and determine whether HR HPV infections other than HPV 16 and 18 are predominant in women with abnormal cervical cytology.The study received ethical approval from the Ethics Committee of the Public Hospital Authority and the University of the West Indies – Bahamas Campus. All participants provided written informed consent. Following Institutional Review Board approvals, 176 consecutive non-pregnant, HIV sero-positive females 18 years or older were recruited from the Infectious Disease Clinic at the Princess Margaret Hospital (PMH) in New Providence, Nassau, Bahamas from February to September, 2008. Cervical samples were collected through a PAP smear from all women at the time of the visit, and DNA was extracted for HPV testing. Nine women were excluded from the study due to insufficient quality DNA; therefore, the final study population consisted of 167 women. The first 80 patients were part of a previous publication The Infectious Disease Clinic at PMH caters to all the Bahaman Islands where the majority of persons (70%) reside in New Providence, Nassau and each year about 1,500 HIV-positive women are seen. This clinic's mandate is to cater to and treat all patients regardless of immigration status, nationality or finances by providing access to antiretrovirals and care. As a result, a small percentage of patients from other Caribbean countries are also seen at the clinic. Our study population reflects this demographic, whereby 93% (n = 155) of women are from Bahamas, while 7% are from other Caribbean countries  and Jamaica ).Each participant received a vaginal examination, Pap Smear and completed a questionnaire administered by an interviewer. The questionnaire collected demographic information, tobacco and alcohol use, reproductive information such as number of pregnancies, age at first menses, number of sexual partners, age at first intercourse, history of sexually transmitted infections.Clinical information was collected for each participant and included the number of years diagnosed with HIV, number of years on HAART and compliance with therapy. In the Infectious Diseases clinic, patients were initiated on HAART when their CD4 count was less than 350 cells/μL. For all women, results from HIV testing (ELISA and Western Blot), CD4 counts (Flow Cytometry), HIV viral load (Polymerase Chain Reaction (PCR)) and HR HPV status (Hybrid Capture II (HC II)) were recorded in the patient records in a clinical data base. The HIV testing, viral load and CD4 counts were performed in the clinical laboratory at the Princess Margaret Hospital. The HC II assay was performed in a clinical laboratory at LabCorp in the USA . Review of patient records was performed to obtain these results for inclusion in this study. The participant's last CD4 count and HIV viral load were recorded. These tests were performed either at the time the cervical sample was obtained or within the previous two months.The HC II assay is capable of identifying HR HPV infections , results are reported as “detected” or “not detected” and were available from the medical records for 81 patients in this study. For the remaining 86 patients, cervical thin-prep samples were shipped to the United States (Ragin laboratory) where HPV genotyping was performed using the HPV Linear Array protocol. To confirm that the extracted DNA samples were PCR amplifiable, the β-globin gene fragment was amplified using PCO4 and GH20 PCR primers. All DNA extraction and PCR set-up were performed in a PCR-clean area separate from the post-DNA amplification areas in the laboratory. The specific HPV types in each cervical specimen were identified using a Linear Array HPV genotyping protocol as previously described et al. Both the Linear Array and HC II assays are comparable for HR HPV status since each detects the same HR HPV genotypes which are classified based on the previously published risk classification by Munoz Age was categorized into tertiles . Age at first intercourse was categorized as a binary variable based on mean age of responses to the question (≤16 years and >16 years). Current contraceptive use was categorized as yes/no. Length of time on HAART was categorized as less than 2 years, 2–4 years, and greater than 4 years. CD4+ cell count and viral load were both divided into two groups based on the median value for each respective variable. Cervical cytology reports were categorized into three categories: negative, dysplasia , and atypical squamous cells of undetermined significance (ASCUS).P value of ≤0.05 was considered statistically significant.Descriptive statistics were generated for demographic, behavioral, and clinical variables according to the presence or absence of HR HPV infection, using Fisher's exact test to determine statistically significant differences between the proportions for each variable. Multivariable logistic regression models were used to assess the association of demographic, behavioral, and clinical variables with HR HPV infections. Pair-wise association of each variable with HR HPV status was performed. Covariates were included in the models based on statistically significant associations with HR HPV status (p<0.05). For the subset of participants where specific HPV genotypes were available, multivariable logistic regression models were used to assess the association between demographic, behavioral, and clinical variables and the odds of having HR HPV types 16 or 18 versus any other HR HPV type. Statistical analysis was performed using STATA version 10.1 software . A P value  = 0.040). Overall 78% (130/167) of the women had HR HPV infections, and the prevalence of abnormal cervical cytology was 38% (49/130) among women who were HR HPV-positive compared to women who were HR HPV-negative (22% (8/37)). Cervical dysplasia rather than ASCUS was more prominent irrespective of HR HPV status. Seventy-seven percent (38/49) of HR HPV-positive women with abnormal cervical cytology had dysplasia compared to 62% (5/8) HR-HPV-negative women with abnormal cervical cytology. As expected, a significantly higher proportion of women who carried HR HPV infections had HIV viral load ≥400 and CD4 count ≤200 compared to women who were HR HPV-negative. HR HPV-positive women were more likely to have had a history of pregnancy compared to HR HPV-negative women (P = 0.048).The study population (n = 167) consisted of women, ages 19 to 71 years old (mean age: 40 years). Among the women with available HPV genotype data (n = 86), a wide distribution of HR and low/unknown-risk HPV types was detected . The preWomen who had a CD4+ count of ≤200 had 7 times increased odds of carrying HR HPV infection  The majority of women in our sample carried multiple HR HPV infections; this could be attributed, among others, to the immunosuppressive state due to HIV infection. Patel Another interesting finding is that 78% of the women carried HR HPV subtypes, but only 38% presented with abnormal cervical cytology; this suggests that the majority of these infections were likely transient rather than persistent, or that these were new infections. In addition, a high rate of cervical abnormalities was observed among women without evidence of HR HPV types yet cervical dysplasia rather than ASCUS was more frequently diagnosed. Assuming that HPV remains the main risk factor for cervical cancer in the Caribbean, this finding may indicate that other HPV types, considered low risk, are actually responsible, alone or in combination with specific environmental/behavioral factors, for the observed cervical abnormalities.et al. screened over 145 HIV-positive Zambian women and detected squamous cell carcinoma in 28 females. Thirteen (46.4%) SCC cases were positive for HPV 52, and 10 (35.7%) cases were positive for both HPV 58 and 16 et al. reported a lower prevalence of HPV 16 and 18 in HIV-positive women with invasive cervical carcinoma compared to HIV-negative women with invasive cervical carcinoma There is limited epidemiologic evidence of a specific role of HPV 52 and 58 in cancer development in HIV-positive women. Although high-risk HPV types 16 and 18 are known to be associated with more than 70% of all cervical cancer cases, few studies suggest that this may not necessarily hold true for immunocompromised populations of non-European descent. Sahasrabuddhe Our study has several limitations: despite the fact that we enrolled all consecutive patients from the Clinic, we cannot exclude that some selection bias occurred, thus we cannot affirm that the results have external validity for the entire HIV positive community in the Bahamas. In addition, only a subset of the study population had available type-specific HPV information. Another limitation in this study is that, given the retrospective nature of the design, the participant's last CD4 count and HIV viral load were either performed at the time of enrollment or within the previous two months. In the first month after initiating HAART, CD4 count will start to rise, and will continue to rise for the first three years on average before reaching a plateau. It is possible that the levels of CD4 and viral load may be inaccurate in patients where CD4 and viral load data were obtained prior to enrollment, and HAART was initiated at the time of enrollment.Another limitation of this study is that we examined exfoliated cervical cells rather than cervical biopsies. A recent study compared HPV prevalence and genotype infections between exfoliated cells and the corresponding cervical biopsy from women who HIV-positive Our findings support the need for follow-up of HIV-positive women in a longitudinal study in the Bahamas. The data generated from these efforts would provide important clinical information related to HPV persistence and the dynamics of multiple infections with HR HPV types in this population. Comparisons of HPV infections between cervical biopsies and exfoliated cells would provide meaningful information for the development of appropriate screening and HPV triage protocols needed for the evaluation and management of HPV infections in HIV-positive women.To our knowledge our work represents the first study of HR HPV infections in a unique population of Black HIV-positive women treated in the Bahamas. Our findings correlate with what has been reported in other populations. This information will need to be confirmed in larger studies but already warrants the significance of HPV screening in HIV-positive populations. Furthermore, the findings from our study could provide some insight on the potential efficacy of the current HPV vaccines in a population where HIV infection is wide-spread.


Reported associations of male circumcision (MC) with human papillomavirus (HPV) infection in men have been inconsistent.4,033 healthy men were examined every six months for a median of 17.5 months. In each study visit, exfoliated cell specimens from the coronal sulcus/glans penis, penile shaft, and scrotum were collected and combined into one sample per person for HPV DNA detection. Samples were tested for 37 HPV types. Cox proportional hazards models were used to evaluate the association between MC and the incidence and clearance of HPV infections and specific genotypes.The overall incidence of new HPV infections did not differ by MC status  1.08, 95% confidence interval (CI) 0.91-1.27). However, incidence was significantly lower among circumcised versus uncircumcised men for HPV types 58 (p = 0.01), 68 (p < 0.001), 42 (p = 0.01), 61 (p < 0.001), 71 (p < 0.001), 81 (p = 0.04), and IS39 (p = 0.01), and higher for HPV types 39 (p = 0.01) and 51 (p = 0.02). Despite the lack of an overall association in the risk of HPV clearance by MC , median times to clearance were significantly shorter among circumcised than uncircumcised men for HPV types 33 (p = 0.02) and 64 (p = 0.04), and longer for HPV types 6 (p < 0.001), 16 (p < 0.001), and 51 (p = 0.02).MC is not associated with the incidence and clearance of genital HPV detection, except for certain HPV types. The use of a single combined sample from the penis and scrotum for HPV DNA detection likely limited our ability to identify a true effect of MC at the distal penis. The majority of sexually active men and women will acquire genital human papillomavirus (HPV) infection at some point during their lifetime. In 2008, an estimated 610,000 cancers in men and women were attributed to HPV infection worldwide -5.Our previously published data regarding the prevalence of genital HPV among all men enrolled in the HPV Infection in Men (HIM) Study showed no overall association between MC and genital HPV infections, except for certain HPV types . The purFrom June 2005 through September 2009, healthy men were enrolled in an ongoing longitudinal study of HPV infection in men, the HIM cohort study. Men were recruited from the general population, universities, and organized health-care systems. Details of the study have been previously described . In brieConsenting participants completed a pre-enrollment visit, an enrollment visit scheduled approximately two weeks later, and eight additional visits after enrollment that occurred every six months over a period of four years. At each study visit, participants completed an 88-item computer-assisted self-interview (CASI) which collected information regarding sociodemographic characteristics, tobacco consumption, and sexual behavior. The primary languages spoken by participants from Brazil, Mexico, and the United States were Portuguese, Spanish, and English, respectively, and the CASI was available in these languages. After the interview, men underwent a clinical examination at which time circumcision status was assessed. Participants with full or partial circumcision were considered circumcised.Sampling techniques have been described in detail previously . BrieflyThe detailed protocol for HPV analysis has been previously described . BrieflyDifferences in the distribution of sociodemographic characteristics, tobacco consumption, and sexual behavior characteristics by circumcision status were compared using the Pearson’s chi-square test. Differences in the median time to follow-up by MC status were compared using a nonparametric equality of medians test.The classification of “any HPV” was defined as a positive test result for at least one of the 37 HPV genotypes included in the Linear Array test. HPV detection of single or multiple oncogenic HPV types was classified as “oncogenic HPV”. Similarly, HPV detection of single or multiple non-oncogenic HPV types was classified as “non-oncogenic HPV”.HPV incidence by circumcision status was estimated according to different classifications of HPV types: any HPV, oncogenic HPV, non-oncogenic HPV, and for each specific HPV type. For each of the above analyses, only participants free of the relevant HPV type at enrollment were included. Men with concomitant incident HPV infections could contribute to several HPV classifications. Time to newly acquired HPV was estimated using the time from the date of study entry to the date of the first detection of HPV DNA, assuming a new infection arose at the date of detection. The exact 95% confidence intervals (CIs) for incidence estimates were based on the number of events modeled as a Poisson variable for the total person-months. The unit of observation was the individual participant, and each man with an incident HPV infection was counted only once during follow-up using only data from the first occurrence. Cumulative incidence of any HPV, HPV 16, oncogenic HPV, and non-oncogenic HPV types was estimated for circumcised and uncircumcised men using the Kaplan-Meier method.Cox proportional hazards models were used to assess the association between HPV incidence and circumcision status . HazardsHPV clearance was defined as a participant testing HPV negative at two subsequent consecutive visits following a positive HPV test result, excluding those testing HPV positive for the first time at a participant’s final visit. Time to HPV clearance was estimated by using the time at which the participant first tested positive to the date of the first negative test. Median time to clearance was estimated among incident infections using the Kaplan-Meier method for any HPV, oncogenic HPV, non-oncogenic HPV, and for each specific HPV type, according to circumcision status. Analyses were performed for each individual HPV type. Men whose HPV infections did not clear were censored in the analysis.Cox proportional hazards models with the robust covariance matrix estimator to account for within-subject correlation were used to assess the association between HPV clearance and circumcision status . Men witAn HPV infection was considered persistent if a man was HPV DNA-positive at two or more consecutive visits with the same specific HPV type, and an HPV infection was considered transient if a man was positive only once. When a participant missed a study visit, the results from the next visit were used.The same variable selection procedure was used to evaluate factors associated with incidence and clearance of HPV infections. Factors that had a p-value < 0.10 were considered covariates. Backwards selection methods, with a significance threshold of 0.05, were used to identify covariates for inclusion in the final multivariable model. Candidate variables included education, marital status, smoking status, lifetime number of female sexual partners, lifetime number of male anal sex partners, number of female sexual partners in the past 3–6 months, number of male anal sex partners in the past 3 months, and six-month visit compliance status (i.e. whether the elapsed time between follow-up visits was longer than 6.5 months). Country  and age  were included in all models as study design factors. In addition, HPV status at baseline was a candidate variable in the HPV clearance models.Statistical analyses were conducted using R 2.13.0 (R Development Core Team) and SAS software, version 9.2 . Statistical tests were two-sided, with a significance threshold of 0.05.Of the 4,074 initial HIM Study participants, 4,033 contributed valid samples for HPV DNA detection and were included in the analyses. Thus, 19 circumcised and 22 uncircumcised men  contributed inadequate samples, as determined by both lack of β-globin detection and absence of any HPV genotype. The median duration of follow-up was 17.5 months  for this analysis. There were no significant differences in the median duration of follow-up for circumcised (17.9 months) versus uncircumcised men (17.1 months) . More than 60% of men contributed at least 4 visits . The majority of men were uncircumcised (63.6%) . Similarly, incidence of HPV 16, oncogenic HPV, and non-oncogenic HPV did not differ by circumcision status  Figure . SimilarUnivariate and multivariate analyses for clearance are presented in Table MC was not associated with an overall reduction in the incidence of genital HPV detection in men. Other longitudinal studies also found no differences in the risk of HPV incidence by MC -5. Lu etDespite the lack of evidence for an overall association, we did find higher HPV incidences rates in uncircumcised men than in circumcised men for most genotypes. These differences were statistically significant for HPV types 58, 68, 42, 61, 71, 81, and IS39. In contrast, the incidence of oncogenic HPV types 39 and 51 were significantly higher among circumcised than uncircumcised men. Consistent with our study, VanBuskirk et al. [No differences in overall HPV clearance by MC were observed in our study. This finding is in agreement with findings from other longitudinal studies ,5. VanBuDifferences in HPV clearance by MC for certain HPV types were observed in the present study. Median times to clearance for HPV types 33 and 64 were significantly shorter among circumcised men compared to uncircumcised men. The RCT in Uganda reported higher rates of clearance among circumcised men than uncircumcised men at the coronal sulcus for most HR-HPV types, but the differences were only statistically significant for HR-HPV types 39, 51, and 58 . In contEven though our study was not designed to assess the effects of MC and HPV by anatomic genital subsite, there is evidence from the literature that the association between MC and HPV DNA detection varies according to the subsite sampled. Four out of five studies show that the effect of MC in reducing HPV infection is stronger at the glans/corona than at other, more distant, subsites -18. WeavFurther supporting the evidence for an effect of MC on HPV infection on the proximal region of the penis, three additional studies reported specific inverse associations between MC and HPV infection in the glans, coronal sulcus, and the distal urethra , the glaIn addition to the subsites included for HPV DNA detection, several other factors may explain the contrasting effects observed across studies, such as differences in participants’ ages, the proportion of circumcised men, the number of HPV genotypes included in testing, the time intervals between visits, and the age at which circumcision was performed.To our knowledge, this is the first international study reporting HPV incidence and clearance by specific HPV types in circumcised and uncircumcised men. With a sample size of 4,033 men, it is also the largest study exploring these associations. A key strength of the present study is its longitudinal design, which allowed repeated measures of genital HPV DNA status for each participant, with a median follow-up of 17.5 months and scheduled visits every six months.Our study, despite being large, multinational, and prospective, is not free of some limitations, including: (1) the potential for misclassification of HPV infection, as we combined samples from different anatomic subsites; (2) the potential for misclassification of prevalent infections as incident infections, which may inflate the estimates of cumulative incidence; (3) the possibility of not distinguishing HPV clearance from failure to detect a true HPV infection, even though two HPV negative results following one positive result were required to define HPV clearance; (4) potentially limited generalizability, as only men willing to comply with multiple clinical visits over four years were included in the study; and (5) the potential for confounding, as there may have been relevant factors related to religious or cultural practices that may also be associated with both MC status and HPV incidence or clearance that were not taken into account.Overall, our study found that circumcision status was not associated with incidence and clearance of genital HPV detection, except for among specific HPV types. However, the use in this study of a single combined sample from the penis and scrotum likely limited our ability to identify a true effect at the distal penis. Further research is needed to determine how male circumcision impacts HPV incidence and clearance by specific anatomic subsite and HPV types.HPV: Genital human papillomavirus; MC: Male circumcision; RCT: Randomized controlled trials; HR-HPV: High-risk human papillomavirus; HIM Study: HPV Infection in men study; STIs: Sexually transmitted infections; CASI: Computer-assisted self-interview; PCR: Polymerase chain reaction; CIs: Confidence intervals; HRs: Hazard ratios; IQR: Interquartile range; aHR: Adjusted hazard ratio; RR: Rate ratio.GA: Travel grants to conferences/meetings are occasionally granted by either GlaxoSmithKline, Merck, Sanofi Pasteur MSD, Roche or Qiagen.GA, XC, and FXB: My research unit is involved in HPV vaccine trials organized by GlaxoSmithKline, Merck and Sanofi Pasteur MSD.XC: Travel grants to scientific meetings and honorarium for consultancy are occasionally granted by either GlaxoSmithKline, Merck, Sanofi Pasteur MSD.ARG: has received research grant support from Merck & Co., Inc. and GSK.ARG and LLV: are on the speakers’ bureau for Merck and are members of its advisory board.AGN: has received research funding from Merck & Co.FXB: Travel grants to conferences/symposia/meetings and honorarium are occasionally granted by either GlaxoSmithKline, Merck, Sanofi Pasteur MSD, Roche or Qiagen.All other authors declare that they have no competing interests.ARG, LLV, and EL-P were the principal investigators, conceived the study, wrote the protocols, assured funding, identified clinical investigators and study personnel, and made critical revision of the manuscript. GA was responsible for conduct analysis, interpretation of data, and drafting and revision of the manuscript. WF, H-YL, and MRP made the statistical analyses, and made substantial comments to the manuscript. MA trained and supervised study clinical staff, and made substantial contributions to the manuscript. JS and MQ coordinated the field work in terms of study implementation and data collection, and made substantial comments to the manuscript. AGN, BL, XC, and FXB participated in the interpretation of data, and critical revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/14/75/prepub