Recent studies in Puerto Rico have reported an increasing incidence of anal cancer in Puerto Rican men. The objective of this study was to determine the prevalence, genotype distribution and risk factors associated with anal HPV infection among men attending an STI clinic in Puerto Rico.We conducted a cross-sectional study among 205 men 18 years and older. A comprehensive survey was administered that included a demographic and a behavioral assessment. Separate logistic regression models were performed to determine factors associated with any, high-risk (HR), and multiple anal HPV infection.% of the sample. A third (29.8%) of participants reported being men who had sex with men (MSM). MSM had a significantly higher prevalence of any, HR and multiple HPV infection . Separate multivariate logistic regression analyses showed that being MSM was associated with any , HR  and multiple anal HPV infection . HIV was marginally associated with multiple anal HPV infection in multivariate analysis .The mean age of the study sample was 38.0±13.5 years. The most common HR types were 58, 51 and 31. Overall, HR anal HPV infection was found in 53.5% of the participants. Multiple HPV types in the anal canal were found in 47.6Anal HPV is common among sexually active men attending this STI clinic, with higher likelihood of anal HPV infection among MSM. Human Papillomavirus (HPV) infection causes approximately 600,000 cases of cancer of the cervix, vulva, vagina, anus and oropharynx annually, as well as benign diseases such as genital warts and recurrent respiratory papillomatosis High-risk (HR) anal HPV infection, particularly genotypes 16 and 18, is a significant risk factor for the development of anal intraepithelial neoplasia (AIN) and anal cancer The study was conducted from 2009 to 2011, as part of an ongoing epidemiological study among patients attending a public STI/HIV screening and treatment center in Puerto Rico. This study was previously approved by University of Puerto Rico Medical Sciences Campus (UPR MSC) Institutional Review Board (IRB). The design and methods of the parent epidemiological study have been described elsewhere Following the completion of the behavioral survey, all male participants were invited to participate in the HPV sub-study A man was considered to have HR HPV infection if he was positive for one or more HR genotypes, whether or not he was also positive for one or more LR HPV genotypes. On the other hand, a man was considered to have LR HPV infection if he was positive only to LR HPV genotypes. Finally, multiple HPV types to HPV were identified if study participant was positive for two or more HR or LR HPV genotypes. Sociodemographic variables included age, education, current employment, annual income and marital status. A man was considered MSM if the participant reported having had sex  with another man in his lifetime. Use of cigarettes, alcohol and marihuana during the past 90 days was collected as well. Sexual behaviors included lifetime sexual partners , lifetime anal sex partners  and condom use in the last sexual event. Self-reported STIs included HIV and syphilis.For the anal sample collection, trained clinicians moistened a Dracon swab with tap water and inserted it into the anal canal as far as it would go. Applying gentle pressure to the walls of the anal canal, the physician removed the swab with spiral motion over a 30-second period, and immediately inserted it in a vial containing sample transport medium. After collection, specimens were frozen at the core lab at the Puerto Rico Clinical and Translational Research Consortium (PRCTRC), at the UPRMSC, where they were stored at −70°C; and shipped on dry ice to Dr. Palefsky's laboratory at the University of California at San Francisco (UCSF) for anal HPV typing.DNA was prepared from each STM sample and frozen until the specimens were batched for analysis. To prepare DNA, after the samples were thawed they were heated at 56°C for 1 hour. After cooling, 25 µl of 10 mg/ml proteinase K,  were added. The samples were vortexed and digested at 50°C in a waterbath overnight and heated at 95°C for 10 minutes to inactivate PK. After DNA purification, PCR was performed using a modified pool of MY09/MY11 consensus HPV L1 primers as well as primers for amplification of the human beta-globin gene. Five microliters of sample were used for PCR amplification using a 40-cycle protocol. After PCR, 6 µL of amplification mixture were applied to a nylon membrane and probed with a biotin-labeled HPV consensus probe mixture containing HPV 11, 16, 18 and 51 L1 DNA. A separate membrane was probed with a biotin-labeled probe to the human beta-globin gene. Each specimen was also studied for the presence of specific HPV types by preparing membranes as described above with 6 µL of specimen. HPV genotypes sought included HR-HPV types , LR types  and types that are of unknown risk  Frequency distributions and descriptive statistics were used to characterize the study sample. Prevalence estimates and 95% confidence intervals (95% CI) for any HPV, HR, LR, and multiple HPV types in the anal canal were calculated. Descriptive statistics were calculated to describe the most prevalent genotypes in this sample. Chi-square analysis or Fisher exact tests were used to evaluate differences in categorical outcome measures. Sociodemographic characteristics were stratified by sexual behavior (MSM vs. Non-MSM). Sexual practices were presented separately by these two groups.Factors significantly associated with HPV (p<0.05) in the bivariate analysis were included in crude and age-adjusted logistic regression models to identify risk factors associated with anal HPV infection in four separately models: 1) any type, 2) HR, and 3) multiple types as dependent variables). Then, multivariate logistic regression model was performed among all variables that remained significant after adjusting for age. Statistical analyses were performed using SAS . The 95%CI for prevalence estimations were performed using the Binomial CI calculator from Stata Statistical Software .data not shown).Approximately a third of the study participants visited the clinic for the first time at the time of the interview (28.1%). The principal reasons for which study participants were attending the clinic were evaluation/screening for an STI (not HIV) (61.3%) and HIV screening (32.7%) .Among Non-MSM, the mean age of sexual onset was 15.5±2.6 and the mean number of female sexual partners in their lifetime was 19.3±22.4. More than half (81.0%) reported having had anal sex in their lifetime (receptive or insertive), in which 0.7% reporting having had anal sex in the last 90 days. No condom use in the last sexual event was reported in 43.3% of the non MSM participants (data not shown).Among MSM, 5.9% reported having had sex with women in their lifetime and only 3.4% reporting having vaginal sex with women in the last 90 days. More than half (61.0%) reported having anal sex with a men in their lifetime, with 37.9% reported having had receptive anal sex in the last 90 days. More than half (64.3%) reported having had insertive anal sex with a man during the same period of time. None of the MSM interviewed reported any condom use in the last sexual event  Table 1.From the 205 participants from which anal samples were obtained, beta-globin was detected in 192 (93.7%) of the specimens, and thus these are included in this analysis. Data not shown).In multivariate logistic regression models, MSM had 4.49 higher odds of any anal HPV infection after adjusting for level of education and HIV status . No other variables achieved statistical significance in multivariate analysis  as compared with those who identified as non-MSM. On the other hand, those subjects who reported having had syphilis in their lifetime were almost 4 times more likely to be infected with HR HPV  as compared to those who have been never diagnosed with syphilis Table 4.Data not shown).In multivariate logistic regression models after adjusting for age, level of education and syphilis, MSM had higher odds of HR anal HPV infection  (Data not shown).The prevalence of multiple HPV infection was higher among those men who identified as MSM as compared with those who identified as non-MSM ]. Finally, those participants who self-reported as HIV+ had more than 2 times increased odds of being infected with multiple HPV types compared to HIV- men , the prevalence of anal HPV infection (any type) was common (57.8%). HR HPV was also common in this sample (54.1%), with similar prevalence for HPV-16 (6.1%) and HPV-18 (6.1%). Similar findings were reported in other studies. For example, a study in Spain, in an STI clinic reported that the prevalence of any HPV type was similar to our study (49.6%) After multivariate logistic regression models, higher odds of any, HR and multiple anal HPV infection was reported among MSM. In a population-based study in Puerto Rico, it was documented that MSM have significant higher sexual risk practices as compared to Non-MSM In Puerto Rico, a 26.9% increase in anal cancer incidence rates has been documented for men Our findings need to be interpreted with caution. Since this study was done in an STI clinic setting, our findings are not generalizable to the general population of PR. Finally, due to our small sample size and since little variability regarding sexual practices was observed, the lack of identification of well-known predictors of HPV infection (such as HIV infection) were not reported in this sample as an independent predictor of anal HPV infection after multivariate analysis. Also, other clinical factors such as HIV plasma viral load, CD4+ count, were not collected as part of this study. Regarding the HPV laboratory analysis, it is always possible that some infections were missed using one set of primers and probes. This might be possible for all HPV types. Despite these limitations, our study documents for the first time evidence of the high prevalence of anal HPV infection in a clinic-based sample of men in Puerto Rico. Efforts in primary and secondary prevention should target high-risk men in STI clinics, primarily MSM.


The clinical significance of human papillomavirus (HPV) in neck node metastasis from cancer of unknown primary (CUP) is not well established. We aimed to address the relationship of HPV status between node metastasis and the primary tumor, and also the relevance of HPV status regarding radiographically detected cystic node metastasis in head and neck squamous cell carcinoma (HNSCC) and CUP. HPV DNA was examined in 68 matched pairs of node metastasis and primary tumor, and in node metastasis from 27 CUPs. In surgically treated CUPs, p16 was examined immunohistochemically. When tonsillectomy proved occult tonsillar cancer in CUP, HPV DNA and p16 were also examined in the occult primary. Cystic node metastasis on contrast-enhanced computed tomography scans was correlated with the primary site and HPV status in another series of 255 HNSCCs and CUPs with known HPV status. Node metastasis was HPV-positive in 19/37 (51%) oropharyngeal SCCs (OPSCCs) and 10/27 (37%) CUPs, but not in non-OPSCCs. Fluid was collected from cystic node metastasis using fine needle aspiration in two OPSCCs and one CUP, and all fluid collections were HPV-positive. HPV status, including the presence of HPV DNA, genotype, and physical status, as well as the expression pattern of p16 were consistent between node metastasis and primary or occult primary tumor. Occult tonsillar cancer was found more frequently in p16-positive CUP than in p16-negative CUP (odds ratio (OR), 39.0; 95% confidence interval (CI), 1.4–377.8; P = 0.02). Radiographically, cystic node metastasis was specific to OPSCC and CUP, and was associated with HPV positivity relative to necrotic or solid node metastasis . In conclusion, HPV status remains unchanged after metastasis. The occult primary of HPV-positive CUP is most probably localized in the oropharynx. HPV status determined from fine needle aspirates facilitates the diagnosis of cystic node metastasis. Cervical lymph node metastasis from cancer of unknown primary (CUP) is a rare clinical entity and currently accounts for no more than 3% of head and neck squamous cell carcinoma (HNSCC) HPV prevalence in node metastasis from HNSCC has been well studied; it has been shown that HPV-positive node metastasis is specific to OPSCC The association of OPSCC with histologically identified cystic node metastasis is well known We designed the present study to better understand the clinical significance of HPV status regarding node metastasis from CUP. To this end we investigated HPV status, including the presence of HPV DNA, genotype, and physical status, in matched pairs of primary tumor and node metastasis in a large series of HNSCC, and evaluated the relationship between the primary tumor and its node metastasis regarding HPV status. We further investigated not only HPV prevalence in node metastasis from CUP, but also the relationship between the node metastasis and its corresponding occult tonsillar cancer (proved after tonsillectomy) with regard to HPV status and p16 expression pattern. In addition, we studied the relationship between radiographically detected cystic node metastasis and the primary site and HPV status, with an emphasis on HPV detection in cystic fluid.The protocol of the present study was approved by the Institutional Review Board of Osaka University in December 2004. All patients provided written informed consent.18F-fluorodeoxyglucose positron emission tomography (FDG-PET) or FDG-PET/CT. Tonsillectomy was not included in the criteria because in principle tonsillectomy was performed simultaneously with neck dissection when the tumor was resectable.The HPV status of the primary tumor and its corresponding node metastasis, as well as the HPV status of node metastasis from CUP, were addressed in both retrospective and prospective settings. In the retrospective setting, formalin-fixed paraffin-embedded (FFPE) specimens from 28 matched pairs of primary and node metastasis and from 17 CUPs were enrolled. All of the tumors were surgically excised between January 2005 and March 2010 without any prior treatment, and were histopathologically diagnosed as squamous cell carcinoma. In the prospective setting, a total of 53 suspicious node-positive HNSCCs and CUPs were enrolled. Biopsy specimens of suspicious primary tumors and FNA specimens of suspicious node metastasis were obtained from outpatients between April 2010 and September 2012. Biopsy specimens and FNA specimens were stored in RNAlater RNA stabilization reagent  and buffer ATL (QIAamp Mini Kit: QIAGEN Inc.), respectively. When fluid collection was undertaken using FNA, its centrifugate was stored as detailed above. Only a single cycle of FNA was carried out for the HPV analysis, whereas FNA was repeated as necessary for cytopathological analysis. When tonsillectomy revealed an occult primary tumor in CUP patients, the FFPE specimen of the occult primary was analyzed for HPV DNA and p16. Expression of p16 was also examined in surgically excised node metastasis from CUP, irrespective of the settings. For radiographic analysis, a total of 255 HNSCC and CUP patients, who had undergone a pretreatment contrast-enhanced CT scan and had been proven pathologically to be node positive, were enrolled. This population included the retrospective series of 45 HNSCCs/CUPs, the prospective series of 50 HNSCCs/CUPs, and the additional series of 160 HNSCCs. The HPV status of the additional series had been evaluated using FFPE biopsy specimens from the primary tumor http://blast.ncbi.nlm.nih.gov/Blast.cgi). The physical status of HPV16 was addressed according to the ratio of E2 to E6 copy numbers, which was determined by means of real-time PCR amplification of the E2 and E6 open reading frames as previously reported DNA was extracted from FFPE specimens using the DNeasy tissue kit (QIAGEN Inc.), and from fresh specimens using the QIAamp Mini Kit (QIAGEN Inc.). The presence of HPV DNA was screened for by means of a nested polymerase chain reaction (PCR) using the PGMY09/11 primer set (for primary PCR) and the GP5+/6+ primer set (for secondary PCR) as previously reported Immunohistochemical analysis of p16 was carried out using 4-µm FFPE tissue sections with an appropriate positive control. Following antigen retrieval using a Pascal pressurized heating chamber , the sections were incubated with anti-p16 antibody at a dilution of 1∶500 . After incubation, anti-p16 antibody was detected using the ChemMate EnVision kit (DAKO) and visualized by means of diaminobenzidine as a chromogen. Negative control staining was carried out in the absence of primary antibody. Cases were classified as positive for p16 when 50% or more of cells showed nuclear and cytoplasmic staining.The definition of cystic nodes on contrast-enhanced CT scans was in accordance with the criteria reported by Goldenberg et al. The symmetry of HPV status and/or p16 expression between the primary tumor and its corresponding node metastasis was examined using the kappa test. The difference in the phenotype of HPV/p16 between node metastasis from CUP (with and without occult tonsillar cancer) was examined using the Fisher-Freeman-Halton exact test. The relationships between occult tonsillar cancer and HPV status and between occult tonsillar cancer and p16 expression were examined by means of univariate analysis using the logistic regression model and the Clopper-Pearson exact test, respectively. Differences in the prevalence of cystic node metastasis according to the primary site were assessed by means of univariate analysis using the logistic regression model or the Clopper-Pearson exact test, as appropriate. The relationship between HPV status and cystic node metastasis was assessed by means of univariate analysis using the logistic regression model. All statistical tests were two tailed. P values of <0.05 were considered as being statistically significant. All data were analyzed using JMP Version 10.02 software .In the retrospective setting, 40% (6/15) of OPSCCs were HPV-positive and 60% (9/15) were HPV-negative, regarding both the primary tumor and its corresponding node metastasis . The preAs for the prospective setting, PCR analysis was unsuccessful in 6% 3/53) of cases because of poor DNA preparation from FNAs. However, repeated FNAs evidenced malignancy in all three of these cases. Accordingly, the prospective analysis was limited to 50 cases, which were finally diagnosed by thorough clinical workup to be the following cancers: 22 oropharyngeal; 2 nasopharyngeal; 7 hypopharyngeal; 7 laryngeal; 2 oral; and 10 CUPs. In both the primary tumor and its node metastasis, 59% (13/22) of OPSCCs were HPV-positive, whereas 41% (9/22) of OPSCCs and 100% (18/18) of the non-OPSCCs were HPV-negative in both the primary tumor and its node metastasis; again, this indicated the similarity in HPV status between the primary tumor and its node metastasis  and 40% (4/10) of CUPs were HPV-positive, respectively, indicating that a total of 37% (10/27) of CUPs were HPV-positive . DetaileOf 27 patients with CUP, 19 underwent tonsillectomy along with neck dissection, which revealed occult tonsillar cancer in 32% (6/19). The relationship between node metastasis and its corresponding occult tonsillar cancer regarding HPV status and p16 expression are summarized in Of note, 100% (6/6) of the CUPs with unveiled occult tonsillar cancer expressed p16, while 50% (3/6) were HPV-positive. In sharp contrast, only 23% (3/13) and 15% (2/13) of the CUPs without unveiled occult tonsillar cancer were p16-positive and HPV-positive, respectively. The difference in the distribution of HPV/p16 phenotypes was statistically significant between the CUPs, with and without unveiled occult tonsillar cancer (P = 0.004); this finding prompted us to investigate the relationship between occult tonsillar cancer and HPV status or p16 expression in node metastasis from CUP. As shown in Contrast-enhanced CT scans from a total of 255 patients with node-positive HNSCC or CUP were reviewed . None ofIn the present study, we have shown that HPV-positive node metastasis is specific to OPSCC, especially when OPSCC arises in the palatine tonsil and the base of the tongue. We also demonstrated that HPV status, including the presence of HPV DNA, genotype, and physical status, was consistent between the primary tumor and its corresponding node metastasis. These results suggest that the occult primary tumor of CUP with HPV-positive node metastasis is most probably localized in the oropharynx, particularly in the palatine tonsil or the base of the tongue. Findings regarding our series of CUPs were in accordance with this suggestion. Tonsillectomy revealed occult tonsillar cancer in 60% (3/5) of the CUPs with HPV-positive node metastasis and 67% (6/9) of the CUPs with p16-positive node metastasis, but in none of 10 CUPs with HPV-negative/p16-negative node metastasis. Moreover, we have shown for the first time that HPV status, including the presence of HPV DNA, genotype, and physical status, as well as the expression pattern of p16 are consistent between node metastasis and its corresponding occult tonsillar cancer. Collectively, we have established not only that the HPV status of the tumor remains unchanged after metastasis, but also that the occult primary site of CUP with HPV-related node metastasis exists in the oropharynx.Given these findings, it is most likely in the case of CUP with HPV-related node metastasis that the occult primary tumor is localized at the base of the tongue, unless occult tonsillar cancer is proved after tonsillectomy. Weiss et al. reported that tonsillectomy and blind biopsy of the base of the tongue unveiled the occult primary tumor in all of the 12 CUPs with HPV-positive node metastasis, and in all of the 11 CUPs with p16-positive node metastasis According to a systematic review of HPV types in HNSCC, the prevalence of HPV18 in OPSCC was low; HPV18 accounted for only 9 of 909 (1.0%) HPV-positive OPSCC cases OPSCC and CUP frequently form histologically identifiable cystic node metastasis On contrast-enhanced CT imaging, 6% of node-positive OPSCC and 11% of node-positive CUP showed cystic node metastasis. This prevalence of radiographically identifiable cystic node metastasis in OPSCC and CUP is relatively low, as compared with that of histologically identified cystic node metastasis. As much as 56 and 73% of node-positive cancers of the palatine tonsil and the base of the tongue, respectively, have been reported to form histologically identifiable cystic node metastasis In conclusion, we have established that the HPV status of the tumor remains unchanged after metastasis. In HPV-positive CUP, the occult primary tumor is most probably localized in the oropharynx, particularly either in the palatine tonsil or in the base of the tongue. HPV-positive OPSCC and CUP tend to form cystic node metastasis. PCR analysis of the FNA fluid enables nonsurgical detection of HPV DNA, which may facilitate the differential diagnosis of cystic node metastasis and the brachial cleft cyst.Table S1Characteristics of cancer of unknown primary in retrospective setting.(xlsx)Click here for additional data file.Table S2Characteristics of Cancer of Unknown Primary in Prospective Setting.(XLSX)Click here for additional data file.


We investigated the association between alcohol consumption and risk of cervical intraepithelial neoplasia (CIN) and cervical cancer, and determined whether these associations were modified by human papillomavirus (HPV) viral load in high-risk HPV-positive women participating in the Korean HPV cohort study (KHPV).n = 1,243) from March 2006 to December 2009, we analyzed normal cytology (n = 581) as control group, CIN1 (n = 299), CIN2/3 (n = 161), or cervical cancer (n = 202). Multinomial logistic analysis was performed to estimate multivariate-adjusted odds ratios (OR).Among the women recruited in the KHPV (p for linear trend <0.0001). Higher ethanol consumption was associated with an increased risk of CIN1 (p for linear trend = 0.0001). We also observed a synergistic effect between HPV viral load and alcohol consumption: drinkers with a high HPV viral load (≥100 RLU/PC) were associated with a significantly increased risk of CIN1 . There were no associations between alcohol drinking and CIN2/3 or cervical cancer.Alcohol drinkers had an increased risk of CIN1  compared with non-drinkers after adjusting for potential confounders. Subjects with more frequent alcohol consumption had a higher risk of CIN1 (HPV viral load and alcohol was associated with the risk of CIN1 among high-risk HPV-positive women. This is the first demonstration that alcohol is an independent and combined risk factor of CIN1. Although human papillomavirus (HPV) infection is one of the major causes of cervical intraepithelial neoplasia (CIN) and cervical cancer, most HPV infections are asymptomatic and transient and therefore other cofactors in conjunction with HPV infection are necessary for progression to malignant disease The International Agency for Research on Cancer of the World Health Organization has classified alcohol as a Group 1 carcinogen Limited evidence exists on the potential role of alcohol drinking in the carcinogenesis of cervical cancer and its precancerous lesions The KHPV has been conducted with approval from the Korean National Cancer Center institutional review board (NCCNCS-06-062). Subject, aged 18–65, participated in a HPV cohort study from March 2006 up to present and all participants provided the written informed consent as each institutional review boards’ approval. The study was approved by the ethics committees of the Korean National Cancer Center and Korea University Guro Hospital. Participants were randomly selected from the gynecologic oncology clinics of university hospitals in Korea. Women were eligible to participate if they were currently sexually active or seeking birth control, were not currently pregnant, had an intact uterus, had no current referral for hysterectomy, and had no history of treatment for cervical intraepithelial neoplasia within the previous 18 months. Exclusion criteria included a history of gynecological cancers such as cervical, ovarian, or endometrial cancer; insufficient data on the questionnaire; inadequate blood for evaluation; a chronic disease such as liver cirrhosis, renal failure, or cardiovascular disease; drug dependency; or psychological problems. We analyzed baseline data of the total cohort as described in our previous study Among 1,374 enrolled women, 1,319 met the inclusion criteria. Sufficient questionnaire data were not available for 76 women. HPV testing with Hybrid capture 2  was performed in 1,243 women and a total of 674 (54.2%) women were positive with oncogenic HPV . Total participants were included in the present analysis .Gynecologic examinations, HPV DNA tests, liquid-based cervical cytology, and measurement of viral load as relative light units/positive control (RUL/PC) were performed at the first enrollment and each subsequent visit. The cytologic grade for Pap smear reports was based on the Bethesda classification system n = 581), and others were categorized into CIN1 (n = 299), CIN2/3 (n = 161), and cancer groups (n = 202) regardless of the results of HPV test. For CIN, the effect of alcohol consumption was examined for CIN1 and CIN2/3 subgroups respectively Normal cytological diagnosis at entry formed the control group , frequency of consumption of five alcoholic beverages , age at which the subject started to drink alcohol, and duration of the drinking habit. If participants had stopped drinking, information on the duration of alcohol abstinence and the frequency of previous alcohol consumption was obtained. Beverage-specific alcohol consumption was calculated in g/day based on alcohol content of the five beverages, the frequency of drinking, and the amount consumed. We calculated the total alcohol consumption (g/d) by summing the beverage-specific amount consumed, and the total liquor consumption (g/d) by summing the consumed amount of different beverage types.2 test and ANOVA were used for analysis of differences in the distribution of categorical and continuous variables, respectively. Multinomial logistic regression models were used to estimate odds ratios (ORs) and corresponding 95% confidence intervals (CIs). Linear trends were calculated using the median values for each risk factor as a continuous variable. Multinomial logistic regression model was performed to evaluate the association between alcohol and the risk of CINs and cervical cancer after adjustment for age (10-year age groups), smoking habit (never vs. ever), oral contraceptive use (never vs. ever), number of children , physical activity , and energy intake from food . Interaction tests were performed using multiplicative interaction terms of the ordinal score for viral load of HPV and alcohol drinking in the model. Ethanol intake level was categorized into two groups based on the distribution among the control participants, and risk estimates were calculated with the non-drinker group as the reference category. Joint effects of HPV and alcohol were estimated using relative excess risk due to interaction (RERI), attributable risk proportion due to interaction (AP), and synergistic index (SI) and their respective 95% CI The χp-value <0.0001).The sociodemographic, reproductive, anthropometric, and lifestyle characteristics of the study subjects were described in The multivariable-adjusted ORs for CIN1, CIN 2/3, and cervical cancer with respect to alcohol drinking were shown in p for linear trend <0.0001). Compared with non-drinkers, daily alcohol consumption was associated with an increased risk of CIN1 .ORs for CIN1 associated with drinking frequency of <1/month, 1–3/month, and ≥4/month were 2.42 (95% CI: 1.05–5.56), 2.07 (95% CI: 1.04–4.09), and 2.27 (95% CI: 1.09–4.74), respectively . No associations were found between the type, amount, or frequency of alcohol drinking and CIN2/3 or cervical cancer.p for linear trend <0.001). The interaction between alcohol drinking and HPV viral for risk of CIN1 was statistically significant (p<0.0001). RERI, AP, and SI scores were 15.7 (95% CI: −3.95–35.4), 0.71 (95% CI: 0.45–0.96), and 3.89 (95% CI: 1.43–10.6), respectively, indicating a multiplicative interaction between HPV viral load and alcohol drinking.p<0.0001), compared with non-drinkers with the lowest HPV viral load (<10 RLU/PC). A multiplicative interaction between HPV viral load and alcohol consumption level was revealed: RERI, AP, and SI values were 16.7 , 0.72 , and 4.03 , respectively. Compared with non-drinkers with the lowest HPV viral load (<10 RLU/PC), drinkers who consumed alcohol more frequently than once a week and had a higher HPV viral load (≥100 RLU/PC) had a significantly increased risk of CIN1 . There was a multiplicative interaction between HPV viral load and the frequency of alcohol consumption: RERI, AP, and SI values were 17.0 , 0.72 , and 4.08 , respectively. There were no interactions between HPV viral load and alcohol drinking with respect to the risk of CIN2/3 and cervical cancer.We further evaluated the combined effects of HPV viral load, alcohol consumption level, and frequency of drinking. A synergistic association with the risk for CIN1 was detected among subjects with high alcohol intake (>6.34 g/day) and the highest HPV viral load (≥100 RLU/PC)  cells that eliminate tumor and pathogen-infected cells through the innate immune system In our study, smoking status was significantly higher in CINs than control group by χ2 analysis, not in multivariate logistic regression. Smoking is recognized as a risk factor for HPV infection. But, it is still controversial that smoking is a risk factor for CIN Our study has some specific strengths: to our knowledge this is the first multi-institutional epidemiologic study to investigate the development of CIN1 in Korean women with high alcohol intake and HPV viral load, and the study was performed by a trained investigator instead of using self-reports to obtain the drinking habit data. However, a limitation of our study was the lack of information on sexual contact in the questionnaire due to personal and cultural reasons. Alcohol consumption is probably associated with sexual behavior In conclusion, we suggest that alcohol should be regarded as one of the risk factors for development of early cervical dysplasia in women with high-risk HPV infection. We recommend that clinicians encourage high-risk HPV-positive women with normal cytology to abstain from alcohol consumption to prevent the initiation of cervical dysplasia. Further study is needed to understand the exact mechanism by which alcohol affects the development of CIN1, and how a high viral load and other risk factors participate in progression to cervical cancer. Furthermore, we expect to contribute to the discovery and development of targets for chemoprevention through a large-scale study on the pathogenesis of progression to CIN1 induced by alcohol and HPV viral load.nd annual meeting of American Association for Cancer Research in 2011.This work was presented at the 102


Information on HPV genotype-specific incidence and clearance is important to better inform the natural history of cervical neoplasia in context of HIV/AIDS. We conducted a cohort study among HIV-infected women in Pune, India to estimate the genotype-specific HPV incidence and clearance rates.HIV-infected women underwent baseline and annual follow-up visits for cervical cancer screening and collection of cervicovaginal samples for detection of 37 HPV genotypes by Linear Array polymerase chain reaction (PCR) assay.A total of 215 eligible participants were followed for a median time of 11 months (range: 8-23 months) with a follow-up period of 223 person-years. Of the 104/215 (48.4 %) HIV-infected women who were HPV-negative at baseline, 12 women were newly detected with HPV at follow-up visit reflecting an incidence rate of 5.4 per 100 person-years. Type-specific incidence rates ranged between 0.45-3.42 per 100 person-years for carcinogenic HPV types and between 0.45-1.79 per 100 person-years for other HPV types. Of the 111/215 (51.6 %) women with HPV at baseline, 21 women cleared all types, reflecting a clearance rate of 9.4 per 100 person-years. Type-specific clearance rates ranged between 0.45-4.48 per 100 person-years for carcinogenic HPV types and between 0.45-4.04 for other HPV types.This study adds to the scant global data of natural history of HPV infection in HIV-infected women. Knowledge of incidence and clearance rates can inform cost effectiveness and decision analysis models for estimating effectiveness of HPV vaccination and screening strategies for cervical cancer prevention for HIV-infected women.


Immunosuppressive therapy protects the transplanted organ but predisposes the recipient to chronic infections and malignancies. Transplant patients are at risk of cervical intraepithelial neoplasia (CIN) and cervical cancer resulting from an impaired immune response in the case of primary infection or of reactivation of a latent infection with human papillomavirus of high oncogenic potential (HR-HPV).The aim of this study was to assess the prevalence of HR-HPV cervical infections and CIN in 60 female kidney graft recipients of reproductive age in comparison to that in healthy controls. Cervical swabs were analyzed for the presence of HR-HPV DNA. HR-HPV-positive women remained under strict observation and were re-examined after 24 months for the presence of transforming HR-HPV infection by testing for HR-HPV E6/E7 mRNA. All the HR-HPV-positive patients were scheduled for further diagnostic tests including exfoliative cytology, colposcopy and cervical biopsy.The prevalence of HR-HPV did not differ significantly between the study group and the healthy controls . There was no correlation between HR-HPV presence and the immunosuppresive regimen, underlying disease, graft function or time interval from transplantation. A higher prevalence of HR-HPV was observed in females who had had ≥2 sexual partners in the past. Among HR-HPV-positive patients, two cases of CIN2+ were diagnosed in each group. In the course of follow-up, transforming HR-HPV infections were detected in two kidney recipients and in one healthy female. Histologic examination confirmed another two cases of CIN2+ developing in the cervical canal.Female kidney graft recipients of reproductive age are as exposed to HR-HPV infection as are healthy individuals. Tests detecting the presence of HR-HPV E6/E7 mRNA offer a novel diagnostic opportunity in those patients, especially in those cases where lesions have developed in the cervical canal. Solid organ recipients receive immunosuppressive therapy to protect the transplanted organ against rejection, which therapy also unfortunately predisposes them to chronic infections and the development of malignancies . AccordiHR-HPV infection was diagnosed in 11/60 kidney graft recipients and 15/60 healthy women, indicating a comparable infection rate (p = 0.37) in the two groups. HR-HPV was detected significantly more often in females having had >2 sexual partners in the past. There was, however, no correlation observed between the presence of HPV in kidney graft recipients and serum creatinine concentration, age, body mass index (BMI), immunosuppressive therapy regimen and underlying or coexisting diseases.On initial screening, among the HR-HPV DNA-positive women abnormal Pap smear results were detected in two kidney graft recipients (2 cases of HSIL) and two healthy women (LSIL and HSIL). After colposcopy-guided cervical biopsy, in all cases CIN2+ was diagnosed and the patients were scheduled for further treatment. Three of them were offered loop electrosurgical excision procedure (LEEP) and histological examination confirmed that the lesions were excised with negative margins. In one case (a transplant patient) extirpation of the uterus was offered because of concomitant uterine fibroids accompanied by excessive menstrual bleeding, leading to severe anemia that was resistant to hormonal therapy.On follow-up after twenty four months, it was established that the rate of clearance of HR-HPV infection of the uterine cervix was similar in both groups, reaching 81,8% in the study group. In the control group, all women but one (93%) were HR-HPV negative at the time of follow-up (p = ns).Among renal transplant recipients, a persistent infection with HR-HPV was confirmed in two cases. Both women had a positive E6/E7 mRNA test and were scheduled for additional investigations. After colposcopy-guided cervical biopsy, CIN3 was diagnosed in one case and the patient was scheduled for further treatment (LEEP excision procedure). The histological evaluation of specimens from the cervical canal confirmed the previous diagnosis of CIN3. Significantly, this patient displayed a normal cervical cytology, even though the pathologist had been informed about the presence of HPV E6/E7 mRNA. The other transplant patient had a normal Pap smear and innocuous colposcopy finding, but nevertheless qualified for cervical biopsy and canal curettage. Histological examination revealed no pathological lesions in collected tissue samples.Similarly, HPV E6/E7 mRNA-positive females from the control group underwent additional examinations. Repeated Pap smear results revealed HSIL. Colposcopy and subsequent biopsies led to the diagnosis of CIN3 in tissues obtained during cervical canal curettage. This patient was offered LEEP and histological examination confirmed that CIN3 in the cervical canal had been excised with negative margins.et al suggested that transplant recipients receiving long-term immunosuppression may not be more at risk of HPV infection and CIN than healthy controls [et al suggested that HR-HPV infection was relatively rarely encountered among older renal graft recipients with normal Pap smear results. This applied in particular to monogamous or sexually inactive patients. Therefore it was recommended that education about avoiding high-risk sexual relations should be of prime importance among kidney graft recipients [There are relatively few publications dealing with HR-HPV infection in populations of transplant recipients. The incidence of HR-HPV infection as well as abnormal Pap smear results is reported to be quite high in recipients, reaching 59% according to some studies -16). Howcontrols , which icontrols . Morrisocipients . Our reset al observed that, in a group of 408 HR-HPV-positive patients with normal Pap smears (regarded as ≤ HSIL), positive HPV mRNA results were significantly more often associated with CIN ≥ 2 than with CIN ≤ 2 lesions. Therefore the authors concluded that testing for E6/E7 HPV mRNA may have a diagnostic and potentially prognostic role in the management of HR-HPV(+), HSIL(−) patients [Testing for E6/E7 mRNA offers a novel approach in cervical screening. There are published reports pointing out that the introduction of E6/E7 HPV mRNA testing may improve the diagnostic accuracy in HR-HPV-positive women . Benevolpatients .et al conducted another study on a group of 1201 participants and concluded that E6/E7 mRNA testing was more efficient than cytology for the triage of HPV DNA-positive women. However, the sensitivity for CIN2+ was relatively low . That fact means that HPV DNA-positive women, in spite of the negative E6/E7 mRNA test result, would nevertheless require strict follow-up [There is strong evidence that testing for HPV E6/E7 mRNA is more specific than testing for HPV DNA, but the sensitivity of the test may be unsatisfactory for clinical purposes. Benevolo ollow-up . In our Norwegian authors  have raiet al analyzing data from over 1000 female kidney graft recipients confirmed the fivefold increase of risk of cervical cancer in comparison to the general population and emphasized the importance of cervical screening [The clinical value of HPV E6/E7 mRNA testing as well as its future position in cervical screening algorithms remains to be established. The possibility of confirming a transforming HPV infection, thereby facilitating the early identification of women at greatest risk of cervical neoplasm development, seems very promising. This applies especially to immunocompromised renal graft recipients, that in the past were often regarded as a high risk group, although the currently published data are inconsistent. Origoni et al found no increase of CIN in population of Italian female renal graft recipients that remained under long-term follow-up . On the creening . AccordiOne hundred twenty women of reproductive age, in outpatient care at the First Department of Obstetrics and Gynecology, Medical University of Warsaw, between 1st October 2007 and 30th September 2008, were evaluated for the study. The study group included 60 kidney graft recipients with normal cervical smears obtained within the previous 12 months. The time interval that had elapsed since the kidney transplantation varied from 7 months to 20 years, with the mean interval being 6.4 ± 4.9 years. Over 76% of the kidney graft recipients (46/60) had undergone transplantation less than 10 years previously. The majority of graft recipients (34/60) were on a regimen of three drugs, consisting mainly of calcineurin inhibitors with corticosteroids and mycophenolan acid precursors. An immunosuppressive regimen of two drugs was prescribed to 24/60 women. The control group consisted of 60 healthy women under routine gynecological care in the outpatient clinic of our Department. The characteristics of both groups are presented in Table The cervical swabs were analyzed using the Amplicor HPV Roche Molecular Systems test designed to detect the DNA of thirteen high risk HPV types: 16, 18, 31, 33, 39, 45, 51, 52, 56, 58, 59 and 68. All the participants gave informed consent for enrollment in the study which had been approved by the Bioethical Committee of the Medical University of Warsaw.After the initial cervical screening described above, a cohort consisting of 15 healthy women and 11 renal transplant recipients showed the presence of HR-HPV DNA in their cervical samples. As follow-up, these patients underwent further investigations. Prompt cervical smears according to the Bethesda/Papanicolau system, as well as colposcopy, were performed in order to plan further treatment if necessary.The HR-HPV DNA-positive females remained under close observation and cervical swabs were obtained again after 24 months. These were analyzed for the presence of HR-HPV E6/E7 mRNA using the CE-IVD- certified Nucli-Sense EasyQ test , which detected the mRNA of HR-HPV types 16, 18, 31, 33 and 45. All the patients with positive HR-HPV E6/E7 mRNA test results were subjected to further investigations.All the samples obtained from HPV DNA-positive females after 24 months of follow-up were also analyzed using the CE-IVD-certified Linear Array Genotyping Test  which detected of DNA of 37 HPV types . This was done in order to exclude the possibility that these females were carrying other persistent cervical HPV infections.in vitro diagnostic devices indicating fulfillment of the applicable European Directive; CIN: Cervical intraepithelial neoplasia; CIN1: Minor cervical intraepithelial neoplasia; CIN2: Medium cervical intraepithelial neoplasia; CIN3: Severe cervical intraepithelial neoplasia; CIN2+: CIN2 and 3; HPV: Human papillomavirus; HR-HPV: High risk human papillomavirus; HSIL: High grade squamous intraepithelial lesion; LEEP: Loop electrosurgical excision procedure; LSIL: Low grade squamous intraepithelial lesion.ASCUS: Atypical squamous cells of undetermined significance; BMI: Body mass index; CE-IVD: CE mark for The authors declare no conflicts of interests.BP designed the study and contributed to the collection and analysis of data and writing of the manuscript. NM contributed to the collection and analysis of data as well as writing of the manuscript. AME, GM, MD, PK and MW contributed to the analysis of data and critical revission of the manuscript. All authors approved the final version of the manuscript.


The success of HPV vaccination programs will require awareness regarding HPV associated diseases and the benefits of HPV vaccination for the general population. The aim of this study was to assess the level of awareness and knowledge of human papillomavirus (HPV) infection, cervical cancer prevention, vaccines, and factors associated with HPV awareness among young women after birth of the first child.This analysis is part of a cross-sectional study carried out at Hospital Maternidade Leonor Mendes de Barros, a large public maternity hospital in Sao Paulo. Primiparous women (15-24 years) who gave birth in that maternity hospital were included. A questionnaire that included questions concerning knowledge of HPV, cervical cancer, and vaccines was applied. To estimate the association of HPV awareness with selected factors, prevalence ratios (PR) were estimated using a generalized linear model (GLM).Three hundred and one primiparous women were included; 37% of them reported that they "had ever heard about HPV", but only 19% and 7%, respectively, knew that HPV is a sexually transmitted infection (STI) and that it can cause cervical cancer. Seventy-four percent of interviewees mentioned the preventive character of vaccines and all participants affirmed that they would accept HPV vaccination after delivery. In the multivariate analysis, only increasing age (P for trend = 0.021) and previous STI (P < 0.001) were factors independently associated with HPV awareness ("had ever heard about HPV").This survey indicated that knowledge about the association between HPV and cervical cancer among primiparous young women is low. Therefore, these young low-income primiparous women could benefit greatly from educational interventions to encourage primary and secondary cervical cancer prevention programs. Genital infection by oncogenic human papillomavirus (HPV) is a necessary factor in the development of cancer of the cervix . AlthougTwo prophylactic vaccines to prevent infections by high risk HPV viral genotypes 16 and 18 were available; ideally they should be administered before sexual debut or shortly thereafter to achieve optimal vaccine effectiveness. The US Advisory Committee on Immunization Practices (ACIP) recommended routine HPV vaccination of girls at age 9-12 years and catch-up vaccination for females aged 13-26 years who have not been previously vaccinated or who have not completed the full immunization series .However, providing a vaccine "against cancer" to adolescent girls raises several challenges because many young unmarried girls and women face significant challenges in accessing the health care necessary to meet their sexual and reproductive health needs . For thiThen, the success of HPV vaccination programs will require improving awareness regarding HPV, cervical cancer, and the benefits of HPV vaccination for the general population.Probably, knowledge about HPV has been changing in recent years, given public awareness campaigns around the announcement of the regulatory approval and public announcements of the HPV vaccines.Thereafter, identifying which groups of women remain unfamiliar with these subjects and would, therefore, benefit from educational messages is crucial, particularly in the target age group for HPV vaccination.Hence, the aim of this study was to assess the level of awareness and knowledge of HPV infection, cervical cancer prevention, and vaccines, and factors associated with HPV awareness among low-income young women after first delivery in the city of São Paulo, Brazil. The rationale for studying this population is that first delivery health care services could represent a suitable opportunity to offer HPV vaccines for adolescents and young women who have not been previously vaccinated.This study is part of a cross-sectional study carried out from June 2006 to February 2007. The study was conducted out at Hospital Maternidade Leonor Mendes de Barros (HMLMB), one of the largest public maternity hospitals in the city of Sao Paulo, Brazil. All primiparous women aged between 15 and 24 years who had been living in the metropolitan area of Sao Paulo for at least six months and gave birth at this hospital after more than 32 weeks of gestation were eligible for the study. The following exclusion criteria, as previously published [The study protocol was submitted and approved by the National Ethical Committee (CONEP) (number 188/2006).Women were recruited to take part in the study during the post-delivery follow-up period in the hospital. Eligible women were contacted by a health professional (a nurse or physician) and asked whether they wanted to know about a study on prevention of cancer of the cervix; those interested had a post-natal visit scheduled within 43 to 60 days after delivery to be enrolled in the study. Women had to attend the post-natal visit and sign the informed consent form to be included in the study.A total of 509 women were invited to participate: 24 refused, 163 women previously interested in participating did not return to the post-natal visit, and 322 attended the post-natal visit. However, 18 women were not eligible . Three eligible women were excluded by the investigators: one had an acute infectious disease and two aged <18 years lived in a reformatory and had difficulty obtaining a legal representative's signature on the informed consent form within the study period. Therefore, 301 primiparous women were included in the analysis.During the routine post-natal visit, women were enrolled and interviewed, in an appropriate setting ensuring privacy, by trained interviewers. Using a standardized questionnaire  and 95% confidence intervals (CI) were calculated, with HPV awareness as the dependent variable and various factors as independent variables. Most independent variables were grouped into two or more categories. For ordered categorical independent variables, tests for linear trend (Chi-square for trend) in the PR were conducted by categorizing the independent variables and entering the continuous scores. Variables selected in univariate analysis at a 0.20 significance level were included in the multivariate analysis. PR and their 95% CI were estimated using a generalized linear model (GLM) with binomial distribution and log link function . StatistThe mean age of study participants was 19.9 years (median 20.0 years). Over 60% were white and most women (88%) had at least eight years of schooling (the first grade). About two thirds reported incomes  of less than four minimum wages per month .Awareness of HPV among these young women after first delivery was low: only one third of them reported that they had ever heard of HPV. Among those who had heard of it, less than a quarter knew that HPV can cause cervical cancer; about half knew that HPV is a sexually transmitted infection (STI), and only two participants knew that it can cause genital warts. Only 7% (n = 20) of all participants answered both that HPV is an STI and that it can cause cervical cancer.When asked about cervical cancer cause(s), very few participants admitted knowing the cause(s) of cervical cancer (8%) and only 6% of women in the sample enumerated HPV as a cervical cancer cause.Slightly more than a half of the total number of participants referred to knowing about the examination to prevent cervical cancer or cytological tests. However, only 27% answered that in this test some kind of material is collected .Seventy-four percent of interviewees mentioned the preventive character of vaccines, and only 57% of them answered correctly concerning vaccines that had been given to them (giving the name of at least one vaccine or the name of the disease that the vaccine targeted).All participants affirmed that they would accept vaccination after delivery if the HPV vaccine were available Table .HPV awareness increased with increasing age (P for trend = 0.003) and with increasing years of schooling (P for trend = 0.039) Table . Table 3All selected variables , were included in the multivariate analysis model. However, when years of schooling and income were included, the model did not converge. Then, the variable income was taken out. In the analysis including the other four variables, years of schooling (P for trend = 0.307) and marital status (P = 0.296) were not significantly associated with HPV awareness. The multivariate analysis revealed that only age (P for trend = 0.021) and previous STI (P < 0.001) were independently associated with HPV awareness. The prevalence ratio of HPV awareness for women aged 19-21 years was 1.32 with a 95% CI of 0.87-2.01, and for women aged 22-24 years it was 1.63 with a 95% CI of 1.07-2.48 (reference group: women 15-18 years old). Women who reported a previous STI were more likely to be aware of HPV  compared to women who had never had any STI.The awareness of HPV among these young primiparous women was low, as only one third of the participants reported having "ever heard about HPV", despite the fact that the present analysis began 16 days after public news and announcements about the first regulatory approval of one of the HPV vaccines, on June 08, 2006 , and theSurveys conducted previously and before the regulatory approval of HPV vaccines also showed a low level of awareness of HPV (30-40%) -14. The In the present study, awareness of HPV was the first question and we did not ask any open questions concerning knowledge of HPV, cervical cancer causes and prevention, or vaccines when the participant was not aware of any of theses subjects, in order to avoid influencing the answers to the open questions or obtaining an answer given correctly by luck, as can occur in studies that use multiple-choice answers.Only 19% and 7% of the present study participants, respectively, knew that HPV is an STI and that it can cause cervical cancer. Another study, carried out in north-eastern Brazil, assessing young women (16-23 years) showed similar results to the present study: less than 10% of participants acknowledged that HPV might lead to cervical cancer; however, a higher proportion of those women (67%) knew that HPV is sexually transmitted . This diWe also studied the relationship between HPV awareness and several factors. The multivariate analysis highlights two factors: having had a previous STI and increasing age remained as factors associated with HPV awareness. Accordingly, some authors reported that increasing age women 14-24 years)  and havi-24 yearsHalf of all participants reported awareness concerning cervical cancer prevention by cytological test, although a smaller number were aware of how it is performed. The query was intended to estimate how many women were aware, and whether they were able to recognize the differences between the ordinal gynecological test and the cytological tests. Based on our data, just 27% of the young primiparous women were able to recognize the differences.Other studies regarding cytological tests estimated whether the women were aware of their purpose, and hence are not suitable for direct comparisons. They reported a variety of results (10-89%) concerning the interviewees' awareness of the cytological tests' purposes ,16,17.In the present study, the awareness regarding vaccines was high, with 74% of the interviewees mentioning their preventative aspect, and 57% of women could identify at least one of the vaccines they had received; that is, they could name the vaccine or the disease which it was intended to prevent.With regard to the acceptability of the vaccine, despite the inadequate knowledge of HPV and cervical cancer, all participants reported that they would accept vaccination after delivery if the HPV vaccine was available. As other studies have reported, there was a generally favourable attitude toward HPV vaccines; despite the low level of knowledge about the link between HPV and cervical cancer, 91% and 88% of women would agree to receive the vaccine in surveys that found that only 15%  and 38% However, it is important to report that the question about the knowledge of vaccines preceded the question about the acceptability of the HPV vaccine, and for the participants who did not know the answer to the first question, one brief explanation on the prevention of illnesses through vaccines and on the HPV prophylactic vaccine was given by the interviewers in the present study.In fact, the main factor associated with the acceptance of the HPV prophylactic vaccine in studies carried out prior to its approval was the knowledge of the participants concerning the purpose of vaccines ,21.Public acceptance and usage of a prophylactic vaccine are related to the level of knowledge about the disease, which the vaccine will provide protection from . EducatiThe main limitation of this study is that 32% of eligible women who were previously interested in participating did not return to the post-natal visit. The likely reason for the relatively large number of women not attending the post-natal visit at our hospital is the availability of post-natal services in public health care centres near their homes, and therefore women may have preferred those for convenience. However, we compared participants and non-respondents using medical hospital records and they did not differ according to several factors: age (P = 0.205), marital status (P = 0.480), smoking habits (P = 0.183), prenatal health care (P = 0.436), and number of prenatal health care visits (P = 0.214). Therefore, this limitation is unlikely to have affected our results significantly.In Brazil, Quadrivalent and Bivalent HPV vaccines have been approved by regulatory authorities for females aged, respectively, 9 to 26 years and 10 to 25 years but they are not yet included in public vaccination programs ,24. DespAlthough the possibility of knowledge of HPV can be changing in Brazil, probably it has not been changing significantly, because no large educational campaign about HPV for the population has been improved by the government in the last years.Our findings could add information to knowledge of the Latin American scenario reflecting the views of young women of lower socio-economic status after first delivery. Despite the possibility to provide a large number of information to mothers during the prenatal and postpartum periods, this group of women had low levels of knowledge of HPV and cervical cancer development and prevention. Thus, these women could benefit greatly from educational interventions to encourage participation in primary and secondary cervical cancer prevention programs.Young women of low socio-economic status after first delivery had low levels of knowledge of HPV and cervical cancer development and prevention. Thus, opportunities for educational interventions during the prenatal and postpartum periods are valuable to improve knowledge about these subjects.(CI): Confidence Intervals; (GLM): Generalized Linear Model; (HPV): Human Papillomavirus; (PR): Prevalence Ratios; (STI): Sexually Transmitted Infection.Luisa Lina Villa is a consultant and speaker for the Quadrivalent HPV Vaccine of Merck Sharp & Dohme. José Eluf-Neto has served as a consultant to GlaxoSmithKline in 2006. The others authors have no potential conflicts of interest to disclose.CHR: participated in study design, coordination during field work, acquisition of data, interpretation of data and helped to draft the manuscript. LLV: conceived of the study, participated in its design and helped to draft the manuscript. SP: conceived of the study, participated in its design and helped to draft the manuscript. MAA: have made substantial contributions to acquisition of data, and helped to draft the manuscript. MCC: have made substantial contributions to acquisition of data, and helped to draft the manuscript. ALA: have made substantial contributions to acquisition of data, interpretation of data, and helped to draft the manuscript. ALF: have made substantial contributions to interpretation of data and helped to draft the manuscript. JEN: participated in the design of the study, performed the statistical analysis and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/10/35/prepubQUESTIONNAIRE. Structured epidemiologic questionnaire with information about demographic characteristics, sexual behavior, reproductive history, contraceptive practice, smoking habits and questions concerning knowledge of HPV, cervical cancer, and vaccines.Click here for file


HPV infection in the genital tract is common in young sexually active individuals, the majority of whom clear the infection without overt clinical disease. However most of those who develop benign lesions eventually mount an effective cell mediated immune (CMI) response and the lesions regress.Failure to develop effective CMI to clear or control infection results in persistent infection and, in the case of the oncogenic HPVs, an increased probability of progression to CIN3 and invasive carcinoma. The prolonged duration of infection associated with HPV seems to be associated with effective evasion of innate immunity thus delaying the activation of adaptive immunity.Natural infections in animals show that neutralising antibody to the virus coat protein L1 is protective suggesting that this would be an effective prophylactic vaccine strategy. The current prophylactic HPV VLP vaccines are delivered i.m. circumventing the intra-epithelial immune evasion strategies. These vaccines generate high levels of antibody and both serological and B cell memory as evidenced by persistence of antibody and robust recall responses. However there is no immune correlate - no antibody level that correlates with protection. Recent data on how HPV infects basal epithelial cells and how antibody can prevent this provides a mechanistic explanation for the effectiveness of HPV VLP vaccines. It is chastening to remember that until the mid to late 1970's - 40 years ago - infection with human papillomaviruses was regarded as trivial. The received wisdom was that HPV caused warts, benign epithelial proliferations of cutaneous and internal squamous mucosal surfaces and nothing more. This view was overset by two quite disparate reports - one clinical and one, fundamental molecular virology. In 1976 Meisels & Fortin published a report in which they showed that the "halo cell" in pap smears read by the cytologist was a koilocyte - the pathognomic cell of HPV infection . Shortlyhttp://globocan.iarc.fr/ Overall it is estimated that HPV is the causal agent in 5% of all human cancers with HPV16 by far and away the major player.Developments since then need little repeating - infection with one of a subset of mucosal HPVs is the major risk factor for the development of cervical cancer. There are at least 15 oncogenic (cancer causing) HPV types or strains but HPV16 and 18 are the most virulent causing an average 70% of all cervical cancers [The contribution to the cancer burden is very significant but the disease burden of the "benign" or low risk HPVs - mainly 6 and 11 - should not be underestimated. Genital warts - condyloma acuminata - are not a preferred topic of polite conversation but they are the commonest viral sexually transmitted infection with a life time risk of acquisition of 10% . This reHPV infection is determined by detection of DNA, not isolation of virus. Genital HPV infection is predominantly, but not exclusively, a sexually transmitted infection but penetrative vaginal or anal sexual intercourse is not a prerequisite for infection, virus is transmitted by skin to skin contact via intimate contacts of the genitalia or other mucosal surfaces . These iThe natural history of genital HPV infection is illustrated in Figure A minority variously estimated as being between 10-20% do not effectively clear virus, they remain DNA positive with a persistent active viral infection and it is these individuals who are at risk for progression to high grade precancers in the cervix - cervical intra-epithelial neoplasia CIN2/3 and thus invasive cancer . HPV infClearly HPV effectively evades recognition by the immune system for many months so how does this occur? The infectious cycle itself is a mechanism for this - there is no viraemia, very low levels of viral protein are expressed but crucially HPV is not cytolytic. Virus replication and assembly occur in cells already destined for death by anoikis or "death by natural causes", there is no inflammation and no danger signal to alert the immune system. The interferon response for HPV infection, a key antiviral defence mechanism , is actiThe most effective control of viral infections is prophylactic vaccination and the development of prophylactic HPV vaccines is one of the scientific triumphs of the past 20 years. Sero conversion in natural genital infection results in detectable serum neutralising antibody to the major capsid protein L1 but this response is slow with an average time to sero-conversion after the first detection of HPV16 DNA of 8-9 months, antibody concentrations are low and only 50-70% of women with incident HPV infection sero convert . However® a bivalent HPV 16/18 vaccine from GlaxoSmithKline Biologicals (GSK) and Gardasil®, a quadrivalent HPV16/18/6/11 vaccine from MSD Merck. Both vaccines have been shown in randomised control trials to be highly efficacious against HPV 16/18 caused high grade cervical intra epithelial disease (CIN2/3) in 15-26 year old women naïve for these HPV types at trial entry and during the 3 shot immunisation schedule  [There are two licensed HPV L1 VLP prophylactic vaccines - Cervarix months) ,29. Addi months) . In RCTsThere is preliminary evidence for population effectiveness for the quadrivalent vaccine. In 2008 Australia offered publicly funded immunisation with the quadrivalent vaccine to all women aged 12-26 years and achieved, overall, 60-70% coverage. Audit of new female patients with external genital warts, 28 years or less attending a large sexual health clinic in Melbourne, Australia before and after vaccine introduction showed a fall in incidence of EGW after vaccine introduction in this age group of up to 40% Women older than 28 years who were not in the group eligible for free vaccines showed no fall in incidence .rd immunisation that are 1-4 logs higher than those in natural infections [The current assumption is that the protection afforded via these vaccines is antibody mediated since passive immunisation is protective in animal models ,27. HPV fections ,33. In pfections ,35. Mathfections ,37. Bothfections . At the fections .The enhanced immunogenicity of VLP immunisation in contrast to natural infection very probably relates to the route of immunisation. Natural infection is exclusively intra epithelial, virus is shed from mucosal surfaces and there is little or no viraemia. Viral antigen therefore poorly accesses the lymphatics and draining lymph nodes (DLN) where immune responses are initiated. Furthermore the most likely antigen presenting cells (APC) are macrophages and Langerhans cells both of which will be relatively ineffective in the non-inflammatory environment of a productive HPV infection (HPV is not cytolytic). VLP vaccines in contrast are delivered by injection via the intra-muscular route with immediate access to the vasculature and lymphatics. They rapidly encounter stromal dendritic cells that, in the inflammatory milieu induced by vaccination, are strongly activated to mature and migrate to the DLN initiating helper T cell responses. At the same time VLPs either surface bound to APC or other local immunocytes are shuttled into the lymph node encountering and priming naïve B cells in the follicle and the whole cascade of events that will result in protective immunity is started. Furthermore the VLP is intrinsically very immunogenic. The exquisite repeat pattern of L1 capsomers that stud the particle powerfully activate the innate immune sensors ,41, evenrd and final dose in the primary schedule. Antibody concentrations wane over the subsequent 12 - 18 months but then stabilise at a plateau level with GMTs on average 10 times greater than in the placebo groups [The antibody response after the 3 dose immunisation schedule follows the expected pattern. After each vaccine dose antibody levels increase until a peak antibody concentration is achieved one month after the 3o groups ,33. Thiso groups . Antigeno groups . A similo groups . Collecto groups , a prereHPVs have an exclusively intra-epithelial life cycle with either minimal or no viraemia so how can serum neutralising antibody protect against infection? One explanation often offered is that transudated serum antibody in cervical secretions is the major mechanism of protection. This must certainly contribute but cannot explain protection at the well keratinised and comparatively dry surfaces of the vulva and vagina, penis and peri-anal skin. Virus neutralising antibody prevents virus entry into cells thus the questions to be addressed are how does HPV access and infect the basal cell of stratified squamous epithelium and how do neutralising antibodies prevent this. The emerging evidence is that HPV cell entry is a complex process involving epithelial microtrauma and wound repair . HPV infInfection with an oncogenic HPV particularly HPV 16 is associated with 5% of all human cancers but predominantly cervical cancer and other ano-genital cancers. HPV infection with both oncogenic and non oncogenic types is common in young, sexually active men and women but the majority of infections resolve due to a cell mediated response to early non structural proteins. This response is usually accompanied by sero-conversion with type specific neutralising antibody to the major capsid protein L1.Prophylactic HPV vaccines are sub-unit protein vaccines consisting of L1 only virus like particles for HPV 16 and 18 only or HPV 6,11,16 and 18. These VLP vaccines are highly immunogenic generating high titres of type restricted neutralising antibody to L1 and robust immune memory.It is generally considered that the >90% protection afforded by these vaccines against ano-genital disease associated with the vaccine HPV types is antibody mediated but at the present there is no immune correlate - no measurable antibody titre or other quantifiable immune response that correlates with protection. However the mechanism of viral entry may provide insight into antibody mediated protection. HPV infection of the epithelial basal cell has been shown to require epithelial micro-wounding and repair -49. ThisThe author declares that they have no competing interests.


Exploring different sampling sites and methods is of interest for studies of the epidemiology of HPV infections in the male. Expressed prostate secretions (EPS) are obtained during digital rectal examination (DRE), a daily routine urological diagnostic procedure, following massage of the prostate.Urethral swabs and EPS samples were obtained from a consecutive sample of 752 men  visiting urology outpatient clinics in St. Petersburg, Russia and tested for HPV DNA by general primer PCR, followed by genotyping using Luminex.Overall, 47.9% (360/752) of men were HPV-positive, with 42.0% (316/752) being positive for high-risk (HR-) HPV and 12.6% (95/752) for multiple HPV types. HPV-positivity in the EPS samples was 32.6% (27.7% HR-HPV) and in the urethral samples 25.9% (24.5% HR-HPV). 10.6% were HPV positive in both EPS and urethral samples. 6.4% had the same HPV-type in both EPS and urethral samples. 10.6% were HPV positive in both EPS and urethral samples. 6.4% had the same HPV-type in both EPS and urethral samples. The concordance between the urethral samples and EPS was 62.5% (470/752), with 80 cases double positive and 390 cases double negative in both sites. The sensitivity of urethral samples for overall HPV detection was 54.2% (195/360). Compared to analysis of urethral samples only, the analysis of EPS increased the HPV prevalence in this population with 26.2%.EPS represent informative sampling material for the study of HPV epidemiology in the male. Studies of the epidemiology of Human Papillomavirus (HPV) infection in the male are essential for understanding HPV natural history, transmission dynamics and optimal uses of HPV vaccines. Research on optimal methods and anatomical sites for sampling are essential for enabling informative studies. A variety of different anatomical sites in men have been studied, including glans penis, prepuce, penile shaft, distal urethra, anal canal, perianal area, scrotum, semen and urine EPS has been commonly used in urology ever since the Meares-Stamey 4-glass test, which included a quantitative culture of pure EPS, was launched in 1968 More than 155 different HPV types have been identified and are referred to by number Using the multiplexed genotyping method, we explored whether HPV was detectable in EPS and whether analysis of EPS would yield any additional information compared to analysis of samples from the distal urethra.A consecutive series of men who were visiting for STD testing in the urology units of two university outpatient clinics and a large clinic that provides testing for HIV and STDs to the general population in St. Petersburg were invited to participate in the study from May 2006 to February 2009. A total of 760 men, aged 18–60 (mean age 31.7) years, were enrolled after receiving a written instruction and providing written informed consent. The institutional review board of St. Petersburg State University and Medical Academy of Postgraduate Studies  approved the study.Treponema pallidum testing. In men over 40 years, prostate-specific antigen (PSA) testing was also performed.A urologist obtained a detailed medical history and performed a physical examination, including DRE. We also collected data on lifestyle and sexual behaviors, such as age at first intercourse, number of lifetime sex partners, sex preferences, and STDs history. All men provided blood samples for HIV and Chlamydia trachomatis, Neisseria gonorrhea, Trichomonas vaginalis, and herpes simplex virus (HSV) types 1 and 2 at the local laboratory, while the second sample was stored at −20°C prior to HPV testing. After urethral sampling, the man was asked to urinate. Afterwards a DRE with massage of the prostate was performed. The EPS was allowed to drop freely out of the urethra directly into a separate tube, which was also stored at −20°C prior to HPV testing.Before sampling, men were instructed to abstain from any form of sex for 3–5 days and from urination for 3–4 hours. The study clinician sampled the urethra with a urethral swab. Once inserted into the urethra, the swab was rotated 180° right- and leftwards. Then the swab was rinsed in 1000 µl of phosphate buffer in two separate tubes. The first sample was used for detection for STDs, such as 2O) and 8 positive controls (HPV plasmid pools) were run on every PCR and Luminex plate.HPV testing of urethral and EPS samples was conducted using PCR amplification of a fragment in the L1 gene http://www.R-project.org).HPV and HR-HPV concordance was calculated as the proportion of men double positive or double negative for both urethra and prostate specimens as compared to the full cohort. Comparisons of HPV prevalences and determinants of HPV infection used binomial logistic regression to calculate odd-ratios (ORs) and their confidence intervals (95%CI) using the statistical software R  in the urethral samples and 32.6% (245/752) in the EPS samples. Oncogenic HPV infections (HR-HPV) were found in 24.5% (184/752) and 27.7% (208/752) of the urethral and EPS samples, respectively.Combining urethral and EPS samples resulted in an overall 47.9% HPV-positivity in the studied population, twice as much as seen when analyzing only samples from the distal urethra. Similarly, the combined prevalence for oncogenic  and multiple HPV infection was 42.0% and 12.6%, respectively .The 5 most common HPV types were HPV-16 (17.2%), HPV-66 (5.1%), HPV-45 (4.4%), HPV-87 (3.9%) and HPV-6 (3.2%). In the male distal urethra the 5 most common HPV types were HPV-16 (8.9%), followed by HPV-18, -45, -51 and -6 , whereas the 5 most common types were HPV-16 (10.8%), followed by HPV-66, -87, -45 and -91  in the prostate secretion specimens. Three of the HPV types tested for were not detected in any sample . Single HPV infections were found in 20.8% (n = 156) of urethral and 24.5% (n = 184) of prostate samples but only 44 men (4.9%) were positive for the same single HPV type in both types of samples . MultiplHR-HPV infection tended to be more common and LR-HPV infection was significantly more common in the EPS than in the urethral samples .HPV concordance between the distal urethra and prostate secretions specimens obtained from the same men was low: 10.6% (n = 80) for all HPV, 10.1% (n = 76) for HR-HPV and 2.3% (n = 17) for LR-HPV types, respectively, with only 6.4% (n = 48) and 5.1% (n = 38) being concordant based on exactly the same HPV or HR-HPV type, respectively. The sensitivity of urethral samples for overall HPV detection was 54.2% (195/360).We found only one determinant of the HPV prevalences, namely a lower HPV prevalence with increasing age. This was found both for urethral (p = 0.009) and EPS (p = 0.003) samples. HPV prevalence was not significantly related to the life-time number of sexual partners .Genital warts were found in 7 (0.9%) men in total; all of them were visibly presented on penile heads. The urethral swabs were negative for HPV infections for 5 of these men and 2 of the EPS samples were also negative.C. trachomatis in 43 (5.7%) men with one (0.1%) positive case for N. gonorrhea among them. The HIV-positive man had multiple HPV infections . In the single case of gonococcal urethritis, HPV-91 was detected in both samples. Treatment against C. trachomatis infection in the past was reported by 31.5% (237) of the men. Only 10 (1.3%) men reported practicing sex with other men. There were no differences in HPV prevalences in relation to STD history, neither for urethral nor for prostate specimens (Recently diagnosed STDs were present in 47 (6.3%) males: HIV in one (0.1%), HSV in 3 (0.4%) and pecimens .Prostate secretions were found to represent an informative sample material for the study of HPV epidemiology in the male, greatly increasing the number of HPV-positive cases as compared to the study of samples from the distal urethra. The concomitant study of EPS and urethral swabs was necessary in order to answer the question whether virus presence in the EPS may be derived from the urethra when the EPS is transported through the urethra. To minimize urethral contamination of the EPS samples, the men were asked to urinate between collecting samples, as is the recommended procedure for urological patients Semen samples have shown only low HPV prevalences This is the first and only study where multiplex high-throughput genotyping of an extended spectrum of HPV types was performed on prostate secretion samples, analyzed and compared with the paired distal urethra samples obtained from the same men, representing the male upper and lower urogenital tract, respectively.A limitation of our study was that we did not compare the HPV prevalences in EPS to the HPV prevalences in samples from various parts of the body, such as penile or anal swabs. Penile swabs are reported to be the anatomic site with the highest published prevalence of HPV Prostate cancer is the most common non-cutaneous cancer among males Studies of HPV DNA detection in prostate cancer tissue have been controversial. Although some studies have found HPV DNA A high number of female sex partners is a major risk factor for male acquisition of genital HPV infection HPV infection in men is often asymptomatic, resulting in a large number of asymptomatic carriers In summary, we find that expressed prostate secretions are commonly positive for HPV infections that are not detectable in urethral swabs. Continued studies using EPS might allow for a better understanding of HPV epidemiology and natural history, its involvement in the urological diseases in the male as well as its transmission to the sexual partner.


Salicylic acid and cryotherapy are the most frequent treatments for common warts, but can be painful and cause scarring, and have high failure and recrudescence rates. Topical vitamin A has been shown to be a successful treatment of common warts in prior informal studies.Common warts  led to replacement of all the warts with normal skin. Most of the smaller warts had been replaced by 70 days. A large wart on the middle knuckle required 6 months of vitamin A treatment to resolve completely.Retinoids should be further investigated in controlled studies to determine their effectiveness in treating common warts and the broad range of other benign and cancerous lesions induced by HPVs. Other types of warts include plantars warts (verruca plantaris) that occur most commonly on the soles of the feet (HPV 1 and others) [verruca plana) usually appearing on the face  [condyloma acuminata; HPV 6, 11, 16, 18 and many others) [Human papillomaviruses (HPVs) are the causative agents of a variety of benign and cancerous lesions of the skin and other epithelial surfaces. At least 189 HPV genotypes have been described [ others) , flat wa others) , and ora others) . While c others) -7. HPV 1Many different treatments have been described for HPV-induced lesions. Salicylic acid (SCA) and cryotherapy, which are intended to kill HPV-infected cells, are the most frequently employed treatments for common warts by dermatologists. Over-the-counter (OTC) versions of these treatments are also available. Numerous studies, albeit with highly variable protocols, have examined the efficacy of SCA and cryotherapy for treating HPV-induced lesions (reviewed in ). The efThe subject is a healthy 30 year old woman of European descent with an uneventful medical history. There was a large . A needle was used to puncture the softgels and the oil was applied topically to the warts every night prior to sleep. The oil was allowed to soak into the tissue before the excess oil was removed with a dry towel. Soap was not used to wash the hands until the morning. On 3-4 days of the week, the oil was applied a second time, usually around midday. The daily topical application of vitamin A led to replacement of all the warts with normal skin. Most of the smaller warts had been replaced with normal skin by 70 days (Figure Throughout the course of the failed attempts at treatment, the number of warts increased. All warts had returned to their original appearance prior to treatment with vitamin A. The source of vitamin A was natural fish liver oil (NOWs Figure . The lars Figure , requires Figure . The sliverruca vulgaris. Topical vitamin A should be further investigated as an alternative to the most frequently-utilized wart treatments, cryotherapy and SCA, which have relatively low cure rates [The case reported here is similar to experiences in prior informal studies suggesting that topical vitamin A is an effective treatment for re rates -21. In cThere are a number of plausible mechanisms by which retinoids may affect HPV-induced lesions. Warts display abnormal keratin expression -24. RetiFurthermore, warts can have psychologically devastating effects on patients' lives  and the Because warts may "spontaneously" resolve, it is possible that clearance of the warts after treatment with vitamin A in this case was due to chance timing. However, this is unlikely given that the warts had only increased in size and number over the preceding 9 years. In addition, the case is typical of subjects in a prior informal series in which warts always began to clear within a few weeks of initiating topical vitamin A treatment . TretinoInformed consent was obtained from the subject for publication of this Case Report and accompanying images.HPV: Human papillomavirus; OTC: Over-the-counterThe authors declare that they have no competing interests.AG performed the investigations described in this study. RFG participated in its design. AG and RFG wrote and edited the manuscript. Both authors read and approved the final manuscript.


Gammapapillomavirus genus.A divergent human gammapapillomavirus (γ-HPV) genome in a nasal swab from an elderly Finnish patient with respiratory symptoms was genetically characterized. The L1 gene of HPV-Fin864 shared <70% nucleotide identity to other reported γ-HPV genomes, provisionally qualifying it as a new species in the  Papillomaviridae family are small double-stranded circular DNA viruses. Human papillomaviruses (HPVs) are highly diverse and have been classified into five genera, each made of multiple species that are further divided into types (Members of the to types . A subseto types –4, whileto types . Here, wto types . A complto types . Two chato types . The E1 to types . The E1 to types .Gammapapillomavirus genus currently consists of 10 viral species known to infect humans (Gammapapillomavirus genus, pending ICTV review. Given the association of human papillomaviruses with benign or malignant proliferative diseases of cutaneous and mucosal epithelia, the detection of HPV-Fin864 in the respiratory fluid of a patient with respiratory symptoms may have been coincidental.The L1 gene of HPV-Fin864 showed a best BLASTn match to HPV-156, a recently described γ-HPV species found in skin samples from immunocompetent patients . The Gamt humans , 13. Acct humans . PairwisKC311731.The complete genome sequence of HPV-Fin864 is available in GenBank under the accession no.