Higher prevalence of any HPV type in men and women was associated with having ≥2 sex partners in the past 12 months; always using condoms in the past 3 months was associated with a lower HPV prevalence. These data provide baseline information for future evaluation of the population impact of the HPV vaccination programme, including potential herd effects in men.In 2015, Botswana introduced the quadrivalent human papillomavirus (HPV) vaccine as a two-dose schedule in girls aged 9–13 years. We sought to establish a baseline HPV prevalence in unvaccinated young adults in Botswana. HIV-uninfected men and women aged 18–22 years were recruited from the University of Botswana in Gaborone during October 2019–February 2021. Demographic and behavioural characteristics were self-reported during structured interviews. Self-collected vaginal and penile swabs were tested for 28 HPV types using Seegene Anyplex II HPV28. We compared any HPV type, quadrivalent vaccine -type and non-quadrivalent vaccine-type prevalence in men and women and evaluated the risk factors for prevalence of any HPV type. A total of 493 men and 500 women were included in the analysis. Compared to men, women had higher prevalence of any HPV type (63.0%  Human papillomavirus (HPV) infection causes cervical cancer as well as other anogenital cancers  and oropharyngeal cancers . HPV typth birthday, and for persons with immunocompromising conditions, including human immunodeficiency virus (HIV) infection.Highly effective prophylactic HPV vaccines have been developed and were introduced in many high-income countries starting in 2006 . All thrBotswana's first comprehensive national cervical cancer control strategy focused on secondary prevention through cervical cancer screening. In 2015, after conducting an HPV vaccine demonstration project, Botswana introduced HPV vaccine into their national immunisation programme , 9. NatiMeasuring the impact of HPV vaccination after introduction into national programmes has focused on early and intermediate outcomes of HPV infection, as HPV-associated cancers take years to decades to develop. Reduction in the prevalence of HPV vaccine-targeted types has been observed soon after introduction (within 2–5 years); data through 10 years after the start of programmes are available from some high-income countries , 12. FurWe recruited a convenience sample of male and female students aged 18–22 years from the University of Botswana, in Gaborone, Botswana from October 2019 to February 2021. A comparison of HPV prevalence among women living with HIV and women without HIV from this study was published previously . ParticiDNA was isolated from specimens with proteinase K lysis followed by automated extraction. STM swab specimens were agitated on an orbital shaker for 45 min at ambient room temperature. For specimen lysis, 400 μl of penile swab STM or 200 μl of vaginal swab STM was incubated with 20 μl proteinase K  and enough NucliSENS easyMAG Lysis Buffer  to bring the total processing volume to 800 μl. After incubation at 65 °C for 1 h, extraction was completed on NucliSENS EasyMAG (bioMérieux). DNA was eluted in 100 μl of buffer 3 at a pH >8.0 and a temperature of 70 °C. Sterile water aliquots were processed in parallel with specimens as negative controls for DNA contamination assessment.Extracts were tested according to manufacturer End Point-CMTA protocol with Anyplex II HPV28 assay . This assay detects 28 HPV types  and human internal control DNA. The assay was conducted on CFX96 Dx System . HPV typing results were considered invalid if both internal controls were negative and no HPV was detected.This analysis was limited to participants without evidence of HIV infection, who had valid HPV typing results. All analyses were performed using SAS 9.4 . Demographic variables included age, sex and marital status . Sexual and behavioural characteristics included being sexually experienced , lifetime number of sex partners , number of sex partners in the past 12 months , age at first sex , age of first sex partner , age of current sex partner , sexual orientation , condom use in past 3 months , tobacco use ; in females, ever pregnant (yes/no) and in males, circumcised (yes/no) and age of circumcision .For individual HPV types, all detected types were reported. HPV types were also categorised as any HPV, quadrivalent vaccine-types , HR vaccine types , low-risk (LR) vaccine types , non-vaccine types , non-vaccine HR types  and non-vaccine LR types . Type categories are not mutually exclusive, as a participant could have both HR and LR types, and both vaccine types and non-vaccine types, detected.P < 0.05). Bivariate analyses were conducted to determine participant characteristics associated with any HPV prevalence. In sexually experienced females and males, unadjusted prevalence ratios (PR) and 95% confidence intervals (CI) were calculated using log-binomial regression to evaluate associations between participant characteristics and any HPV type. Multivariable models were developed using backward selection  to identify characteristics independently associated with having a prevalent HPV infection in this population. Unadjusted and adjusted prevalence ratios (aPR) and 95% CI are reported for all variables included in the final model.Demographic and behavioural characteristics were described overall and by sex. HPV prevalence was also described by sex, in all participants for both individual HPV types and HPV type categories, and in sexually experienced participants for HPV type categories. Any HPV, vaccine, and non-vaccine-type HPV prevalence by sex was further described by selected demographic and behavioural characteristics. Chi-square tests were used to identify statistically significant differences in categorical variables . Males were more likely than females to report first sex at age <18 years , younger ages at first sex and current sex partners (P < 0.001), and always using condoms in past 3 months . In females, 8.4% reported ever being pregnant. In males, 60.9% reported being circumcised; of these, 84.0% reported circumcision prior to age 16 years.Of 500 HIV seronegative female and 500 HIV seronegative male participants, 500 (100%) females and 493 (98.6%) males had valid HPV results and were included in the analysis. Females and males had a similar distribution of ages and nearly all participants were single (99.8%) . A similOverall, females had a higher HPV prevalence than males . In femaThe most common HR-HPV and LR-HPV types detected were similar in females and males . The fivIn bivariate analyses, the prevalence of any HPV was significantly higher in females who were older, sexually experienced, had an older age of current sex partner, higher number of sex partners in the past 12 months or lifetime, sometimes or never used condoms in the past 3 months, and were daily smokers . In maleIn multivariable analyses limited to sexually experienced participants, the number of sex partners in the past 12 months and condom use remained significantly associated with any HPV prevalence in females and males . CompareThis cross-sectional study is the first to characterise HPV prevalence in college-attending, vaccine-naive young adult females and males aged 18–22 years in Gaborone, Botswana. Importantly, we report the prevalence of HPV types targeted by the quadrivalent vaccine, which can be used as a baseline for monitoring future HPV vaccine impact in females and herd protection from the female vaccination programme in males.The prevalence of any HPV type in females in this report (63.0%) was similar or higher than in other studies of HPV prevalence in females of comparable age in Africa. In a meta-analysis of HPV types detected in African women aged 15–24 years who had normal cytology, the prevalence of any HPV was 48.2% 95% CI 14.7–81.6) [.7–81.6 . HoweverFew prior studies have reported on HPV prevalence in young adult males in sub-Saharan Africa , and eveSimilar to most studies conducted in sub-Saharan Africa, the majority of HPV-positive participants in this study had multiple HPV types detected . A study in South Africa reported a multiple-type prevalence of 31.7% in females and 48.6% in males aged 18–25 years , and a sDue to the recent initiation of most HPV vaccination programmes in Africa, Rwanda is the only country which has reported HPV vaccine impact . A few oUsing multivariable modelling to understand associations between participant characteristics and prevalence, we identified the number of sex partners in the past 12 months and condom use as the characteristics most strongly associated with the prevalence of any HPV in females and males. The number of sex partners is a well-known risk factor for HPV infection and has also been identified in other studies in university students in Africa . ConsistA major strength of this study is the concurrent sampling of females and males and the HPV typing with the same assay in the same laboratory. Importantly, although this study was conducted after the start of the national HPV immunisation programme, we enrolled females who were not eligible for vaccination and, therefore, were able to obtain an unvaccinated baseline. Although it could not be assessed in this study, depending on ages of sex partners, indirect effects from vaccinated younger females could have impacted the baseline HPV prevalence in unvaccinated females and males aged 18–22 years in this study, but we expect any such indirect effects to be small and to have minimal impact on a future vaccine impact evaluation. In 2024, the first vaccinated girls will reach the age group enrolled in this study and another cross-sectional study will allow evaluation of the impact of the vaccination programme. While a previous evaluation in Rwanda reported impact in the first country in Africa to introduce HPV vaccination, that country started their programme with a 3-dose schedule [The study had some limitations. We used convenience sampling at one university; therefore, the HPV prevalence estimates may not be fully generalisable to the target population of males and females aged 18–22 years but repeating the same recruitment methods in 4–5 years for a follow-up study to assess vaccine impact should yield a comparable population. Although the study enrolled participants from one site, this study still included a diverse population. Students come from across the country to attend this one major university in Botswana.In conclusion, the findings from this study indicate a high prevalence of HPV, including HPV types targeted by the quadrivalent vaccine, in both females and males in Botswana. The national HPV vaccination programme in Botswana, which achieved vaccination coverage as high as 90.0% , is thus expected to have a substantial impact on reducing HPV infection and HPV-associated cancers. The data from this study provide a baseline HPV prevalence in Botswana that will facilitate evaluation of HPV vaccine impact in the future, including direct impact in young women and potential herd protection in young men.


The Royal College of General Practitioners (RCGP) Veteran Friendly Practice Accreditation Programme launched in 2019, aiming to allow practices to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services.To evaluate the effectiveness of the accreditation programme, focusing on benefits for the veteran, the practice, and the delivery of the programme itself.The study evaluated the views of veteran-friendly accredited GP practices across England.A mixed-methods study was undertaken, which collected data via an online survey from 232 accredited primary healthcare (PHC) staff and 15 semi-structured interviews with PHC veteran leads. Interviews were analysed using modified grounded theory.n = 228) of responders would recommend the programme, 78% (n = 180) reported improved awareness, and 84% (n = 193) a better understanding of veterans' needs. Seventy-two per cent (n = 166) identified benefits for veterans who were engaging more with PHC but participants felt more time was needed, largely owing to the COVID-19 pandemic, to fully assess the impact of the programme on help-seeking behaviour. Challenges included identifying veterans already registered, promoting the accreditation process, and ensuring all PHC staff were kept up to date with veteran issues.The study found 99% (The programme has increased signposting to veteran-specific services and resulted in greater understanding of the NHS priority referral criteria for veterans. Recording of veteran status has improved and there was evidence of a better medical record coding system in PHC practices. These findings add to the limited empirical evidence exploring veteran engagement in PHC, and demonstrate how accreditation results in better treatment and identification of veterans. Accreditation aims to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services. So far, over 1000 practices have gained accreditation. This evaluation demonstrates GP practices have a greater knowledge, awareness, and understanding of veterans' needs and services as a direct result of the accreditation. The programme also led to improvements in the recording of veteran status in GP practices. with the UK having witnessed considerable statutory and non-statutory investment in military veteran health services in recent years. Since 1985, the UK has utilised Read codes , which are applied to a patient’s PHC medical record to annotate demographic characteristics including age, sex, diagnosis, and therapeutic interventions. The UK’s Department of Health and Social Care asserts that a Read or SNOMED code should be applied to medical documentation indicating a 'history relating to military service'. For the minority of veterans who need mental health (MH) support, poor help-seeking leads to unnecessary delays in addressing operationally attributable MH issues, which are often left until they are in crisis and social isolation. Additionally, some veterans are unaware of the potential health and social care benefits of disclosing their ex-armed forces status to their GP; only approximately 8% of veterans are registered under the correct Read or SNOMED code.The NHS is responsible for the health care of an estimated 2.4 million military veterans in Great Britain, GPs are often unaware how many veterans are registered with their practice and may require more guidance on how to meet the needs of their veteran patients. To maximise the uptake of these services, it is vital that veterans and their families register with PHC practices and are aware that these services exist.PHC staff can positively change health behaviour patterns, but there is a lack of knowledge among them regarding veterans. It has also assisted the NHS in being able to meet the health commitments of the Armed Forces Covenant, which is the nation's pledge to acknowledge and understand the commitment and sacrifices made by veterans. It states they should be treated with fairness and respect, and not be disadvantaged in the support they receive. By October 2021, over 1000 of the 6993 English PHC practices have been accredited across England (approximately 14% of GP practices). NHS England funded the accreditation programme for an initial 3-year period with an evaluation scheduled for the final year. After an open call and then interviews of the short-listed applicants, the University of Chester’s Westminster Centre for Research in Veterans was selected to complete an independent evaluation.The RCGP Veteran Friendly Practice Accreditation Programme was launched in June 2019 as part of an NHS 10-year plan to improve veteran engagement with PHC providers. The aim of accreditation was to allow practices to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services, thereby demonstrating motivation and commitment to ensuring veterans and their families are provided with better patient-centred care within GP practices.The aim of this study was to evaluate the effectiveness of the RCGP Veteran Friendly Practice Accreditation Programme to highlight positive outcomes and identify areas for improvement.The objectives were to: a) identify GP and PHC staff assessment of the effectiveness, benefits, problems, and means for improvement of the RCGP Veteran Friendly Practice Accreditation Programme for both veterans and the practices; b) recognise the challenges of this intervention, why they exist, and how they can be positively addressed; and c) distinguish the potential for lessons learnt to improve the programme. would take approximately 10 minutes to complete. Demographic information about the practices and veteran leads was acquired, along with the impact of COVID-19. Content analysis was used to analyse the survey’s written comments, and identified the inclusion of certain words and themes to help expand on the responders’ replies. Surveys included a request for PHC staff to voluntarily take part in a short interview, which aimed to understand positive outcomes, challenges, and to determine whether the programme had improved veteran help-seeking behaviour. Qualitative data from the interviews were analysed using a modified grounded theory approach. This facilitated a structured and systematic means of viewing the programme from the participants’ perspectives and included the following: constructing analytical codes and categories from the data and not from preconceived suppositions; using the constant comparative method to construct comparisons during each stage of the analysis; and memo-writing to develop categories, specify their properties, define correlations, and identify gaps. The qualitative analysis complied with the EQUATOR Network resources for reporting qualitative research and undertaking qualitative research with a British Armed Forces population. The research team were independent of the accreditation programme. Authors 6 and 7 were the RCGP military veteran champions, and they provided direction regarding the background to the accreditation programme and helped with facilitating the data collection.A survey was designed with questions aligned to the aims and objectives, and included open-ended questions to facilitate exploration of the benefits and challenges of the programme. A pilot study indicated the 25-item online survey, using the Jisc Online Surveys tool,The evaluation started at the beginning of May 2021, at which time 949 practices were accredited. As some practices were multiple location practices, the number of practices recorded as accredited by the RCGP was 925. The inclusion criterion was being an RCGP-accredited practice; all were contacted. The performance indicator set by the funders was 10% of practices, which meant a minimum of 92 participants were required to complete the survey.n = 925); survey distribution is presented in Email addresses of accredited practices were held on an RCGP database, which the research team were able to access for this evaluation only. The survey link was initially sent to 50 veteran-friendly accredited practices via email to ensure they were being distributed and received correctly. All accredited practices then received the survey  and included descriptive statistics of frequency distributions and percentages with scope for cross-tabulations, allowing examination of relationships between variables.The RCGP included details of the survey within their quarterly newsletter, reminding accredited practices to complete the survey. Quantitative survey data were kept anonymous and confidential. Data were exported directly from Jisc Online Surveys,Fifteen semi-structured interviews were conducted via Zoom and Microsoft Teams, and were audio-recorded using a dictaphone. This sample was based on a ‘first come, first served’ basis. Qualitative data obtained from the interviews were transcribed manually, coded, and kept anonymous and confidential.n = 167) recorded the number of veterans in their practice but only 18% (n = 42) included a veteran in their patient participation group. Of 230 responses, 95% (n = 219) of practices had a veterans lead, of whom 33% (n = 75) were veterans themselves. Of the 219 veteran leads, the most common appointment held was GP 69% (n = 151), followed by nurse 13% (n = 29), and practice manager 7% (n = 15).A total of 232 practices completed the survey (25% response rate). Given the significant pressures faced by GP practices during the pandemic, this was considered an exceptional response rate. The mean total practice population was 9883 (range 1650–31 000). Some practices, however, recorded unusually high population figures. This may be owing to multiple practice locations or human error. The mean number of veterans registered at these practices was 99 (range 2–800). Again, this figure should be interpreted with caution as it may not reflect a verified SNOMED or Read code search for veteran status. Seventy-two per cent of practices (n = 228) of participants would recommend the accreditation, with 76% (n = 176) finding the accreditation process ‘easy’ or ‘very easy’. Communication with the RCGP during the accreditation process was perceived as ‘good’ or ‘very good’ by 74% (n = 170), and an online module was the preferred method of training material for 84% (n = 194). Since becoming accredited, 84% (n = 193) of responders had a greater understanding of veterans' needs, while 78% (n = 180) were more aware of veteran’s needs. Only 52% (n = 120) of participants believed veterans were ‘aware’, ‘very aware’, or ‘somewhat aware’ of the programme, while 67% (n = 154) felt veterans did have an awareness of the priority treatment system. Seventy-two per cent (n = 166) of survey responders believed their increased understanding was having a positive impact on veterans. Sixty-eight per cent (n = 123) of overall responses suggested the accreditation process was the most effective way of providing veteran leads with the experience they needed to support veterans. Quantitative survey data are presented in Ninety-nine per cent (n = 34) felt the greatest challenge presented by the pandemic was limited time, 24% (n = 17) reported the lack of footfall, while 15% (n = 11) felt the reduced communication with patients made implementing the programme more difficult.The survey included an open-ended question about the impact of COVID-19 on the programme. Of 71 responses, 48%  of interviewees reporting a greater appreciation of veterans' needs since becoming accredited; 72% (n = 166) of survey responders believed this increased understanding benefitted veterans. GP practices became more understanding of veterans' experiences and were more aware of their need for veteran-specific care:Accreditation was perceived to have a positive impact on military veterans, with 67% This resulted in more successful engagement with secondary health care. Similarly, interviewees believed their increased understanding had led to an improved doctor—patient relationship. Improved understanding was also demonstrated by nursing and administrative staff.Ten interviewees had a better understanding of veteran-specific services since becoming accredited, particularly in relation to MH and orthopaedic referrals:'Just having an awareness of what services are available, I didn’t know about things they could access — particularly with mental health. Now I know where I can refer that veteran who really needs that help.' (FF)This knowledge was informed by RCGP updates and self-motivated online learning (webinars and veteran-specific websites). Overall, accredited practices have a good appreciation of the Armed Forces Covenant priority referral process and utilise this well. They felt it was being implemented by secondary health care, although there were isolated instances requesting further education to inform both primary and secondary care services about priority treatment:'I didn’t understand what priority treatment is and I don’t think NHS trusts do, so they don’t follow it through on a secondary level. So, if I put a referral through and he’s in chronic pain, I don’t think they’d register it more than if it was a truck driver or a builder, to them they’re all the same.' (LL)bridged’ the gap between the veteran and available services, utilising veteran-specific services that would not otherwise have been accessed by the veteran:Eleven interviewees believed veterans were unaware of the veteran-specific services available, and GPs have essentially ‘'It’s me knowing it exists rather than patients coming to me telling me it exists … if I wasn’t there, I guess they would just get referred in the standard NHS way and longer waiting times and a less bespoke service.' (EE)Several interviewees had developed a veteran resource database in their practice since becoming accredited, utilising it as a foundation to access guidance regarding signposting their veteran patients to the most appropriate service.Five interviewees reported a small but definite increase in veteran help-seeking since becoming accredited, especially in younger veterans:'I think it has made veterans more likely to come forward and seek help … I think a lot of patients are the type of patients who wouldn’t normally come to seek help. They tend to be younger to middle-aged men really, which you don’t see a lot of.' (JJ)n = 6) of survey responders believed veterans aged >80 years would engage with an accredited practice. This reinforces previous findings highlighting a need for further exploration into the needs of older military veterans. Eight interviewees reported that veterans had registered with practices directly as a result of hearing about their accreditation:Participants felt it was easier to communicate with older veterans once they became aware their GP had an understanding of their military experience. Older veterans were considered to have little appreciation of their veteran status, with some being unaware they were classed as a veteran. Survey data supports this finding, whereby only 3% ('We have patients who have registered with our practice deliberately because we are veteran friendly or transferred to our practice from other practices for that reason.' (CC)As a direct result of the initiative, GP practices were better able to understand veterans' needs and have a greater awareness of how to meet them. Overall, GP practices have a good appreciation of the Armed Forces Covenant priority referral process and utilise this well. Veterans themselves are perceived to lack understanding of veteran-specific services, which highlights the importance of the GP practice’s veteran-specific knowledge and consideration. However, it is important to note that in the qualitative aspect of the evaluation, 10 interviewees were veterans themselves, which makes it difficult to assess whether their knowledge was influenced by their own military experiences. Indeed, interviewees who were veterans appeared to have greater access to priority health care as they had forged military connections within other health and social care services. Nevertheless, interviewees who were not veterans were equally motivated to use both priority referrals and veteran-specific services in order to maximise the care and support to their veteran clients.Seven interviewees believed it was too early to gauge the impact of the accreditation on veteran help-seeking, largely owing to COVID-19, and felt this evaluation may be better timed in another 12 months. This was also evidenced in the open-ended survey responses.Since becoming accredited, some GP practices reported an increase in veteran registrations:'We’ve certainly seen more veterans. People have deliberately registered with us as a result of the accreditation including some who have been out of area who we wouldn’t normally register. They’re wanting to see somebody who understood the military and could assist them more.' (NN)'Have you ever served?', while nursing and GP staff asked patients during consultations whether they were veterans, and this was positively received by veteran patients. This form of proactive engagement was not done before accreditation. Awareness of veteran patients subsequently led to improved coding of veterans:However, participants believed there was work still to be done to identify veteran patients, believing they needed more time to increase their veteran registrations. This was in part pre-empted by COVID-19. Nevertheless, participants felt that improved awareness had resulted in practice staff who were more motivated to identify veterans and willing to accept and adopt new strategies. Reception staff asked new patients, 'I’ve been a lot more aware of registering veterans as the right Read Code … I’ve registered a lot more as the right Read Code since becoming accredited.' (FF)Motivation to register veterans appeared to be guided by a desire to improve veteran health care, although two interviewees reported that their clinical commissioning group had not been allocated funding to undertake veteran-specific coding searches, suggesting that funding may be a motivator to further improve PHC engagement.Eleven interviewees described how PHC staff’s motivation and commitment to the programme invoked a sense of pride in all practice employees. This was considered to have benefitted the reputation of the practice:'When we first got registered, there was huge support from the staff, particularly the admin team. They were really positive, quite a few of them have got spouses who are ex-military or children in the military. It raised the profile of military awareness. We have a real sense of pride in the staff, supporting the military.' (CC)Several interviewees felt they had become a better practitioner as a result of the understanding and awareness gained from being accredited. Reinforcing survey results, all practice staff were described as having an improved appreciation of veterans' needs:'The main thing is having somebody in the surgery who understands them. It’s not just me, it’s the fact the receptionists are more understanding … It’s allowed us to be more focused and because of the fact they know about the different referral pathways, we can often refer them into a service where they get a better answer, especially for mental health.' (NN)The accreditation itself has had a positive and beneficial impact on GP practices. Participants felt accreditation resulted in increased veteran registrations, improved SNOMED and Read coding systems, and greater motivation to identify veterans. While there remains work to be done in terms of reaching all patients, the fact that improvements have been observed should be considered a positive outcome. A better working environment was also noted and staff motivation to improve veteran health care highlighted. This is an encouraging finding and suggests continuation of this programme would be warmly received by PHC staff.Identifying veterans so they could be correctly coded on their medical records and made aware of the accreditation status was a primary concern for seven interviewees and was also highlighted consistently in the survey data:'We are quite new to this so numbers are fairly small but we found several veterans who were relatively new out of service and we’ve been able to engage with them and they’ve been very positive about it, it’s been quite helpful for them.' (II)Reaching these veterans was more problematic owing to the lack of footfall as a result of COVID-19. Several participants also raised concerns about veterans’ understanding of their status. Interviewees suggested many veterans had little appreciation of the benefits associated with disclosing their status to their GP, highlighting a need to promote understanding of veteran status in the veteran community.PHC practices advertised their accreditation on their website, introduced veteran-specific material to posters and to the public health information shared on their internal TV screens in their practice waiting rooms and through local communication by 'word of mouth'. However, 11 interviewees felt these methods of advertising were not having maximum impact and were considering alternative ways of promoting their accreditation status. Interviewees believed ‘word of mouth’ was the most effective method of promoting their accreditation but acknowledged this would take time:'I’m always looking for ways to help veterans. We are quite proactive. Veterans aren’t even aware that practices are veteran friendly so they’ve been quite shocked. I’ve put messages out to the Armed Forces Community that I’m in touch with, the armed forces breakfast clubs and things. A couple of our patients, when they’ve moved into area and gone along to armed forces breakfast clubs, they’ve said the surgery is veteran friendly so we’ve had a few patients come down and register.' (GG)Ensuring all practice staff were made aware of the programme was considered an additional responsibility for veteran leads, especially for practices with a high turnover of staff. Six interviewees advocated a need for further training, and the survey results revealed GP practices found RCGP updates extremely useful, although there were recommendations for these to be received on a more regular basis. This might suggest a need for more frequent veteran-specific updates from the RCGP and the NHS. Others suggested further training would be beneficial such as a conference, meetings, and/or study days.GP practices have found it difficult to reach veterans as a result of COVID-19 and have had little time to implement changes, although the veterans they have reached have benefitted greatly from the programme. In addition, GP practices may profit from further opportunities to enhance their knowledge of how best to meet the needs of veterans and ensure they receive the optimum level of care.Since 2019, over 1000 GP practices have gained veteran-friendly accreditation status. The positive outcomes of this independent evaluation have demonstrated the importance of the accreditation programme. Veterans receive better PHC when PHC staff understand their needs, receiving improved signposting to veteran-specific statutory and non-statutory services. Veteran leads’ enhanced knowledge of veteran-specific services and the priority referral pathway is of great benefit to veterans, who themselves have little understanding of these provisions.Recording of veteran status in GP practices has improved and staff appear motivated to engage with the programme. As time goes on, the number of veterans registering with accredited practices will likely increase. However, reaching veterans already registered (but not correctly coded) and promoting the accreditation remains a concern. Some GP practices have developed veteran-specific resource databases, highlighting commitment from PHC staff to engage with the programme. A better understanding of the coding system is evident in GP practices, although correct coding of veterans is an ongoing process. GP practices felt they needed more time to fully assess the programme’s impact on veteran help-seeking behaviour.This evaluation adds to the limited empirical evidence exploring the effectiveness of veterans’ engagement in PHC and staff’s willingness to connect with veterans. Recording of veteran status in GP practices has improved and momentum to do so is likely to continue. PHC veteran leads’ knowledge of veteran-specific services and the priority referral pathway is beneficial to veterans, who themselves have little understanding of these provisions. The study presents an exceptional response rate from GP practices who were experiencing great pressure as a result of the COVID-19 pandemic.The recruitment approach taken for the qualitative interviews meant the PHC practices that answered the questionnaire had both applied for accreditation and so were motivated to complete the survey questionnaire, which may have influenced the results. In addition, 10 of the 15 interviewees were military veterans themselves, meaning that they may have had a greater understanding of veterans' experiences than non-veteran interviewees. The effect of the COVID-19 pandemic on PHC will have impacted on the results. This could have been improved by identifying the number of veterans registered before accreditation and the number registered at a fixed time period  after accreditation. which makes identifying this population particularly difficult. Part of the challenge is that veterans are a hard-to-reach group who often bottle up their feelings, fearing the impact of sharing personal burdens with their family or appearing weak. Veterans may believe that civilian health professionals will not understand their past military experiences and therefore not register with a PHC practice, or not disclose their veteran status.There is a lack of international literature exploring veteran engagement with PHC, hence the RCGP funding this evaluation. Within the UK, patients are seldom asked whether they have ever served in the armed forces and recording of veteran status was, before this programme, rarely documented or coded,This evaluation adds to the limited empirical evidence exploring the effectiveness of veterans’ engagement in PHC and staff’s willingness to connect with veterans. It highlights better treatment and identification of veterans since becoming accredited, while commitment from practice staff demonstrates the possibility of further developing the Veteran Friendly Practice Accreditation Programme. These factors have important implications for future policy development, research, educational programmes, and clinical delivery. The combination of these will help ensure veterans and their families receive the optimum care and support that they deserve. Study recommendations are shown in


Cervical cancer is a leading cause of death for women in low-resource areas around the world. However, the disease can be prevented through vaccination, screening, and early treatment. Recently, the World Health Organization released a strategy with the goal of eliminating cervical cancer through a combination of these three preventive strategies. In El Salvador, a screening program has been in place for some years, and vaccination is in its early stages. Here, we describe the Salvadoran experience and discuss successes to date and challenges for the future. We also provide recommendations that may be helpful for other countries working to meet the WHO elimination goals.Cervical cancer is preventable through vaccination, early detection, and the treatment of pre-cancerous lesions. However, global inequalities mean that the disease remains a leading cause of cancer death around the world, with over 80% of new cases and 90% of deaths occurring in low- and middle-income countries (LMICs). In El Salvador, joint efforts between the Ministry of Health (MoH) and the non-profit organization Basic Health International (BHI) have been in place since 2008, with the goal of reducing the country’s disease burden. While the World Health Organization’s (WHO) call to action to eliminate cervical cancer provided worldwide momentum to implement new public health initiatives, the COVID-19 pandemic disrupted ongoing programs and jeopardized plans for the future. The purpose of this manuscript is to describe the progress that El Salvador has achieved in improving cervical cancer prevention, the impact of the pandemic on current strategies, and potential solutions that can help the country meet the WHO’s strategic targets by 2030 to accelerate the elimination of cervical cancer. Cervical cancer is a disease of inequality. Wealthy countries have access to preventive strategies that have significantly reduced incidence and mortality rates in the last 50 years, but low- and middle-income countries (LMICs) continue to bear a large burden of disease . It is eWhile the WHO’s strategy presents challenges to resource-poor countries with competing health priorities, the call to action has provided momentum to increase access to cervical cancer-preventive services. El Salvador is well positioned to demonstrate an effective implementation of cervical cancer control programs. The country has historically high rates of incidence and mortality  [Since 2008, a collaboration between the Ministry of Health (MoH) and Basic Health International (BHI), a non-profit organization, has resulted in a range of initiatives to strengthen cervical cancer prevention in the country . PreviouFollowing the success of this project, the screen-and-treat program was scaled-up in the paracentral region . Cost-efIn 2017, after the initial success of a primary HPV-based screen-and-treat demonstration project, El Salvador was able to obtain grant funding for further HPV tests in addition to HPV vaccines. The MoH included the procurement of HPV tests in its 2022 annual budget, cementing the screen-and-treat program as part of the national cervical cancer control effort. Today, HPV screening is available across the network of primary care units distributed in all five regions of the country . ProvideMulti-disciplinary health teams form the backbone of the HPV screening program. These consist of healthcare providers at various levels, including general practitioners who head municipal health clinics, nurses at the clinics, educators and community health promoters, among others. Health promoters are the first line of advocacy and education. They are responsible for contacting women due for screening to set up appointments at local clinics according to their catchment area. Currently, El Salvador’s guidelines recommend HPV testing for women aged 30–59, and cytology for those between 20 and 29 and over 59 years of age. Participants of the HPV program receive an educational session taught by nurses on arrival at the local clinic. Women then undergo a provider sample collection using careHPV, which detects 14 types of high-risk HPV . Screened women are given an appointment to return after 4 weeks for their test results. HPV positive women must schedule the second appointment at the nearest treatment center. There are 74 such centers strategically distributed throughout the country. On the second visit, those who test positive are offered a pelvic exam to visually assess eligibility for the ablation treatment and, if eligible, gas-based cryotherapy. HPV testing, a visual assessment, and treatment are performed by trained general practitioners or gynecologists. Women who are deemed ineligible for treatment during the visual assessment are referred to colposcopy and biopsy by colposcopists at regional hospitals. Criteria for ablation treatment ineligibility are drawn from WHO guidelines, and include a lesion that is larger than 75% of the cervix, enters the endocervical canal, or is suspicious for cancer, or cases where the squamocolumnar junction is not fully visible.To date, over 4500 healthcare providers have been trained as part of the screen-and-treat program  and 145,After the WHO call for elimination was released, the MoH engaged in further efforts to maximize the impact of this opportunity in El Salvador, with two important outcomes. First, the MoH released a new screening target to increase the number of eligible women screened to 15% per year for the next 5 years, which would achieve the WHO target of 70% of eligible women screened by 2030. Second, after a series of stakeholder meetings that included MoH and BHI personnel, changes were planned to the national cervical cancer guidelines. BHI had successfully completed several projects on the feasibility of HPV self-collection in hard-to-reach areas ,17,18. SThe MoH introduced HPV vaccination in 2020. The WHO call to action coincided with a donation from the World Bank, providing the necessary momentum to begin implementation efforts. An advisory committee was convened, and the MoH settled on a school-based strategy targeting 9-year-old girls for a first dose, with a second dose administered after six months. Quadrivalent Gardasil  was the vaccine of choice. Usually, childhood vaccines are given at local health units, but given the need for two doses and the target ages, it was determined that a school-based approach would result in better follow-up. HPV vaccination was projected to start in April 2020 during the Americas Vaccination Week, with the goal of vaccinating approximately 55,000 girls the first year. The HPV vaccine was also included in El Salvador’s vaccination schedule. Finally, the vaccine data collection system was prepared to receive general outcomes of the HPV vaccination effort. As the program was about to begin, COVID-19 was declared a pandemic by the WHO and became a national health priority. The HPV screening and vaccination programs were immediately suspended. In March 2020, as COVID-19 cases began to rise nationally, public health services focused on containing the pandemic. Women who had been screened as part of the HPV screen-and-treat program had follow-up care delayed for several months. The planned April start date for the new HPV vaccination campaign was re-scheduled to November 2020. As non-essential medical services slowly restarted in late 2020, an urgent COVID-19 vaccination campaign was prioritized. Screening and vaccination initiatives for cervical cancer gradually resumed.The true impact of the pandemic on routine medical services has only recently begun to surface. In the Occidental and Oriental regions of El Salvador, an estimated 5000 HPV-positive women were awaiting follow-up care since the beginning of the lockdowns in 2020. Thus, in collaboration with BHI, a funding opportunity was identified, and a project initiated with the goal of locating these women and providing follow-up care. Since MoH providers and laboratories remained at capacity with COVID-related care, private colposcopists and pathology laboratories were engaged to conduct this intervention. From March 2021 to March 2022, 3017/5000 (60%) screen-positive women were identified, and efforts are ongoing to locate the remaining 1983/5000 (40%). Of those accounted for, 702/3017 (23%) had already received follow-up care at private clinics, 210/3017 (7%) refused further care, and 96/3017 (3%) were lost to follow-up . The remaining 2009/3017 (66.5%) underwent colposcopy and biopsy as part of this project. Laboratory analyses have been completed for 1990/2009 (99%). Results showed high rates of high-grade pre-cancer at 23% (452/1990) and invasive cancer at 1.3% (26/1990). Although there were no comparable pre-pandemic figures available, findings from the original HPV screen-and-treat demonstration project provided a frame of reference. Among HPV-positive women in the colposcopy management group who completed biopsy within 6 months, 56/385 (15%) were diagnosed with high-grade pre-cancer and 1 (<1%) with invasive cancer . These wThe HPV vaccination effort has also faced challenges. Since public schools were shut down for most of 2020 and part of 2021, the MoH decided to shift its strategy to an at-home approach. The age range was also expanded to encompass girls aged 9 to 11 years old. Despite these adjustments, the total number of first doses provided was 15,286, 28% of the original target for 2020. Although these figures fell short of initial projections, the inclusion of the HPV vaccine in the national budget means that the procurement of HPV doses in the next few years is assured. This, in turn, should facilitate meeting elimination goals.El Salvador achieved significant gains over the last decade to reduce its cervical cancer burden. Since 2022, there is a scalable screening program in all regions of the country and HPV test kits were purchased solely with government funds. The WHO call for elimination provided additional motivation to set defined screening targets and begin the implementation of a new HPV vaccination program, despite the challenges of the pandemic. However, significant barriers remain, many of which represent broader issues that can impede elimination goals globally. Although HPV screening is highly acceptable to patients and providers, there are limited low-cost options. In addition, many existing HPV tests require complex equipment or long processing times. Inexpensive, rapid HPV tests are in development, but none are yet available that allow for the maintenance of a nation-wide, single-day screen-and-treat program. There is also an urgent need for affordable and accessible triage options that can minimize over-treatment and more efficiently channel resources. Better follow-up options for women ineligible for ablation, who may be at greater risk for invasive cancer, are also lacking. Innovative and affordable point-of-care screening and treatment alternatives will be necessary to meet elimination goals.In terms of primary prevention, the HPV vaccination program in El Salvador is still in early adoption. It is a positive sign that the vaccine has been included in the national vaccination schedule, which will greatly assist in ensuring its sustainability. However, original targets were not reached and it will be important to devise strategies to reach those populations. As in other countries, even if vaccines become widely available, effective interventions to overcome vaccine hesitancy will be essential. On the other hand, if a single-dose schedule is eventually introduced, this would facilitate implementation by reducing costs and avoiding loss to follow-up. The COVID-19 pandemic has also highlighted the need to strengthen health systems globally, with cervical cancer programs in particular. In El Salvador, the return of screening has been gradual and irregular due to recurring infection waves, and there is a backlog of women waiting for results or treatment. While other health emergencies will always exist, there are strategies that can help mitigate these challenges. For example, HPV self-collection can allow for at-home testing and including HPV vaccination in national schedules can help prioritize cervical cancer prevention. In order for LMICs to meet the WHO’s elimination goals by 2030, more affordable and accessible vaccination and screening modalities are necessary, but are not currently sufficient. It is also essential to follow evidence-based strategies and recommendations to implement and sustain population-level programs. Our experiences in El Salvador have taught us valuable lessons in this regard. First and foremost, it is crucial to engage stakeholders at the early planning stages of any project. At the local level, a joint BHI and MoH team organized meetings and workshops with MoH staff at various levels, professional organizations, and other actors working in the cervical cancer space in order to build interest in a pilot demonstration. We also activated an international network of academic connections, which proved valuable in bringing expertise to the design and implementation of the project. The MoH has been extremely receptive of these contributions, and this has helped to build an in-country capacity across multiple sectors. We would encourage any government team involved in screening or vaccination initiatives to seek out partnerships with research or non-profit groups that can bring flexible skills and resources to the development of a new initiative. Once a program is ready for implementation, it is crucial to design an education and awareness plan, not only at the community level, but also targeting the staff that will run it on a day-to-day basis. In El Salvador, there are training and refresher courses for clinicians and health promoters, which ensure that providers at all levels are knowledgeable and motivated to recruit participants. On the more practical side, negotiating with local distributors to supply tests and necessary materials can be helpful in avoiding customs delays and cutting down costs. Finally, surveillance and data collection, at any scale that is feasible, are absolutely necessary to gauge program success and detect areas where more work is needed. In our case, data were also essential to effect guideline change and ensure a meaningful and sustainable impact. The WHO call for elimination has placed cervical cancer prevention at the front and center of global health. It is crucial that governments, funding agencies, researchers, and other stakeholders take advantage of the current moment to meet elimination targets and ensure that future generations are free of this preventable disease.


Oropharyngeal cancer (OPC) is one of the most common cancers in the head and neck region. The incidence of OPC is still growing, mostly due to the human papillomavirus (HPV), which has become the dominant etiological factor. HPV16 is the most relevant genotype for OPC, whereas other high-risk genotypes are rare and may be associated with a worse prognosis. The aim of this article is to discuss the molecular response (MR) obtained by assessing circulating tumor-related HPV DNA (ctHPV) in a liquid biopsy (LB). This quick and simple diagnostic tool reflects the presence of the tumor and thus, can support some clinical decisions. We provide a comprehensive overview of the clinical benefits of the blood-based molecular response, focusing on the decision-making process of the tumor response during the therapy, assessment of early treatment results, and post-treatment follow-up in patients with HPV-related OPC.Recent findings have shown that human papillomavirus (HPV) DNA is present in the blood as a tumor-specific biomarker  in patients with HPV-related oropharyngeal cancer (HPV-related OPC). The molecular response (MR) in patients with HPV-related OPC can be defined as the change in the number of ctHPV copies in relation to its initial quantity. The optimal model for assessing the MR using a liquid biopsy (LB) should be based on the E6/E7 sequences of the viral genome. MR assessment can help to evaluate the intensity of ongoing treatments in relation to the tumor response. The evaluation of the residual disease at the end of therapy may also be performed by MR assessment. If a partial MR (pMR) is found, caution is indicated and a subsequent LB should be considered, due to the likelihood of disease progression. Complete radiological and clinical responses together with a complete MR (cMR) convincingly indicate a low risk of treatment failure. Moreover, molecular recurrence (Mrec) during a follow-up, confirmed in two consecutive assays, even despite the lack of any other clinical or radiological symptoms of progression, indicates patients at high risk of disease recurrence. In conclusion, MR by ctHPV assessment may hasten the early detection of disease progression, at any stage of the management of the patient with HPV-related OPC. Recognizable and well-known cancer biomarkers, although desirable, are scarce in the oncological diagnostics. Eligible biomarkers not only play important role in the detection of neoplasmatic diseases, but also help to monitor both the active disease (through the therapeutic process) and cured patients (during surveillance). The cancer cell differs from its normal archetype in many aspects and, at different levels of magnification, morphological, cytogenetic, and genetic changes can be observed. The genetic changes found in the blood come exclusively from the tumor cell ,2,3,4 anThe percentage of HPV-related oropharyngeal cancer (HPV-related OPC) has increased significantly over the past twenty years, with sharper and faster rates of increase reported in Western Europe compared to North America . An incrIn this review, we propose a quick and simple diagnostic method for HPV-related OPC, based on a LB and the most-documented HPV16 genotype. We provide a comprehensive overview of the clinical benefits of blood-based ctHPV analysis, focusing on the decision-making process of the tumor response during therapy, assessment of early treatment results, and post-treatment follow-up.Alphapapillomavirus, Betapapillomavirus, Gammapapillomavirus, Mupapillomavirus, and Nupapillomavirus. It has been estimated that there are at least 400 different types of HPV, and the number of newly discovered types continues to increase thanks to rapidly advancing metagenomic sequencing technologies [The human papillomaviruses are a large and diverse group of viruses with five main genera: nologies ,17. Fromnologies . Among tnologies ). The prWith advances in HPV genotyping, more information has been gained from studies comparing the clinical significance of HPV16 with other HR genotypes. In most reported series, clinical factors were similarly distributed between HPV16 and other HR HPVs, including p16 expression, smoking, alcohol use, race, age, and sub-site of the tumor ,32. Varip = 0.01) for patients with HPV16-related OPC and those with other HR HPVs, respectively. Notably, the 5-year OS for HPV-unrelated OPC was 50%, which was similar to the OPC with other HR HPVs [The presence of HPV in tumors was first considered a strong positive prognostic factor for patients suffering from squamous cell carcinoma of the head and neck (HNSCC) ,34. Sinc HR HPVs . In cont HR HPVs . In a la HR HPVs . In cont HR HPVs ,31.The true mechanisms underlying the poorer results for OPC patients with HR HPVs other than HPV16 have not yet been fully elucidated, although a possible role of the immune system has been highlighted. Dramatically inferior outcomes for patients with HPV33-related HNSCC compared to HPV16-related HNSCC have been noted by Chatfield-Reed et al. , who paiIn summary, HPV16 is the most relevant HR genotype for OPC, whereas other HR genotypes, such as HPV33, HPV35, and HPV18, are rare and may be associated with a worse prognosis. The survival benefit of an HPV-related patient may be genotype-specific, so care should be taken in extending the knowledge based on HPV16 to other HR genotypes in patients with HPV-related OPC.For patients with HPV16-related OPC, the viral load (VL) of ctHPV16 is assessed as the number of viral particles per milliliter of fluid ,41. The Some differences between males and females regarding the VL have also been observed in HPV-related OPCs. Men with detectable ctHPV16 mainly showed N2/N3 diseases and high tVLs, while those with no ctHPV16 showed predominantly N0/N1 diseases and low tVLs. For women, multiple regression revealed that both an advanced T-stage and high tVLs significantly increased the detection of ctHPV16 . A partiIn summary, the VL describes the amount of viral DNA in tissue or in the blood. In general, the larger the tumor mass (T-stage and N-stage), the higher the number of copies of the viral DNA in the tumor and, thus, the larger the blood-based VL.It has been successfully proven that ctHPV is correlated with the existence of cancer and is not detectable in healthy people or in patients with an HPV-unrelated tumor ,48. The Suitable methods for HPV detection have become increasingly complex. Although detection by the polymerase chain reaction (PCR), quantitative real-time PCR (qPCR), reverse transcription PCR (RT-PCR), immunohistochemistry (IHC), in situ hybridization (ISH), or a combination of these methods are appropriate when considering tissue samples ,64, nextAll three methods—namely, qPCR, ddPCR, and NGS—are based on PCR technology. A common feature of qPCR and ddPCR is the use of fluorescent probes and primers for the detection of a specific fragment, where the developed set (probe and primers) can be used interchangeably. The difference is that ddPCR is stoichiometrically designed, such that there is only one template per droplet. As such, both the wild and mutant form initially have the same chance of amplification; in other words, there is no possibility of faster amplification of one of them, which would result in the inhibition of the reaction by the amplified product. This is important in mutation testing, where it is assumed that there is one mutant and one normal allele in the droplet. However, when testing viral DNA—the number of copies of which often exceeds the number of normal alleles (one of which serves as a control) by tens to several hundreds of times—stoichiometric matching is not possible. Thus, the stoichiometric ratio of virus copies to control alleles may be under- or over-estimated in droplet PCR. For qPCR, the stoichiometric ratio is not important, but it is undesirable to amplify the control gene too quickly. This can lead to the accumulation of the control product, an excess of which can inhibit the amplification of the target gene in situations where there is not enough of it; hence, qPCR is a less-sensitive technique . NGS tecThe diagnostic accuracy regarding ctHPV, almost exclusively based on ddPCR or qPCR and with the detection of E6/E7 fragments, has been discussed in a few meta-analyses. At the first diagnosis, ctHPV detection in pre-treatment blood samples showed an overall sensitivity of 81% ,69, and As HPV16 is known to be the most prevalent HPV genotype in OPC, it is better to focus on the detection of the HPV16 genotype by LB, based on qPCR/ddPCR, in the first line of diagnostics .Since there are currently no commercial tests using LB for OPC patients, the laboratory can use a molecular test developed in-house to make decisions regarding patient care ,71. The The discrepancies between ddPCR and qPCR in the sensitivity of detection of ctHPV16 can be adjusted by using NGS in the second line of LB-based diagnostics, allowing for the further detection of other genotypes. While the importance of these genotypes in the survival is not yet clear, their use as biomarkers for recurrence has been well-documented ,73,74. NIn summary, the E6 and E7 fragments can only be found in a LB in the presence of cancer and, consequently, can be used as tumor markers. In the first line of diagnostics, the detection of E6/E7 fragments of the most common type (HPV16) can be efficiently performed using the ddPCR or qPCR methods; NGS, as the next step, is expected to complement such a diagnosis.Determination of ctHPV16 in the LB, in order to monitor the effectiveness of treatment in patients with HPV-related OPC, seems to be a particularly useful diagnostic tool. A LB is relatively easy and safe, and it may be subsequently repeated. Serial measurements of the amount of ctDNA show its change, which can be used to determine the molecular response (MR) to ongoing therapy, or to confirm the residual tumor after completion of the treatment .The MR of patients with HPV16-related OPC can be defined by the change in number of ctHPV16 copies in relation to the initial quantity . If the Patients with HPV-related OPC tend to respond better to treatment and present a higher overall survival (OS) rate ,79,80. CIt seems reasonable to support molecular pathological diagnosis by conducting a LB in the situations where the amount of the tissue sample is insufficient to confirm the HPV etiology, or when biopsies would require repetitions, due to the localization or composition of the tumor A.As there is a considerably more favorable prognosis for HPV-related OPC than HPV-unrelated cases, the possibility of de-escalating therapy to reduce treatment-related toxicity has been considered. While many prospective trials considering this aspect are ongoing, due to the lack of convincing results, the treatment strategy for HPV-related OPC has not yet changed . The sel2 was observed [The standard treatment approach for patients suffering from HPV-related OPC consists of either seven weeks of RT (70 Gy) combined with concurrent cisplatin , or surgery followed by six weeks of adjuvant RT (60 to 66 Gy) with or without cisplatin, depending on various risk factors . To incrobserved . It has observed ,97. In sobserved . The MR observed .It should be stressed that the efficacy of de-escalation has not yet been confirmed in clinical trials for patients with HPV-related OPC. Nevertheless, due to a distinctive sub-group with a worse prognosis , a well-defined risk sub-group in the HPV-related population poses a challenge for continued de-escalation in clinical trials .In summary B, molecuFor patients with HNSCC, the complete response rates after CHRT at the primary site and regional nodes are in the ranges of 35–55% and 40–70%, respectively ,101. SurIt is of special concern that, for patients with HPV-related OPC, the regression of residual lymph nodes may present a prolonged course, and a radiologically evident post-treatment residual mass may not necessarily indicate the presence of active cancer . The resDue to these observations in addition to radiological findings in clinical practice, for patients with cMR, postponing surgery could be reasonable, while it seems necessary in those with pMR. Tanaka has suggested three categories of treatment failure risk for patients with HPV-related OPC after completion of the treatment: patients with pRR in PET-CT and pMR, discordant results between PET-CT and MR, or cRR in PET-CT together with cMR are at a high, intermediate, and low risk of treatment failure, respectively. According to these groups, the proposed recommendations are as follows: salvage surgery with pathological examination, imaging in shorter intervals, or routine follow-up, respectively . Campo eIn summary C, if pMRp = 0.25) [Local recurrence occurs in approximately 20–30% of patients with HNSCC, remaining the most common cause of treatment failure. Regional recurrence in the neck occurs in 10–15% of patients, which is the next most-common cause of death in such patients. Distant metastases (DMs) are relatively uncommon, appearing in around 10% of patients . Convinc = 0.25) . Interes = 0.25) . Sites o = 0.25) . In HPV- = 0.25) . As such = 0.25) ,121. One = 0.25) .Considering these observations, the detection of disease recurrence can be accelerated by ctHPV16 assessment, increasing the chances of a successful rescue. Cao et al. have reported a patient who presented Mrec only four months prior to the detection of lung metastasis . In the In summary D, MR by Detailed knowledge of the etiology of OPC is essential for precise therapy and relevant prognoses in patients suffering from this disease. In patients with active HPV-related OPC, ctHPV16 usually is present in the blood. Consequently, a ctHPV16 assay in a LB may help to confirm the HPV etiology. Moreover, a change in ctHPV16, described as MR, may support clinical decisions at all stages of the treatment and surveillance of the patients with HPV-related OPC. The assessment of MR may facilitate the modification of the ongoing treatment if necessary, early identification of treatment failure, and detection of recurrence or metastases. At present, the clinical application of MR is not a standard approach and only has supplementary value, typically being used along with other parameters such as the tissue-derived HPV etiology in primary diagnosis, radiological and clinical assessment of the treatment response shortly after treatment completion, and during surveillance. Despite the beneficial features of an LB, including its safety and repeatability, more data are clearly needed to confirm the value of ctHPV16-based MR in the prediction and/or prognosis of patients with HPV16-related OPC.


Knowledge about HPV infection in the oral cavity/oropharynx may contribute to the elucidation of the role it plays in Head and Neck Squamous Cell Carcinoma (HNSCC).To determine the effectiveness of the methodology used for sampling the oral cavity and oropharynx mucosae and to determine the prevalence of HPV in the oral cavity and oropharynx of adults and children.The study population was served by an assistance program in a rural district of São Paulo. The subjects were asked to donate samples regardless of complaints.The study included 47 men, 77 women and 22 children, of which the oral cavity samples were obtained by gargling with commercially-available antiseptic mouthwash. We found 3 positive samples (2.4%) in adults: 2 HPV 55 and one HPV 58. No positive results were found in children. Furthermore we concluded that the sampling method with the mouthwash proved effective and fast for the detection of HPV in the oral cavity and oropharynx in the general population. Human papillomavirus (HPV) is one of the most common causes of sexually transmitted infections worldwide. Although the causal relationship between high-risk HPV and cervical cancer is well establishedMuch of this lack of knowledge happens because there is no conclusive evidence on the prevalence of oral cavity infection by HPV. Existing studies resort to various methods, either in sampling or in the detection of HPV, eventually producing different results.Based on the literature, high-risk HPV types have been regularly detected in 16% to 33% in oral cavity squamous cell carcinoma (OCSCC), 28.2% to 47% in SCC of the oropharynx and 13.8% to 48.5% in laryngeal SCCAs observed in carcinomas of the cervix, HPV + OCSCCs are acquired predominantly via sexual transmissionSince we have the availability of prevention tools such as the HPVvaccineThe objectives of this study were to investigate the usefulness of employing oral antiseptic mouth rinse in order to collect samples from the oral cavity and oropharynx, comparing the prevalence of HPV in the sample with that in the literature.This study was carried out with prior approval from the Ethics Committee on Research with protocol number: 419/10.The population under study participated in the assistance program conducted in 2011 in Votuporanga (latitude 20° 25'22 “South and longitude 49° 58'22” West) in São Paulo, Brazil. The entire population served by the assistance program was submitted to an ENT examination, regardless of complaints during the interview and screening. All patients participating in the assistance program conducted in the city, who were informed about the research and agreed to participate after signing the consent form, were enrolled in the program. We took off the study those who refused to participate in it.Our study had men, women and children from 4 years of age. We collected samples from the mouth and oropharynx cells of the patients by peeling the skin after rinsing and gargling with commercial oral antiseptic (Alcohol-free Plax and Colgate). The subjects were instructed to avoid consumption of any food or liquid and remove dentures about 30 minutes before collection. The participant was then instructed to rinse the oral cavity with a single dose of 15 ml of mouthwash, gargling vigorously for about 15 seconds involving the entire surface of the mouth. Then, the subject was told to tilt the head back and gargle for another 15 seconds. After this time, the solution was spat back to a previously labeled 50 ml conical tube.Immediately after collection, all samples were kept in a refrigerator at 4°C for a maximum period of 48 hours, when they were transported under refrigeration to the city of São Paulo and processed. PCR and DNA extraction tests were performed according to routine protocol. The DNA was extracted and purified according to instructions from Roche's AmpliLute Liquid Media Extraction Kit , and quantified in a full spectrum Nanodrop spectrophotometer. Equal amounts of DNA were subjected to HPV DNA detection and typing by polymerase chain reaction (PCR) using the Linear Array HPV Genotyping kit . Biotinylated primers were used for a polymorphic region of 450 L1 HPV genome base pairs and another couple of primers for the human beta-globin gene used as DNA quality control, following manufacturer's instructions. This method enables the detection of 37 different types of HPV and has been validated in several studies carried out worldwide.Of the 166 individuals invited to the study, 145 (87.3%) agreed to participate, signed a consent form and were included in the study. Samples were collected from 77 adult women between 20 and 74 years of age (mean age ± SD = 45.3 ± 15.4), 47 adult males between 18 and 89 years of age (mean age ± standard deviation 51.4 ± 16.8) and 21 children between 4 and 17 years of age (mean age ± standard deviation 10.1 ± 4.2). The DNA was successfully isolated from all samples. In addition, all samples had beta-globulin, indicating good quality of the material submitted to PCR. Three positive results were obtained in adults, with a prevalence of 2.4%. The HPV types found were HPV 55 - in two samples and HPV 58 in one. No positive results were found in children .Table 2HIn a study which assessed the prevalence of HPV infection in the oral and oropharyngeal mucosae from 1,688 healthy men from Mexico, USA and Brazil, the authors found 4% of HPV infections, and 1.3% were positive for HPV-16 - the most prevalent type in this populationIn a study carried out in Esquenazi et al.Kreimer et al.Of the three positive samples in the study, two of them were type 55 and one was HPV 58, coinciding with the types found in the papers by Kreimer et al.The main limitations of this study are related to the low number of participants, the proportion of adults and children and the inability to characterize the population on habits and sexual behavior. However, the methodology demonstrates the feasibility of conducting a study on the prevalence of HPV in a region with low technological resources, limited time and space, with results similar to those available in the literature.The collection method using rinsing with mouthwash was fast and effective for the detection of HPV in the oral cavity and oropharynx evidenced by the presence of DNA in all the samples and by PCR control by the beta-globulin gene - positive in all samples.We found three positive (2.4%) samples for HPV in the oral cavity and oropharynx of the adult population participating in the study and no positive sample among the children. The HPV types found were the HPV 55 in two specimens, and one with HPV 58. This data is in agreement with the literature, showing low HPV prevalence in the mouth and oropharynx of healthy individuals.


Vaccines have been demonstrated to protect against high-risk human papillomavirus infection (HPV), including HPV-16/18, and cervical lesions among HIV negative women. However, their efficacy remains uncertain for people living with HIV (PLHIV).We systematically reviewed available evidence on HPV vaccine on immunological, virological, or other biological outcomes in PLHIV.We searched five electronic databases  for longitudinal prospective studies reporting immunogenicity, virological, cytological, histological, clinical or safety endpoints following prophylactic HPV vaccination among PLHIV. We included studies published by February 11th, 2021. We summarized results, assessed study quality, and conducted meta-analysis and subgroup analyses, where possible.sN=18), evaluating the quadrivalent (sN=15), bivalent (sN=4) and nonavalent (sN=1) vaccines. A high proportion seroconverted for the HPV vaccine types. Pooled proportion seropositive by 28 weeks following 3 doses with the bivalent, quadrivalent, and nonavalent vaccines were 0.99 , 0.99 , and 1.00  for HPV-16 and 0.99 , 0.94 , and 1.00  for HPV-18, respectively. Seropositivity remained high among people who received 3 doses despite some declines in antibody titers and lower seropositivity over time, especially for HPV-18, for the quadrivalent than the bivalent vaccine, and for HIV positive than negative individuals. Seropositivity for HPV-18 at 29–99 weeks among PLHIV was 0.72  and 0.96  after 3 doses of the quadrivalent and bivalent vaccine, respectively and 0.94  among HIV-negative historical controls. Evidence suggests that the seropositivity after vaccination declines over time but it can lasts at least 2–4 years. The vaccines were deemed safe among PLHIV with few serious adverse events. Evidence of HPV vaccine efficacy against acquisition of HPV infection and/or associated disease from the eight trials available was inconclusive due to the low quality.We identified 43 publications stemming from 18 independent studies . We identified five systematic reviews including two reviews with quantitative summaries of data. The studies summarized evidence from up to seven randomised controlled trials (RCTs). The reviews suggested the HPV vaccines were safe and immunogenic across different populations. Despite highlighting heterogeneity across studies, none of the reviews evaluated the influence of vaccine type, vaccine dose, timing of measurement, or baseline serostatus.There are four licensed HPV vaccines, which are effective in preventing cervical cancer caused by the most common high-risk HPV infections. Cervical cancer incidence in women living with HIV is 6 times higher than for women without HIV, but there remains uncertainty regarding the vaccine effectiveness among people with HIV. We searched PubMed, Medline and Embase for peer-reviewed articles without language restrictions. We used terms for HIV, HPV, HPV-associated disease, and HPV vaccines, and included studies published up to February 11We identified 43 publications stemming from 18 independent prospective longitudinal studies, including 20 new publications and 2 new longitudinal studies compared to previous systematic reviews. We demonstrate that people with HIV develop a robust initial immune response following HPV vaccination and that vaccines were regarded as safe for all three vaccine types evaluated. Among people living with HIV (PLHIV), who were seronegative for the vaccine type HPV infection prior to vaccination, seroconversion rates were high 28 weeks after receiving the first vaccine dose: more than 94% of PLHIV seroconverted for HPV-16/18 across three vaccines. Seropositivity remained high among people who received 3 doses despite some declines in antibody titers, with more pronounced decline among PLHIV as compared to people without HIV. We conducted subgroup and meta-regression analyses to assess heterogeneity by vaccine, participant, and study characteristics. Four trials reported immunogenicity results by HIV disease stage. There is modest evidence to suggest that antibody titers and seroconversion rates were lower among PLHIV who had lower CD4 cell counts or who had detectable HIV plasma viral loads.Our findings demonstrate important data gaps in the evidence-base for vaccine effectiveness against HPV infections and associated disease among PLHIV. The few studies identified offered low quality evidence with only 2 clinical trials including a placebo arm. Issues with measurement of the outcome, and baseline serostatus limit the inferences that can be drawn.PLHIV can develop a robust humoral immune response following HPV vaccination. The vaccine is safe and well tolerated, with few serious adverse events. Evidence of vaccine efficacy on biological outcomes following vaccination was generally of low quality. The evidence-base is lacking from well-designed studies that account for the underlying HPV infection status, timing of infection, and have a sample size and follow-up time that are appropriate for estimation of efficacy of HPV vaccine in PLHIV. The evidence of a robust immune response generated among all PLHIV who have received HPV vaccination supports cervical cancer elimination efforts to increase HPV vaccination coverage including in high HIV prevalence settings.Alt-text: Unlabelled box,The Human Papilloma Virus (HPV) is a common sexually transmitted infection. High-risk (HR) oncogenic HPV types cause cervical cancer and other anogenital cancers in women and men.,,HPV vaccination produces a long-term immune response lasting at least 8–14 years in the general population.,,,The burden of HPV-associated diseases is disproportionately concentrated in low- and middle-income countries, where approximately 80% of cervical cancer diagnoses and deaths occurred in 2020.Meta-analyses of longitudinal studies suggest that HIV amplifies HPV-associated disease burden in multiple ways.,,,,,The efficacy of HPV vaccination in individuals without HIV has been evaluated in large randomized controlled trials (RCTs) and summarized in systematic reviews.The WHO has adopted HPV vaccine and cervical cancer-screening based strategies to accelerate cervical cancer elimination. Given the elevated risk of anogenital cancers among PLHIV, the purpose of the study is to evaluate the efficacy of HPV vaccination in PLHIV to inform clinical and public health guidelines and identify where important data gaps remain. We conducted a systematic review and meta-analysis to provide summary estimates in three domains: immunogenicity, safety, and efficacy of HPV vaccination in PLHIV taking into account baseline HPV DNA and/or HPV serostatus, when possible. We also conducted subgroup analyses by age, sex, vaccine type and dose, and HIV disease status from available data.Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).This systematic review reporting follows the ,We searched for peer-reviewed articles in PubMed, Medline and Embase using terms for HIV, HPV, HPV-associated diseases and for any of the HPV vaccines published by February 11th, 2021 (full search terms in Supplement Table S1). We also searched clinicaltrials.gov and the WHO clinical trial database for online records of published or unpublished trial results on HPV vaccination in PLHIV.Peer-reviewed articles and online clinical trial records (henceforth referred to as ‘publications’) were eligible for inclusion if they reported prospectively collected longitudinal data from clinical trials with one or more arms on the safety, immunogenicity, or any relevant HPV related biological endpoints following prophylactic vaccination of PLHIV with any of the licensed HPV vaccines. Studies were included regardless of how many vaccine doses were given, but we excluded studies if they did not report results by dose (i.e. studies were excluded if the seropositivity results included a mix of people with different number of doses received). Mathematical modeling studies, qualitative studies or literature reviews, studies that did not report outcomes by HIV status, retrospective studies, and studies which did not report any immunogenicity results by HPV type were excluded. No language, date, or location restrictions were placed. We first screened publication titles and abstracts for inclusion. Full texts of selected publications were then retrieved to confirm eligibility. Finally, the references of publications were searched to identify any additional ones.For each included publication, we extracted available estimates or data to derive estimates. Where possible, study estimates were extracted by baseline HPV status, and were categorized as “unknown HPV status” otherwise. We included the following outcomes in the study: immunogenicity , HPV-related biological endpoints  and vaccine safety . We extracted data on endpoints specific to the HPV types included in the vaccines . We also extracted information on study and participant characteristics such as sex, age, use of antiretroviral therapy (ART), CD4 cell count, location, study design, follow-up time, and number of vaccine doses.The search and screening of the publications was done independently by two reviewers (LS and MEB or NS), using Covidence software.Results were presented as forest plots (seropositivity), line graphs (GMT) or tabulations (other outcomes) by timing of the measurement after administration of the first vaccine dose  and by baseline HPV seropositivity status, by vaccine type, and by relevant participant characteristics where possible.When multiple publications reported on the same outcome from one trial , we selected results, in order of priority, from the i) peer-reviewed article, ii) the publication providing the longest follow-up data, or iii) the publication with the largest sample size to use in pooled estimates. Most studies reported immunogenicity and GMT results based on the competitive Luminex immunoassay (cLIA), and cLIA results were favored in pooled estimates in studies reporting estimates from multiple assays. For publications that reported on HPV seronegative participants at baseline without reporting baseline GMT levels, we used the cLIA assay cut-off for HPV seropositivity as baseline value. We grouped results based on cLIA, LIA and ELISA assays together as they produced qualitatively comparable GMT results and presented results based on neutralization assays separately as they produced substantially higher GMT values.We pooled independent estimates of seropositivity results following vaccination using DerSimonian-Laird random effects models,The main analyses on seroconversion (seropositivity among those seronegative at baseline) and GMT titers focused on results from participants who were HPV seronegative for the vaccine-type at baseline and subsequently seroconverted since this represent the most reliable evidence on the immune response to vaccination. In addition, and for completion, we also analysed data for the participants who were HPV seropositive or had unknown serostatus for the vaccine type HPV at baseline for completion. We conducted subgroup analyses for the outcomes by age, sex, vaccine, and HIV disease indicators.We tailored the Newcastle-Ottawa-Scale to our specific research question to evaluate study quality and risk of bias  separately for the three main types of outcomes seropositivity and antibody titers (based on 12 criteria), biological endpoints (based on 15 criteria), allocating one point per criteria as detailed in Supplement Table S2A-B. The scale was applied independently by two researchers (LS & MMR) and differences were resolved by a third researcher (MCB).The study was partly funded by the World Health Organization. WHO contributed to study design, and interpretation of the results. The other funding sources had no role in this work. LS and MMR had full access to all the data used in the study and had final responsibility for the decision to submit for publication.pN=32 published articles and 11 online trial records) from 18 independent prospective longitudinal studies , with approximately 3900 participants.Of the 3843 peer-reviewed articles identified through our literature searches, 76 underwent full text review and 32 met our inclusion criteria . We idensN=8) or Europe (sN=5), evaluated the quadrivalent (sN=15) rather than the bivalent (sN=4) or nonavalent (sN=1) vaccines, and evaluated three doses (sN=18) rather than four doses (sN=3). No studies of Cecolin vaccine, nor studies evaluating one or two doses, in PLHIV were found. Controlled trials compared the quadrivalent (sN=4) or bivalent vaccines (sN=1) to a placebo, the bivalent to the quadrivalent vaccine (sN=2), three versus four doses (sN=2), or vaccination between HIV positive and HIV-negative individuals , males only (sN=4) or both sexes (sN=7), and children aged between 7 and 18 years old (sN=5), adults aged >18 years old (sN=9), or a mixed age population (sN=6)   B. Most t: Ns=12) C. All eiThe quality assessments for each outcome are presented in Supplement Tables S9-S10 based on the criteria in Table S2A-B. Most studies were conducted in relatively healthy PLHIV and/or PLHIV receiving ART; few studies included patients with low CD4 cells counts or untreated HIV limiting the representativeness of results for all PLHIV , 0.94 , 0.99 , and 0.98 , for HPV-16, HPV-18, HPV-6, and HPV-11, respectively. Similarly, high seroconversion levels for HPV-16 and HPV-18 were reported for the bivalent vaccine  and for the nonavalent vaccine , and for the five additional HR-HPV types included in the nonavalent vaccines (Supplement Table S3).Almost all HPV seronegative PLHIV seroconverted to vaccine specific types and remained seropositive 28 weeks after the first vaccine dose A-D. The sN=8, I2=72%) than the bivalent vaccine    B. Conseq I2=94%) B. No infIn subgroup analyses (combining HPV seronegative and seropositive at baseline), results were generally similar by sex, age, and region across HPV types and timing of measurements (Supplement Table S4A-D). The only statistically significant differences were that the proportion who were seropositive for HPV-18 after 3 doses was higher for participants receiving the bivalent vaccine than the quadrivalent vaccine at week 28 and weeks 29–99. Seropositivity results between adults and children were similar albeit potentially seropositivity after vaccination was a little lower in adults. However, the number of estimates pooled in the subgroup analyses pooled was low, which also reduces ability to detect differences between subgroups. It was not possible to conduct subgroup analysis by CD4 level, viral suppression or being on ART or not given the few estimates and/or the heterogeneity in exposure categories used.Antibody titers increased by week 28 and were higher for HPV-16 than HPV-18 and HPV-6/11 in those receiving the quadrivalent vaccine as shown in s=3, I2=68% vs 0.72, 95%CI: 0.60-0.82, Ns=5, I2=78%, p-value<0.001) and remained relatively small for HPV-16 .Differences in seropositivity between HIV negative and PLHIV after three doses were small albeit statistically significant for HPV-16, HPV-18  and HPV-6 (29-99 weeks) . The difference in the pooled proportion seropositive between HIV negative and PLHIV was largest at 29-99 weeks for HPV-18  and 0.3-0.8 for HPV-18 (sN=5).Antibody titers following vaccination declined for both HIV-negative participants and PLHIV but declined further among PLHIV participants over time . For example, the HIV-positive versus negative ratio of GMT levels at 28 weeks across studies ranged between 0.4-0.8 for HPV-16 .,,Only four studies reported seroconversion and/or GMT levels stratified by HIV disease stage , men (sN=3), or both (sN=3), and among study participants HPV negative at baseline (sN=7) or with unknown baseline HPV status (sN=3). . No results were available for children. No results by HIV disease stage or ART status were available. Estimates of biological outcomes were generally deemed of low quality following our study quality assessment. Main study limitations included failure to specify the HPV vaccine type present in abnormal cytology samples, define baseline HPV DNA status, not reporting timing of measurement, and/or poor comparability of what with the control group. Furthermore, it was unclear if the analyses accounted for the time lag required to mount an effective immune response against infection following vaccination, and follow-up tended to be short compared to the development of most outcomes. Thus, it was unclear whether results reflected incident infection acquired after having developed a full vaccine immune response, an infection acquired before developing an immune response, or persisting prevalent infections present at baseline. Given the study quality limitations highlighted above and the variety of anogenital endpoints reported  at different time points following vaccination and the mixed, or lack of, information on past and current exposure status to HPV of study participant at baseline, it was not possible to pool results, and individual study results were difficult to interpret.Results on various biological outcomes among PLHIV following vaccination were available from two RCTs with placebo arms,sN=14), serious AEs (SAEs) (sN=14), and AEs that were possibly, probably, or definitely related to the vaccine (sN=5) (Supplement Table S7). Most results were for the quadrivalent vaccine (sN=12) and from trials conducted in the Americas (sN=6). AEs are events such as diarrhoea, injection site reactions or coughing, that are not categorized as ‘serious’ whereas SAEs are commonly defined as events that are life-threatening, require/extend hospitalization, or result in death.Trials reported on the occurrence of AEs  of participants.sN=13) of PLHIV receiving either the bivalent, quadrivalent or nonavalent vaccine experienced SAEs (Supplement Table S7B). In addition, one placebo-controlled RCT of the quadrivalent vaccine reported 12% (33/288) of SAEs in the vaccine arm but similar frequency 16% (46/287) in the placebo arm.Most trials reported between 0-7%  to occur, and/or had sufficient sample size to assess an efficacy outcome. Most studies were conducted in the Americas or Europe, with only two trials conducted in Africa, where some of the highest prevalence of both HPV and HIV infections and most cervical cancer cases occur, highlighting important data gaps, which limit the interpretation of results for Sub-Saharan Africa.,Our systematic review and meta-analysis have several strengths. Our review included 43 publications on 18 independent trials updates and extends previous work by including 20 new publications and 2 new trials compared to a previous systematic review.,Our results have implications for public health policy. Current evidence does not support the need for HIV testing prior to vaccination since the vaccine appears safe and immunogenic across age, sex and risk populations. PLHIV could benefit from vaccination, since PLHIV can elicit a robust immune response following vaccination, PLHIV have a high HPV disease burden, and that 90% of cervical and anal cancers are estimated to be due to HPV-16/18/33/45/52/58.MCB and MMR conceptualised this review. MCB, MMR, and LS planned the analyses. LS, MEB and NS did the search and independently did the screening, extracted data and assessed study quality. LS, MEB and NS resolved any discrepancies in screening and data extraction with input from MCB and MMR. LS, MCB, and MMR designed the modified quality assessment, and LS and MMR independently conducted the quality assessment with input from MCB to resolve conflicts. LS performed statistical analyses and created figures with input from MCB and MMR. LS, MCB, and MMR interpreted the results and conceptualised the first draft of the review, written by LS, with further input from SD and PB. All authors  substantially contributed to the interpretation of the results, drafting of the discussion and editing of the different drafts. All authors  reviewed and approved the final version of the manuscript.Data extracted for this study are presented in the supplementary material. Further information on the data are available upon request to the shared first co-authors .Institut national de santé publique du Québec (INSPQ), the Institut d'excellence en santé et services sociaux (INESSS), the World Health Organization, and the Joint United Nations Programme on HIV/AIDS (UNAIDS), all outside of the submitted work. MB reports funding from Bill & Melinda Gates Foundation (grant number OPP48979), outside the submitted work.LS has received funding from Sanofi Pasteur/AstraZeneca outside of the submitted work. MMR reports funding from Charles A King Trust Postdoctoral Fellowship and Harvard Data Science Institute, and travel support to attend meetings for cervical cancer elimination from the WHO and Canadian Institute of Health Research, all outside of the submitted work. RVB received abstract and manuscript writing support from Regeneron Pharmaceuticals, outside the submitted work. MMG reports an investigator-sponsored research grant from Gilead Sciences Inc., and contractual arrangements from the