South African women of reproductive age have a high burden of sexually transmitted infections (STIs), including human papillomavirus (HPV) infection. However, there is limited information on the prevalence of sexually transmitted pathogens in women from rural Eastern Cape Province, South Africa. The study aims at determining the prevalence of sexually transmitted pathogens and co-infection with high-risk (HR) HPV among women from rural Eastern Cape Province, South Africa.Chlamydia trachomatis (serovars A-K & L1-L3), Haemophilus ducreyi, Herpes Simplex Virus (Types 1 & 2), Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis (TV), and pathobionts  using a multiplex PCR STD direct flow chip assay through a manual Hybrispot platform . HR-HPV detection was performed by Hybrid Capture-2 assay.A total of 205 cervical specimens were collected from women aged ≥ 30 years from a rural community-based clinic. The samples were tested for a panel of pathogenic STIs [TV having the highest prevalence . UP  and MH  were the most frequently detected pathobionts. Co-infection with ≥ 2 pathogens pathobionts was observed among 52.7% (108/205) participants. Of the six pathogenic STIs, three participants had more than one STI (1.46%) with the presence of MH and UP. HSV-2  and HIV infection  were independent STIs associated with HR-HPV infection.High-risk HPV prevalence was 32.2% (66/205) and HIV-1 prevalence was 38.5% (79/205). The overall prevalence of six pathogenic STIs was 22.9% (47/205), with The high prevalence of pathogenic STIs underscores the need to improve syndromic management policy by implementing effective strategies of prevention, screening tests, and management. HSV-2 and HIV positive remain strongly associated with HR-HPV infection. Trichomonas vaginalis (TV), Treponema pallidum (TP), Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG)] was 376.4 million in 2016  and CT   are a significant public health problem, with an estimated more than one million people infected each day. According to the World Health Organization, the global estimate of new infections with commonly treatable STIs [ in 2016 . Africa   . STIs ha  . South A  . The bur  . The acq  . In Sout  .CT, Herpes Simplex Virus-2 (HSV-2), and NG increase the risk of HIV acquisition  and Ureaplasma spp. (UP) are associated with an increased risk of HPV persistent infection and abnormal cervical cytology (Human papillomavirus (HPV) is the most common and infectious viral STI, with 291 million new infections estimated to have occurred in 2016, with a particularly high burden among women in Southern Africa . Most HPuisition . These Suisition . The assuisition . HPV-posuisition . Consequdiseases . Moreovecytology . TherefoTP , and the median number of lifetime sexual partners was three. A total of 61.5% (126/205) of the women reported not using a condom during their last sexual encounter. More than half of women  reported not using any method of contraception with their current partner. One hundred and ten (110) study participants (53.6%) reported having had vaginal discharge with 44.5% (49/110) reporting to have occurred more or equal to six months . 38.5%  using the MagNA Pure Compact Nucleic Acid Isolation kit  on an automated Roche MagNA Pure Compact system. DNA was eluted in 100 µl elution buffer and stored at −20 °C until further use.TP, HSV (Type 1 & 2), TV, CT (Biovar LGV: Serovars L1-L3 & Serovars A-K), NG, Haemophilus ducreyi as well as UP , MG and MH  following the manufacturer’s instructions. The panel detects the following pathogens: G and MH . The imaCervical specimens in Digene transport medium were tested for 13 HR-HPV types  using the Hybrid Capture-2 (HC-2) assay  according to the manufacturer’s protocol. A ratio of relative light units/cut-off ≥1 was considered positive, while a ratio of < 1 was considered negative for HR-HPV types.p-value < 0.05) of the univariate logistic regression models to identify the sexually transmitted pathogens that are independently associated with HR-HPV infection.Single infection was defined as being positive for one of any pathogenic STIs or pathobionts. Multiple infections was defined as having two or more microorganisms (pathogenic STIs/pathobionts). Statistical analysis was performed using STATA 15.0 . Univariate logistic regression models were conducted to determine the association between sexually transmitted pathogens and HR-HPV infection. Multivariate analysis was done using the statistically significant variables  followed by HSV-2 , CT  and NG   and MH  were the most frequently detected (UP (62.5%) and HR-HPV infection (17.2%) , UP/HPV (21.3%), and MH/UP/TV (10.2%) were the most commonly detected co-infections . In the multivariate analysis, HSV-2  and HIV infection  remained the significant risk factors of HR-HPV infection  and HIV-1 prevalence was 38.5% (79/205). The overall prevalence of the six STIs was 22.9% (47/205) with a highest number of women positive for , 3/205) . Of the detected . Overall (17.2%)  and 1C.  (17.2%) . A highefections  and 1D. nfection .TV and 60.0% (3/5) with CT (refer to supplementary data). All women positive for NG self-reported not having had vaginal discharge . Similarly, the pelvic examination done by the study nurse showed that 28 .1% (9/32) of women positive for TV had vaginal discharge but none of the women positive for NG had vaginal discharge. The association of STIs and behavioural factors are depicted in P = 0.042). In addition, women age ≥50 years  or reported having had vaginal discharge for more than or equal to six months  had a lower risk of HPV infections whereas three or more lifetime sexual partners , HIV positive  were significant risk factors of increased HR-HPV infection  were positive for treatable STIs, including 56.3% (18/32) with nfection . Howevernfection .TV (15.6%) in this population. The high burden of TV has been previously reported in South African women of a rural region, occurring in 66% of asymptomatic women  and confirms the high prevalence of ic women . It has nfection . Women wpartners . Also, t studies . TherefoCT (2.4%) and NG (1.5%) was low in this cohort and similar to that observed in community-based studies conducted among older women from rural and urban regions of sub-Saharan Africa  because of biological vulnerability (such as immature ectopic tissue on the cervix) and sexual behaviour which makes them prone to the growth of these pathogens  and MH (36.6%) was observed, occurring in multiple infections. UP and MH are emerging pathobionts found in women both with healthy and unhealthy vaginal microbiota  among women with BV compared to women with normal bacterial flora (49.4%) or aerobic vaginitis (28.4%) , which demonstrate a possible interaction between these pathogens  . MH is cthout BV . Women wthout BV . Additioathogens . The traon of BV . Verteraal tract . Howeveral tract .. Of the multiple infections, the co-infection of UP/HR-HPV occurred at a rate of 21.3% women, similar to that reported among sexually active women attending the outpatient clinic for routine cervical cancer screening  compared to women with normal cytology (21.3%) . Multiple infections are reported to have a negative impact on the treatment of STIs and regarded as a risk factor for cervical cancer . Of the creening . Moreovening (UP . Women w lesions . Similar (21.3%) . The intNG) and is considered as the significant co-factor for HPV in the development of cervical cancer  with HR-HPV infection has been previously observed in other studies . HSV-2 il cancer . Women pl cancer . These vl cancer . Similarl cancer . Moreovel cancer . The finNG and CT (. The screening will be beneficial not only for asymptomatic women but for those with symptoms in the general population or high-risk populations and facilitate receipt of appropriate treatment. Furthermore, considering the high prevalence of HR-HPV observed in this population, STI screening would be of assistance as it will help to reduce the burden of sexually transmitted pathogens that could potentially promote the development of persistence and cervical cancer lesions (With South Africa having a high burden of STIs, particularly among asymptomatic women, an effective strategy to diagnose and treat STIs is needed. The high prevalence of HPV observed in this population confirms the need for HPV vaccination. Syndromic management policy has been reported to have low specificity and sensitivity in identifying the most common STIs, such as G and CT . The synG and CT . The higG and CT . The scr lesions .We acknowledge that the study had some potential limitations including small sample size, thus the results of this study cannot be regarded as the representative sample for the whole population of rural Eastern Cape Province. Also, the study was designed for HPV screening and this may result to a potential sampling bias in the context of sexually transmitted infections. Furthermore, in this study we depended on self-reported questionnaire for some data such as vaginal discharge, frequency of vaginal discharge and sexual behaviour. Therefore, this information may also introduce bias during the collection of participant information and analysis.TV, UP, and MH was documented in this rural community. HSV-2 and HIV were co-factors strongly associated with HR-HPV infection. The high prevalence of these pathogens underscores the need to revise the syndromic management policy by implementing effective strategies of prevention, screening tests, and management for sexually transmitted pathogens. The study also highlights the need to encourage routine screening of STIs for all women screened for cervical cancer. The high prevalence of HPV emphasizes the ongoing need for HPV vaccination.A high prevalence of sexually transmitted pathogens, particularly 10.7717/peerj.10793/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.10793/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.10793/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.10793/supp-4Supplemental Information 4Click here for additional data file.


HPV is involved in the development of some head and neck squamous-cell carcinomas (HNSCC). It was suggested that only transcriptionally active virus can induce carcinogenesis, therefore, the aim of our study was to analyze the frequency of active HPV infection, virus type, and its prognostic role in HNSCC patients.Status of active HPV infection was assessed for 155 HNSCC patients based on p16 expression and HPV DNA presence. Univariate and multivariate analyses with Cox proportional regression model were performed to select independent prognostic factors.p = 0.000; DFS 93.0% vs. 53.35%, p = 0.000, respectively). Longer OS and DFS were maintained for infected patients when oropharyngeal and non-oropharyngeal cases were analyzed separately. Interestingly, all patients infected with other than HPV16 types survived 5 years without cancer progression. In the analyzed group of 155 patients the strongest independent favourable prognostic factor for both OS and DFS was HPV presence.Active HPV infection was detected in 20.65% of patients. We identified 16.0, 40.9 and 1.7% of HPV positive oral cavity, oropharyngeal, and laryngeal cancer cases, respectively. HPV16 was dominant (81.25%) followed by HPV35 (9.38%) and double infections with HPV16 and 35 (6.25%) or HPV35 and 18 (3.12%). Patients with active HPV infection demonstrated significantly higher survival than HPV negative ones  was detected, with HPV16 type the most frequent, followed by HPV35 and HPV18. The presence of active HPV infection improved survival of both oropharyngeal and non-oropharyngeal cancer patients and should be taken into account in treatment planning. Human papillomavirus (HPV) is a small, double-stranded DNA virus responsible for the most frequent sexually transmitted viral infection worldwide, which causes an infection of squamous epithelium in the human body. There are more than 100 types of HPV classified into low-risk or high-risk (oncogenic) group. Low-risk HPVs (mostly HPV6 and 11) can cause benign and transient lesions. On the other hand, high-risk HPV infection may stimulate malignant transformation and HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68 belong to this group  uncontrolled cell growth without checkpoint controls, that further leads to accumulation of mutations, cell transformation and finally causes cancer , virus type and its prognostic role in patients with HNSCC from South-Central Poland.A group of 155 HNSCC patients from South-Central Poland, treated between 1991 and 2014, was enrolled in this study. There were 25 oral cavity, 66 oropharyngeal, 6 hypopharyngeal and 58 laryngeal cancer cases. For all participants, levels of smoking (number of cigarettes per day x years of smoking) and alcohol drinking  as well as treatment outcome  were noted. Patients and tumours detailed characteristics were summarized in Table For each patient a set of available blocks with formalin-fixed paraffin-embedded (FFPE) cancer specimens obtained during surgery were collected. Histopathological reverification for each tissue was performed to confirm cancer diagnosis, assess grade and keratinization status as well as to select a block with at least 50% of tumour component for molecular analyses. The study was approved by Ethical Committee at the Regional Medical Chamber in Cracow, Poland (registration no. 109/KBL/OIL/2012).DNA was extracted from selected FFPE tissues using ReliaPrep FFPE gDNA Miniprep System  according to manufacturer suggestions. The only modification introduced was to extend digestion at 56 °C from 1 h to overnight to provide improved quantity and quality of DNA  were evaluated spectrophotometrically with Biophotometer Plus . Samples were stored at − 20 °C until used.To screen HNSCC samples for the presence of HPV DNA, PGMY09/PGMY11 . Negative (water) and positive  controls were added to each PCR run. For each tumour 3 independent analyses were performed and sample was classified as HPV DNA positive when at least one positive signal was observed.All samples classified as HPV DNA positive in nested PCR were genotyped by AmoyDx Human Papillomavirus (HPV) Genotyping Detection Kit . This assay identifies 19 high-risk HPV DNA  and 2 low-risk HPV DNA (6 and 11). The qPCR reaction was run in 8-tube strips with pre-loaded PCR Reaction Mixes. Each tube of the strip contained different Reaction Mix with primers and probes specific for L1 gene fragment of 2 or 3 different HPV types, hence 2 or 3 different viruses (depending on the Master Mix pre-loaded) could be detected simultaneously in one tube.The procedure was performed according to suggestions of manufacturer and AmoyDx support. Firstly, 2.7 ul of HPV21 Enzyme Mix (containing Taq polymerase) was added to 42.3 µL of DNA sample and 5 μL of this solution was transferred into each PCR tube of 8-tube strip . The reaction was carried out in a volume of 30 µl using ABI7500 System . Thermal cycling conditions were as followed: 1 cycle of 50 °C for 2 min and 95 °C for 5 min, than 10 cycles of 95 °C for 25 s, 60 °C for 20 s and 72 °C for 20 s, and finally 31 cycles of 95 °C for 25 s, 60 °C for 35 s and 72 °C for 20 s.21 positive control containing a recombinant gene with HPV plasmid DNA, and (3) no template control containing sterile water instead of DNA.Three different controls were included into each qPCR run: (1) an internal positive control designed to detect a housekeeping gene, (2) HPVHPV types were defined based on the analysis of FAM, CY5 and VIC fluorescent signals in each well. In the cases of doubtful results analyses were repeated.INK4a Histology Kit . Staining procedure was performed according to manufacturer instructions. In brief, 4 µm thick sections of FFPE HNSCC tissues were deparaffinized and hydrated through a series of xylenes and alcohols. After antigen unmasking  and exogenous peroxidases quenching (5 min), sections were incubated with primary anti-p16 antibody  followed by 30 min incubation with visualization system. P16 was visualized using DAB  and for nuclear counterstaining hematoxylin was applied. Cervical cancer tissue with p16 overexpression was used as a positive control. For negative control the primary antibody was omitted.P16 staining was performed using CINtec p16Stained sections were reviewed independently by 2 researchers. Staining intensity  and the percentage of stained tumour cells were assessed. P16 overexpression was positive if moderate or strong and diffuse, continuous (nuclear and/or cytoplasmic) staining present in > 75% of tumour cells was observed. All other staining patterns  were defined as p16 negative  and overexpressed p16 (according to immunohistochemistry). Such tissues demonstrated an active viral infection and were marked as HPV DNA + /p16 + . All other cases  were classified as HPV negative ones.χ2 test. To analyse prognostic potential 5-year overall survival  and 5-year disease free survival  were assessed. The probabilities of OS and DFS were calculated using Kaplan–Meier method and compared by log-rank test. Because of low number of distant metastasis (n = 16), metastasis-free survival was not assessed. Univariate and multivariate analyses with Cox proportional regression model were carried out to select independent prognostic factors. All parameters with statistically significant influence on survival in univariate analysis were included into multivariate analysis. In all statistical analyses p-value less than 0.05 was considered significant. Calculations were performed using Statistica v.11.To determine mean and median values of continuous variables descriptive statistics were used. Associations between categorical variables were analyzed using Pearson We performed statistical calculations in the whole group of 155 HNSCC patients as well as in the group of 151 patients, after excluding those infected with other than HPV16 types. All analyses were also performed separately in the subgroup of 66 oropharyngeal cancer patients.Detailed data of 155 patients enrolled in this study were summarized in Table n = 32) of patients  in six more tissues (3.87%), but p16 was not overexpressed in them so the infection was rather transient and cancer was not related to the virus . On the other hand, 7 cases (4.52%) of HPV DNA-/p16 + were identified. All other patients (70.97%) were negative for both HPV DNA and p16 overexpression.For all 155 tumours, we found statistical significant differences between HPV positive and negative tumours for most of analyzed clinical and histopathological features (Table p = 0.000). Within oropharyngeal cancer patients the probabilities of 5-year OS were 77.25 and 35.75% for HPV positive and HPV negative ones (p = 0.005), respectively, and for non-oropharyngeal cancer patients 100 and 37.71% (p = 0.007), respectively. Similarly, 5-year DFS were statistically significantly different in presented subgroups . Within patients with tumours of oropharynx DFS was 91.48% and 50.47% (p = 0.002) and with non-oropharyngeal tumours was 100 and 54.25% (p = 0.039) for HPV positive and HPV negative individuals, respectively.In the whole analyzed group of 155 patients 5-year OS and 5-year DFS were 45.61 and 61.73%, respectively. Both parameters were significantly higher in patients with active HPV infection and this was maintained also when we checked OS and DFS within oropharyngeal and non-oropharyngeal cancer patients separately. Five-year OS for patients infected with HPV was 80.89% and without infection 37.08%  infected with other than HPV16 type survived 5 years without any cancer symptoms, while HPV16 infected patients DFS was 92.05%. Five-year OS, in turn, was 75.00% for patients with non-HPV16 types and 81.68% for HPV16 positive ones.Additionally, univariate analysis performed in the whole group of patients revealed Table  that perAll variables, which influenced significantly on OS and DFS in univariate analysis, were included into multivariate analysis. It revealed that in the whole group of patients independent favourable prognostic factors for OS were female gender, lower N stage and active HPV16 infection  to 57%  have better prognosis. We found statistically significant differences in 5-year OS and DFS when we were comparing HPV positive and negative cases in the whole group of HNSCC patients as well as within oropharyngeal and non-oropharyngeal cancer patients separately. Similar results were obtained by Fakhry et al.  who calcTP53, CDKN2A, PTEN, PIK3CA, FBXW7, HRAS and NOTCH1 genes, what influenced the functioning of key cellular signalling pathways including EGFR/PI3K/AKT/mTOR. All mentioned hypotheses are likely to be possible, hence further investigations are highly needed.There is also a global discussion about good prognosis of patients with head and neck tumours related to HPV. However, the mechanism of better survival of those patients remains unclear. In the literature authors consider 4 possible reasons explaining this phenomenon: (1) an increase in radio- and/or chemosensitivity  in the group of not infected patients comparing to those with active HPV. Many researchers get similar results. Fakhry et al. (P = 0.04) even after the tumour HPV status has been taken into account. In contrast, for non-oropharyngeal SCC, HPV positivity and sex were not associated with OS. We noted the risk of death for men 3.2 times higher than for women (p = 0.012) in the group of 155 patients and 4.9 times (p = 0.031) among oropharyngeal cancer patients only. D’Souza (2016), in turn, noted that the risk of mortality was 75% lower for HPV-related oropharyngeal SCC compared to HPV-unrelated . In contrast, among non-oropharyngeal SCC patients active HPV infection was not a significant predictor of survival. Additionally, contrary to us, they found that alcohol use was significant independent predictor of non-oropharyngeal SCC survival.In the present study multivariate analysis performed in the whole group of patients revealed that female gender, lower N stage and active HPV16 infection were favourable independent prognostic factors for OS, and lower T stage and HPV infection for DFS. In the analyzed group of HNSCC patients  the presence of HPV was the strongest favourable independent prognostic factor (and the only one to be repeated) for both OS and DFS. The risk of death and cancer progression 5 years after treatment were over 4 and over 7.6 times higher  female gender, lower N stage and active HPV16 infection were favourable independent prognostic factors for OS and lower T stage and HPV infection for DFS. In the whole group of patients the presence of active HPV infection was the strongest favourable independent prognostic factor for both OS and DFS. The risk of death and cancer progression 5 years after treatment were much higher in the group of HPV negative patients comparing to infected ones . Hence, it seems reasonable that presence of active HPV infection should be taken into account during treatment planning.


Background and objectives: Knowledge of the interactions and influences of infectious, genetic, and environmental factors on the evolution and treatment response of malignant tumors is essential for improving the management of the disease and increasing patient survival. The objective of this study was to establish the contribution of human papillomavirus (HPV), as well as p53 and p16 tumor markers, alongside associated factors , in the progression of malignancies located in the oropharynx and at the retromolar trigone–oropharyngeal junction. Materials and Methods: We performed a prospective study including 50 patients with malignant tumors of the oropharynx and retromolar trigone–oropharyngeal junction. In all patients, the presence and type of HPV were determined, as well as the status of the tumor markers p53 and p16. The associated risk factors, biopsy results, treatment method, and post-treatment evolution were all documented. Statistical analyses were performed to evaluate the correlations between the determining factors and their influence on the post-treatment evolution. An overall increased survival rate was found in HPV(+) patients. Results: Our study outlined the prevalence of different high-risk subtypes of HPV from the ones presented by other studies, suggesting a possible geographic variation. Correlations between the p53 and p16 statuses and patient survival could be established. The association of smoking and alcohol consumption strongly correlated with an unfavorable evolution. Conclusions: Awareness of the differences in the post-treatment evolution of the patients in relation to the presence of the factors determined in our study could change the future management of such cases for ensuring improved treatment outcomes. E6/E7 oncogenes is the current standard criterion for determining the causal role of HPV oncogenes in human tumors. The E6 and E7 genes produce oncoproteins that are responsible for p53 degradation, leading to cell-cycle disruption and subsequent cell destruction [The field literature presents molecular evidence that indicates a correlation between high-risk human papillomavirus (HPV) and the pathogenesis of cancer located in the oropharynx and in the retromolar trigone–oropharyngeal junction region. The expression of HPV with truction ,2.The modification of p16 by a methylation promoter is frequently observed in squamous cell carcinomas (SCCs) of the head and neck. HPV is readily detectable in HPV(+) tumors and correlates with p16 expression, which is most likely the result of infection with a transcriptionally active HPV ,4.The relationship between HPV, p53, and p16 expression in oropharyngeal cancer is known and presented with variable clinical–pathological aspects. Detection using p16 immunohistochemistry can serve, alongside PCR, in the molecular detection of HPV DNA [Oropharyngeal cancer is considered to be a type of mucosal cancer that is associated with HPV infection. HPV is present in 20% of all head and neck cancers and in nearly 60% of tonsillar cancer cases ,6,7,8.The expression of p16 protein is a surrogate marker of HPV infection in oropharyngeal cancers. p53 activity mediates cell proliferation in response to mitogenic stimulation; mediates cell-cycle arrest at the level of the G1 phase after DNA damage, thus allowing for repair of the affected DNA before the cell enters the DNA synthesis phase; mediates the induction of apoptosis in cells whose DNA damage is too severe to be repaired. Thus, the inactivation, degradation, or mutation of the p53 gene may disrupt its functions, resulting in cell proliferation, accumulation of damaged DNA, the increased presence of cells carrying DNA errors, and the prolonged survival of the affected cells.This study aimed to determine the involvement of HPV and p53 and p16 tumor markers, which are associated with factors like alcohol and smoking, in the evolution of malignant oropharyngeal tumors and tumors of the retromolar trigone–oropharyngeal junction.The presence of these factors influenced the therapeutic behavior of the cases included in the study.A prospective study was conducted for a period of 3 years (2013–2015) on a batch of 50 patients admitted in the Ear–Nose–Throat (ENT) and Oral and Maxillofacial (OMF) surgery clinics of the Sf. Spiridon County Clinical Emergency Hospital, Iași, Romania, that were diagnosed with malignant tumors located at the oropharyngeal level and at the retromolar trigone–oropharyngeal junction. The main factors involved in the post-treatment evolution were analyzed.The patients were monitored after treatment until 1 August 2019. The HPV, p53, and p16 tumor markers were dosed in all patients. These aspects were analyzed in the context of the presence of tumor-favoring factors like smoking and alcohol consumption. The anatomopathological features of the biopsy specimens were studied. These were needed to specify the therapeutic conduct, as well as the prognosis and evolution of the cases. Radiological exams—Computed Tomography (CT) scan—were performed in all patients for both diagnostic and post-therapy follow-up, and all cases were discussed by the oncology committee in order to specify the therapeutic approach.This localization has been shown to be increasing in frequency. The extension of the lesion was confirmed by performing imaging studies and via anatomo-pathology. The involvement of HPV, as well as markers p16 and p53, was investigated using immunological and immunohistochemistry (IHC) studies, all of which influenced the treatment, prognosis, and rate of patient survival.The study was performed after obtaining informed consent from each patient and the approval of the ethics committee of the Emergency Clinical Hospital Sf Spiridon Iasi, Romania, and of the Grigore T. Popa University of Medicine and Pharmacy of Iasi, Romania .The inclusion criteria were age ≥ 18 years and the presence of a malignant tumor located in the oropharynx and at the level of the retromolar trigone–oropharyngeal junction. The exclusion criteria were uncooperative patients, the presence of malignant tumors at other locations, history of oropharyngeal surgery, personal history of primary or secondary motor dysfunction , or the presence of clinical signs like unexplained weight loss, hematemesis, hemoptysis, and other general conditions.The biopsy and surgical excision samples were histopathologically processed to establish the diagnosis.All specimens were fixed for 18–24 h in 10% neutral buffered formalin at room temperature and then paraffin-embedded. Histological analyses on hematoxylin and eosin (H&E)-stained slides were performed in order to confirm that all blocks contained cancer tissues. Both histopathological and immunohistohistochemical reactions were performed on paraffin-embedded blocks (FFPE). Thirty-one sections of about 4 µm in thickness were obtained from each tissue block according to the HPV-AHEAD protocol. The next steps for processing the sample were deparaffinization, hydration, microwave antigen retrieval treatment, neutralization of endogenous peroxidase, incubation with the primary antibody, and visualization of the antigen–antibody interaction by using the Novolink Polymer Detection System . As the primary antibody, we used a p53 mouse monoclonal antibody  and a p16 mouse monoclonal antibody . When more than 10% of cells were positive for p53 or p16, the tumor was considered to be positive .® kit . Genomic DNA was isolated from each cytological specimen and amplified via a multiplex PCR technique by using a Seeplex® HPV4A ACE Screening kit .The presence of HPV infection was tested by using the HPV-screening kit from AID-Diagnostika . HPV viral genotyping was performed by using the OpegenDNA was extracted via an overnight incubation of the paraffin tissue sections in a digestion buffer 10 mM). To minimize the risk of cross-contamination during sectioning, a new blade was used for each FFPE block and the microtome was extensively cleaned after each block with 70% ethanol and DNA Away . In addition, to monitor possible cross-contamination during the sectioning, empty paraffin blocks were processed every 10th cancer specimen. The HPV DNA positivity was determined by using a type-specific multiplex genotyping (TS-MPG) assay, which combines multiplex PCR and bead-based Luminex technology  [ mM. To mp-value) was considered significant for p < 0.05, where this value represented the maximum accepted probability of error.The statistical data analysis was performed using the SPSS v.25 software . Quantitative variables were reported as an average with its standard deviation. The qualitative variables were presented as absolute and relative frequencies, and the comparisons between groups were made based on the results of the chi-square Pearson or Yates tests. The multivariate analysis of the prediction factors was performed using a logistic regression model. Survival analysis was performed based on the Kaplan–Meier survival curves, which were compared using Cox’s F-test and a log-rank test. The Kaplan–Meier analysis estimates the likelihood of an event (death) of a group over a period. For each time interval, the probability of occurrence of the event was calculated and risk moments were calculated. The significance level calculated in the tests used  were diagnosed with malignant tumors located at the oropharyngeal junction and at the retromolar trigone–oropharyngeal junction during this period. Of these, only those patients who gave their informed consent and met the conditions for inclusion and exclusion were included in the study (50 cases).The characteristics of the study group showed a high frequency of male patients (92%), an average age of 47.3 ± 8.6 years, and a frequency of 48% of patients with high school education and 24% with higher education. Alcohol use (48%) and smoking (52%) were important features associated with the studied cases of oropharynx and retromolar trigone–oropharyngeal junction tumors. The coupling of the two aspects  was an important factor in the development of these tumors, as evidenced by the high percentage of cases (22%) among the included patients .p = 0.03) compared to that of the p53(+) identified in 70% of the cases. The frequency of HPV(+) cases  was found in 32% of cases  in 86% of cases, which was a significantly higher frequency . HPV51 was found in 12% of cases; HPV16, 31, and 33 in 4% of cases; HPV18 in 2% of cases. Four cases had associations of two strains: HPV16/51, HPV16/66, HPV51/66, and HPV18/31. A total of 32% of the cases were HPV(+) (16 cases), with 3 cases (6%) having 2 detected HPV strains . All HPV(+) cases were associated with p16 or p16 + p53 tumor markers. The results indicated that out of the HPV(+) cases, 6% (3 cases) were associated with the presence of tumor marker p16 and 26% (13 cases) were associated with the presence of both tumor markers (p53 and p16).The most common HPV strain was HPV66 in 14% of the cases , which was explained by the favorable evolution of the cases with HPV(+) with a proportion of 81.3% and 0% deaths   (The association of a p53 presence with a favorable case evolution was demonstrated on the one hand by the increased frequency of those with a favorable evolution (65.7%) and on the other hand by the significant association (χ = 0.01) . The ass = 0.02) .Cases with HPV(+) had a better prognosis, regardless of the treatment performed, compared to cases with an HPV(−) status, in which relapses and deaths were the most frequent in the case of radiotherapy .An important aspect was the fact that the strains found in our study  differed from those usually related to the development of SCCs , as found by other studies, thus confirming the geographical specificity.2 = 15.74, p = 0.015)  .p = 0.01) (p = 0.01) (p = 0.03) was noted  . Similar = 0.01) . At the as noted .The study showed that a favorable evolution was significantly associated with p53(+) patients and with the therapeutic approach involving surgery combined with radiotherapy and chemotherapy or surgery combined with radiotherapy . This wa2 = 14.07, p = 0.02). Furthermore, for the cases with a favorable evolution, the significant association between the presence of p16 and the therapeutic approach involving surgery combined with radiotherapy and chemotherapy was noted. Recurrence was identified in all cases that utilized surgery combined with radiotherapy and chemotherapy in which p16 was not present.In the absence of the p16 marker, a significantly higher rate of deaths (60%) was observed in the patients who underwent radiotherapy. In the case of p16(+), a lower death rate was observed for patients who underwent only radiotherapy (21.8%) . These rp < 0.05) factors regarding the favorable evolution of the cases, significantly increasing the chance of a favorable evolution , the presence of p16 , and the presence of HPV(+)  could be considered important prognostic  status (30%), while patients who did not consume alcohol had an HPV(−) status (38%). A significant proportion of cases that did not consume alcohol and tobacco had the following statuses: HPV(−) (54%), p53(+) (60%), or p16(+) (70%).In the literature, it is mentioned that the majority of smokers, alcohol consumers, and consumers of both tobacco and alcohol had p53(+) and p16(+) statuses . In our p = 0.02) for an unfavorable evolution compared with the risk presented by alcohol consumption  or the association of the two favoring factors   .The prospective study was conducted between 2013 and 2015, with the follow-up of patients who presented at the proposed dates monitored until August 2019 (43 months).p < 0.01). The survival rate in the HPV(+) patients reached 80.21% by the end of the study period, which was a significantly higher value compared with the HPV(−) patients, in which the survival rate was 28.12%    patients, reaching a significant difference between the survival rates at the end of the studied interval (log-rank test: χ = 0.03) . In the  < 0.01) .In our study, it was observed that the patients with an HPV(+) status had higher survival rates than the patients with an HPV(−) status. The figure shows that patients with a p53(+) status had a higher survival rate than patients with a p53(−). In patients with a p16(−) status, the survival rate was lower than in patients with a p16(+) status, which corresponds to the existing data from the field literature ,14.Most cases with an HPV(−) status had a p16(+) or/and p53(+) status and those with a p53(+) status were also p16(+).Intraoral access to voluminous tumors of the oral cavity and to most oropharyngeal tumors is often difficult and inadequate.The sectioning of the mandible offers a good exposure of the entire oral cavity and of the oropharynx. Therefore, it allows for a satisfactory monobloc resection of the primary tumor associated with an appropriate neck dissection.A paramedian mandibulotomy offers all the advantages of a middle mandibulotomy. Furthermore, it does not disturb the genioglossus, geniohyoid, or digastric muscles, cutting only through the mylohyoid muscle. Thus, the paramedian mandibulotomy would be ideal for access to the oral and oropharyngeal cavity.Establishing the direct link between HPV infection, in association with other external factors , and oropharyngeal malignancies are important in establishing the most appropriate therapeutic plan for the patient. Determining the exact type of HPV that colonizes the oropharynx in our geographic region could lead to the development of a vaccine similar to that for cervical cancer.The determination of p53 and p16 tumor markers can improve the prognosis of the patients by selecting the best treatment approach.HPV(+) patients had a longer survival time than HPV(−) patients.Patients with a p53(+) status had a longer survival time than p53(−) patients.Patients with a p16(+) status had a longer survival time than p16(−) patients.An early diagnosis, along with implementing prophylactic measures  can improve the survival rate and quality of life for these patients and also reduce treatment costs . Our resThe involvement of human papillomavirus (HPV), as well as p53 and p16 biomarkers, have been shown to be involved in the genesis of cancers located in the oropharynx, as well as the junction of the retromolar trigone with the oropharynx, a particular area due to the fact that it is at the border of two territories, namely, ENT and OMF surgery.We aimed to determine the exact HPV subtype for the cases in which the virus was detected.Standard investigations were performed, including histopathological analysis of the biopsies, CT, MRI, and ultrasound examinations, in order to specify the topographic limits of the lesions, taking into account the anatomical particularities of the region and the proximity of important vascular and nervous landmarks, while aiming for the precise evaluation of the local extension.The number of patients with tumors arising in the studied anatomical region was too low to have a major statistical significance but it was similar to the numbers reported by other specialized studies. Of the 50 patients tested so far, 16 had a high-risk HPV infection, with this parameter being very important in the evaluation of the therapeutic approach and the prognosis.Due to the rarity of the condition located at the level of the retromolar trigone–oropharyngeal junction, the number of patients was low, which prevented us from performing a complex statistical analysis. However, the post-therapeutic results were superior for the cases detected with high-risk HPV.The presence of the subtypes 16 and 18, described as the most frequent by the field literature, was not detected in our study, which suggested a geographical distribution of the HPV subtypes, hence the need to obtain personalized vaccines for each geographical region. In patients with high-risk HPV, the prognosis after surgery was better than in HPV(−) cases or with other phenotypes.The post-therapeutic results were better in the cases in which a high-risk HPV infection was determined. Smoking and chronic alcohol consumption are traditionally accepted risk factors for SCCs of the head and neck, to which HPV infection has been added as a high-risk factor that is associated with certain subsets of head and neck neoplasms.Patients with HPV(+) neoplasms tend to be younger than those with HPV(−), probably due to differences in sexual behavior ,16,17.The most common HPV subtype detected according to the literature is HPV16, representing approximately 90% of all HPV(+) types involved in head and neck SCCs ,19.The involvement of HPV in oropharyngeal neoplasms has shown a favorable treatment response and a good prognosis with the expression of p16, which may be considered a marker for the identification of HPV(+) neoplasms in the head and neck region ,19.High-molecular-expression p53 mutations are involved in neoplasms found in chronic smokers .The association between HPV status and a vital prognosis was proven, with HPV(+) patients demonstrating a higher survival rate than HPV(−) patients ,19,21.The tests used to detect HPV were in situ hybridization; immunohistochemistry with HPV, p53, and p16 as markers; PCR. HPV is responsible for a variety of skin and mucosal diseases. Clinical manifestations may vary depending on the anatomical location of the lesion and the type of HPV involved. HPV strains are generally divided into two categories: those with a potential low oncogenic risk (low-risk group) and those with a potential medium–high oncogenic risk (high-risk group). High-risk HPV strains are generally associated with precancerous lesions and invasive cancer, while low-risk HPV strains are commonly found in asymptomatic or benign conditions ,16,22.High-risk HPV (HR-HPV) comprises types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73, and 82.Low-risk HPV (LR-HPV) comprises types 6, 11, 40, 42, 43, 44, 54, 61, 70, 72, 81, and 89.HPV with an intermediate risk comprises types 26, 53, and 66.HPV with indefinite risk comprises types 34, 55, 57, and 83.The presence of the subtypes 16 and 18, with the highest frequency in the field literature, was not detected in our study, where the most frequent ones were instead the 31, 33, 55, and 66 subtypes, which highlighted a geographical distribution of HPV subtypes ,23.Several studies have shown that patients with HPV(+) oropharyngeal cancer, as identified using PCR, in situ hybridization, or immunohistochemistry for p16 in tumor tissue, have significantly improved overall survival compared with patients with HPV(−) oropharyngeal cancer ,23,24.HPV(+) tumors may have fewer genetic changes that may be associated with a better response to therapy. HPV(+) tumors have higher radiosensitivity, probably due to the intact apoptotic response to radiation .The immunological response may play a role in improving the response to radiation and chemotherapy in HPV(+) tumors  .The younger age, better overall condition, and fewer comorbidities of HPV(+) patients with oropharyngeal cancer may contribute to an improved survival rate .All these data suggest that HPV status can be used in decision-making to select patients for a less aggressive treatment than surgical treatment. p16 immunohistochemistry (IHC) is a current marker used to detect the presence of HPV.The biology of HPV(+) oropharyngeal cancer is characterized by p53 degradation, inactivation of the RB pathway by retinoblastoma, and the up-regulation of p16. In contrast, tobacco-associated oropharyngeal cancer is characterized by the mutation of p53 and down-regulation of p16. HPV(+) oropharyngeal cancer appears to be more receptive to chemotherapy and radiation than HPV(−) .Given the HPV(+) and HPV(−) oropharyngeal cancers and their molecular changes in p16 and p53 gene expression, we can conclude that patients with HPV(+) cancer with a higher expression of p16 and a lower expression of p53 respond better to treatment and have a better prognosis. The T stage in the TNM  classification differs depending on the HPV status. HPV(+) tumors are more likely to have a lower T stage than HPV(−) tumors, with an advanced T stage being a significant risk factor for relapse and death. Patients with a p16(+) status in oropharyngeal tumors are less likely to have persistent lymph node metastases in the cervical lymph nodes after chemotherapy and it is thus hypothesized that neck dissection may be avoided ,28. SeveHPV(+) tumors represent a new well-defined entity, which may develop even at an early age in individuals with a good performance status, especially males, that can be non-smokers and non-alcoholics and could have different sexual behaviors ,29,31.Oncologists need to be aware of these new findings and HPV PCR testing should be performed routinely since the results have a significant impact on the prognosis, which influences the therapeutic approach. However, changes occur fast in this field and we expect the HPV evaluation will be readily available for these patients in the near future.E6 and E7. These signal the entry of the infected cell into the cell cycle and activation of DNA polymerase for the replication of both viral DNA and host DNA. During the process of differentiation of the basal cell and its ascension from the germinal layer into the distal layers, there is a decrease in the importance of the expression of E6 and E7 genes and the activation of a secondary promoter that leads to the transcription of primary genes . These primary genes initiate amplification of the viral genome in over 1000 copies per cell.The HPV genome has roughly 8000 bp (base pairs) and encodes 8 genes whose expression is closely related to the differentiation process, thus making it possible to complete the life cycle of the human papillomavirus in any multi-layered epithelial tissue. The main target cells of the HPV infection are the basal cells of epithelial tissues. After the infection of the cells from the basal layer, the viral genome is maintained in the form of 50–100 extrachromosomal circular elements (nuclear episomes) per infected cell. The first expressed viral genes are Thus, when the cell reaches the final stage of differentiation, the viral capsid proteins (L1 and L2) are expressed and assembly of the resulting virions takes place. These virions are released with the death of the host cell ,32,33.E6 and E7). These “oncogenes” degrade and destabilize p53 and retinoblastoma 1 (pRB), which are two important oncosuppressor proteins. E6 protein leads to the formation of a complex between p53 and E3 ubiquitin ligase. Thus, ubiquitination of the p53 protein and its degradation by the cellular proteasome takes place.The carcinogenic activity of high-risk human papillomavirus types is largely due to the expression of the two initial viral genes  lead to the expression of the transcriptional factors in the E2F family involved in activating genes involved in the S-phase transition of the cell cycle, allowing for uncontrolled proliferation of the infected cells.Decreased p53 cell concentration results in both loss of control of the G1/S and G2/M transition of the cell cycle and increased cellular stress, with serious repercussions on the stability of the infected cell genome. Binding of the E6 and E7 not only interfere with p53 and pRb activity but also with other proteins involved in the cell cycle control or signaling cascades required for programmed cell proliferation, differentiation, and death.The proteins encoded by the viral genes E6 and PDZ proteins involved in maintaining intracellular connections and apical–basal polarization. Thus, the transformation of infected epithelial cells into mesenchymal cells takes place, which is an extraordinarily important process for inducing the metastasis capacity of tumor-transformed cells.Of major importance in the HPV-induced tumor transformation process is the interaction between protein HPV(+) cancers are associated with very good survival, despite advanced tumor stages. In the case of squamous cell oropharyngeal tumors, determining the HPV status at the beginning of the study using the immunohistochemical expression of p16INK4a together with the detection of the HPV DNA using PCR can be used as prognostic indicators. Further studies are needed to determine the risk factors for HPV-induced tumors ,24,34.TP53 gene has the role of promoting the secretion of the p53 protein, which is a tumor suppressor that controls and regulates the cell cycle, thus preventing premature cell division or abnormal division. The p53 protein located in the nucleus directly binds to DNA. In the case where the DNA is damaged due to various causes , the p53 protein determines whether the DNA can be repaired or whether the cell will commit suicide through the phenomenon of apoptosis, thus preventing the appearance of tumors. If the DNA can be repaired, p53 will train other genes to participate in the repair process; if it cannot be repaired, it gives a signal that will induce apoptosis of the damaged DNA cell [The DNA cell .TP53 gene is located on the short arm of chromosome 17 at position 13.1. Somatic mutations of the TP53 gene were found in approximately 50% of head and neck SCCs. Most genetic mutations of the TP53 gene involved in head and neck carcinomas consist only in changing an amino acid, which leads to protein dysfunction and therefore its inability to exert control over cell division; in this case, damaged DNA accumulates in the cell that continues to divide chaotically, leading to the appearance of the tumor [The he tumor .In conclusion, a new TNM staging for HPV(+) tumors that includes a specific HPV gene and antiviral therapy is desired.A limitation of the study was the small number of included patients since the location of the malignant condition in the retromolar trigone–oropharyngeal junction is quite rarely encountered, thus preventing a complex statistical analysis. At the same time, the anatomical position of the retromolar trigon area made the therapeutical approach challenging due to it being on the border between oral and maxilo-facial surgery and otorhinolaryngology.The most positive prognostic factors were the positivity of p53, p16, and HPV, while the most common negative factor was the combined consumption of alcohol and tobacco.It was not surprising that there was an important association between HPV(+) and neoplasms. Our study indicated a particular situation that is different from the one presented in the field literature, which can be explained by the specificity of the geographical and territorial area, which had an important impact on the current statistics. The utility of these results will be found in subsequent studies that will evaluate the usefulness of making a vaccine corresponding to the genotype that is specific to the geographical area, as well as establishing a specific therapy for neoplasms with this location.These tumors have a continuous rise in frequency in non-smokers and non-chronic alcohol consumers. The mean age for diagnosis is lowering due to changes in sexual behavior.An adaptation of the TNM staging is desired considering that the HPV(+) or HPV(−) statuses of a patient’s tumor permit a better development of therapeutical protocols into the oncological boards.


Gay, bisexual, and other men who have sex with men experience several disparities related to human papillomavirus (HPV) infection, including high incidence rates of anal cancer. Although the HPV vaccine is currently recommended for young adults, HPV vaccine coverage is modest among young gay, bisexual, and other men who have sex with men (YGBMSM).Outsmart HPV, a population-targeted, individually tailored, Web-based HPV vaccination intervention for YGBMSM. The RCT is designed to determine the efficacy of the intervention, the mechanism by which the intervention has an effect , and whether efficacy varies by participant characteristics .We describe the design and methods for a randomized controlled trial (RCT) to rigorously evaluate Outsmart HPV was previously developed and pilot-tested. This study is a 3-arm prospective RCT that will enroll a projected 1995 YGBMSM who are aged 18 to 25 years, live in the United States, and have not received any doses of the HPV vaccine. Participants will be recruited by means of paid advertisements on social media sites and randomized to receive (1) standard information on the Web about HPV vaccine (control group), (2) Outsmart HPV content on the Web with monthly unidirectional vaccination reminders sent via text messages, or (3) Outsmart HPV content on the Web with monthly interactive vaccination reminders sent via text messages. Participants will complete Web-based surveys at 4 time points during the study: baseline, immediately after engaging with Web-based content, 3 months after randomization, and 9 months after randomization. Primary outcomes will include both HPV vaccine initiation  and completion . We will examine constructs from the intervention’s theoretical framework as potential mediators and demographic and health-related characteristics as potential moderators of intervention effects.The institutional review board at The Ohio State University has approved the study. Materials have been developed and finalized for all study groups. Recruitment for the RCT began in fall 2019.Outsmart HPV has the potential to fill an important gap by promoting HPV vaccination among a population at increased risk of HPV infection and HPV-related disease.If shown to be efficacious, ClinicalTrials.gov NCT04032106; http://clinicaltrials.gov/show/NCT04032106PRR1-10.2196/16294 About 45% of men in the United States have a current genital infection with at least one type of human papillomavirus (HPV) . InfectiAlthough the Advisory Committee on Immunization Practices (ACIP) began recommending routine HPV vaccination for females in the United States in 2006 , routineDespite recommendations, HPV vaccine coverage is modest among young gay, bisexual, and other men who have sex with men (YGBMSM) in the United States. Studies have shown that about half or fewer YGBMSM have received any HPV vaccine doses, and fewer than 20% have received all recommended doses -22. AlthOutsmart HPV [Outsmart HPV intervention group). The results of the pilot test showed that HPV vaccine initiation was higher among participants in the intervention group  than those in the control group  [P=.07) [Outsmart HPV [We recently developed and pilot-tested a Web-based HPV vaccination intervention for YGBMSM called mart HPV . During mart HPV . We rand; P=.02) . We also [P=.07) , and the [P=.07) . Particimart HPV .Outsmart HPV. It is important to also identify the mechanism by which the intervention has an effect  and determine how efficacy may vary by participant characteristics . This study describes the protocol for a study that will accomplish this by comprehensively evaluating Outsmart HPV.The next step in this line of research is to implement a well-powered randomized controlled trial (RCT) to determine the efficacy of Outsmart HPV with monthly unidirectional vaccination reminders (Out-U group), or (3) Outsmart HPV with monthly interactive vaccination reminders (Out-I group). Each group is described in detail in the following sections. We will follow up with the participants for 9 months and use an intent-to-treat approach to determine the effects of Outsmart HPV on HPV vaccination.This study is a 3-arm prospective RCT that will enroll a projected 1995 YGBMSM . ParticiWe will recruit YGBMSM through paid advertisements on social media sites. Social media sites will include Facebook and Instagram, with the potential for expanding to other sites if needed. About 90% of adults aged 18 to 29 years in the United States use social media, with Facebook and Instagram being 2 of the most popular platforms for these ages ,34. For Outsmart HPV. We specify the age of 25 years instead of 26 years as the upper age limit so that participants do not age out of the recommended age range for routine vaccination [Advertisements will link potential participants to the project website, which is a mobile-friendly website accessible by desktop, laptop, tablet, or smartphone (iOS and Android). Eligibility will be based on responses to a Web-based screener. Potential participants will be eligible if they (1) are cisgender male; (2) are aged between 18 and 25 years; (3) self-identify as gay, bisexual, or queer; report ever having oral or anal sex with a male; or report being sexually attracted to males; (4) live in the United States; (5) have not received any doses of the HPV vaccine; and (6) did not participate in the pilot test of cination ,13 durinOutsmart HPV or control group materials), and then completing a posttest survey on the Web. Immediately after completing the baseline survey, participants will be randomized using a 1:1:1 allocation scheme to receive (1) standard information about the HPV vaccine (control group), (2) Outsmart HPV that includes monthly unidirectional vaccination reminders (Out-U group), or (3) Outsmart HPV that includes monthly interactive vaccination reminders (Out-I group). Recruitment will continue until a projected 1995 YGBMSM are randomized (about 665 per study group).After account setup, participants will begin their initial project website session. This will consist of completing a baseline survey on the Web, engaging with Web-based content about the HPV vaccine  unidirectional monthly HPV vaccination reminders sent via text messages. The Web-based content will be presented in 4 sequential sections  [esearch) . The endGet Answers uses a question-and-answer format to address barriers and concerns about HPV vaccination , informAction Plan. Participants will also be able to log back into the project website and review the Web-based content throughout the study, except when completing surveys.The monthly vaccination reminders for the Out-U group will be unidirectional, meaning that participants will not have the option to respond to the reminders. The unidirectional reminders will be sent via an automated process and contain only text. The text will provide information about HPV and the HPV vaccine, steps for getting vaccinated , and content addressing common barriers and concerns about the HPV vaccine. After completing their posttest survey, participants will have the ability to print or save a version of their Outsmart HPV content on the Web and (2) interactive monthly HPV vaccination reminders sent via text messages. Thus, the interventions for the Out-I and Out-U groups will be identical except in the type of monthly vaccination reminders sent to participants: participants in the Out-I group will have the option to respond to and/or ask questions to obtain additional tailored information and resources. Research suggests that interactive reminders may be more preferable and effective than unidirectional reminders [The intervention for the Out-I group will consist of 2 components: (1) population-targeted, individually tailored eminders ,42, whiceminders , the memFor each month, the initial text message sent to participants will be automated and include a question that prompts a response . IncludiParticipants in the control group will receive standard information about the HPV vaccine that is closely modeled after the Vaccine Information Statement (VIS) for the HPV vaccine. The VIS is created by the Centers for Disease Control and Prevention to provide easy-to-understand information about the HPV vaccine that is publicly available . We modeAfter the initial project website session, participants will be asked to complete follow-up surveys 3 and 9 months after randomization, for a total of 4 surveys during the course of the project. The final survey will occur 9 months after randomization to allow participants ample time to receive all 3 doses of the HPV vaccine during the study period. To improve retention, participants in all study groups will be sent automated email and text message notifications to complete their surveys.Participants who indicate they have received 1 or more doses of the HPV vaccine on the 3- or 9-month survey will be asked to complete a medical record release (MRR) form on the Web. Completion of the MRR is optional; participants who do not complete one will still continue in the study. At the conclusion of the study, the study team will contact the health care providers of participants who complete an MRR form to verify their HPV vaccination status. No additional health information beyond HPV vaccination status will be requested from health care providers, which is indicated to participants during the MRR form process.Outsmart HPV or control group materials on the Web, and posttest survey), a US $20 gift card for completing the 3-month survey, and a US $35 gift card for completing the 9-month survey. No additional incentives will be provided to participants for completing an MRR form. All incentives will be sent to participants via email.Participants will be able to earn up to US $95 in gift cards for this study. This includes a US $40 gift card for completing the initial project website session  and completion  during perceived vulnerability to HPV-related disease , perceived severity of HPV-related disease , and response efficacy . Additional constructs will include rewards of the maladaptive response , self-efficacy to get the HPV vaccine and to talk with a health care provider about the HPV vaccine , response costs of getting the HPV vaccine , and intention to get the HPV vaccine . We will also assess knowledge about HPV and the HPV vaccine , worry about getting HPV-related disease , and stigma around HPV . These constructs will be assessed at each survey time point with existing measures and those used in our past studies [The results of our pilot test suggest that several theoretically informed constructs may mediate the intervention’s effects on vaccination outcomes . Guided  studies ,32,46,47The baseline survey will assess demographic and health-related characteristics that we will examine as potential moderators of intervention effects. Demographic characteristics will include participants’ age, race/ethnicity, socioeconomic status, relationship status, sexual orientation , and urbanicity. Health-related characteristics and experiences will include health insurance status, health care utilization, perceived experience of discrimination in receiving health care, disclosure and concealment of sexual orientation to their health care provider, sexual history , history of HPV-related disease, and HIV status (as some HIV-positive participants may not be aware they can receive the HPV vaccine ). The baAction Plan, and the 9-month survey will ask these participants about the acceptability of the monthly vaccination reminders . Study surveys will also examine participants’ communication and information seeking about the HPV vaccine.The posttest survey will assess acceptability of the Web-based content about the HPV vaccine across the 3 study groups . Survey paradata). This information will assist in examining whether dosage influences intervention efficacy, which in turn will help inform future dissemination efforts [We will measure engagement using administrative data from the project website about study processes and participants’ interaction with study materials . To achieve this analytic sample size, we will randomize a projected 1995 men (665 per study group) and expect 70% retention over the 9-month follow-up period (based on our pilot test ). Once rWe will examine descriptive statistics for participants’ baseline characteristics and make comparisons across study groups. Using an intention-to-treat approach, we will then use logistic regression models to determine intervention efficacy, with separate models for HPV vaccine initiation and completion. For each outcome, we will perform all pairwise comparisons across study groups. Logistic regression models will produce odds ratios (ORs) and 95% CIs. Sensitivity analyses will include adjusting for possible residual confounders and a tipping point analysis and multiple imputation to examine the impact of any missing outcome data.full model and a more parsimonious final model. The full model will include the study group and all theoretical constructs examined. We will assess the overall model fit of the full model through the root mean square error of approximation (RMSEA) and other metrics  [final model, we will remove pathways  from the full model based on effect size and the chi-square test for nested models. This process will continue until removing pathways no longer improves the model. The resulting model will be the final model. Structural equation models will produce standardized path coefficients that estimate the direct and indirect effects of study group and the theoretical constructs.We will examine theoretical constructs as potential mediators using structural equation modeling. We will examine HPV vaccine initiation and completion separately and use a probit link to transform each binary outcome to a standard normal scale . For eacre test) ,54. We wP<.05.To examine moderation, we will use logistic regression models that include an interaction term between each potential moderator and study group. These logistic regression models will produce ORs and 95% CIs. We will consider moderation to be present if an interaction term has The project has been funded by the National Cancer Institute of the National Institutes of Health under Award Number R37CA226682 . The institutional review board at The Ohio State University has approved this study (study number 2019C0028). The Ohio State University served as the reviewing institution with other study sites ceding review. We have also registered this clinical trial (NCT04032106). Recruitment and enrollment for the RCT began in Fall 2019.There are several potential challenges and limitations to our forthcoming RCT. First, although we will confirm participants’ HPV vaccination status through medical records when possible for primary outcomes, we will use self-reported data for participants who do not provide a signed MRR. We will also rely on the participants’ self-reported HPV vaccination status in determining study eligibility. However, previous research suggests that most young adults can accurately report their HPV vaccination status, with only a 2.2% net bias in self-reported HPV vaccination data among this age group . Second,Outsmart HPV is to increase HPV vaccine coverage among YGBMSM. This study is a critical step toward achieving this goal because it will comprehensively evaluate Outsmart HPV. The results will provide an understanding of the intervention’s efficacy , mediators, and moderators. If proven efficacious, Outsmart HPV has the potential to fill an important gap by providing a Web-based intervention that allows YGBMSM to learn about HPV vaccination and promotes vaccination.The goal of


Human papilloma virus (HPV) vaccine is a proven method for preventing HPV-related cancers and genital warts, especially preventing cervical cancer. It is aimed to systematically review and synthesize conclusions in detail from community-based studies published in Turkey between 2009 and 2019, which evaluate the knowledge, awareness, attitude, and behaviors of individuals towards HPV and HPV vaccination. This systematic review is conducted based on the PRISMA reporting method and includes community-based, descriptive cross-sectional and cross-sectional studies published between 2009 and 2019. In this systematic review, 5132 studies from six databases were scanned in total. It was determined that there were 23 studies that met the eligibility criteria for this systematic review. In the reviewed studies, it was determined that the rate of “Hearing of HPV before” was 3.8% at the lowest and 57.0% at the highest, and the rate of “Hearing of HPV vaccine before” was 2.2% at the lowest and 74.7% at the highest. In the reviewed studies, it was reported that although parents’ willingness to have their daughters vaccinated with HPV vaccine varied between 14.4% and 68.0%, their willingness to have their sons vaccinated with HPV vaccine varied between 11.0% and 62.0%. In addition, it was reported that the lowest rate of vaccination with HPV vaccine among participants was 0.3% at the lowest and 6.0% at the highest. Consequently, it is considered that conducting common, systematic, and continuous health education programs aimed at both sexes and including both parents, which will increase the knowledge and awareness on HPV and its vaccine, would provide positive attitudes, and will be effective in protecting against HPV-related cancers. Human papilloma virus (HPV) infection, which is sexually transmitted to both males and females, is a global epidemic ,2,3. AppHPV vaccine is a proven method for preventing HPV-related cancers and genital warts, especially preventing cervical cancer ,9. It isThe literature reported that negative attitude and behaviors of individuals and parents such as lack of knowledge and low awareness about mode of transmission, protection, and early diagnosis methods of HPV infection, cost of HPV vaccine, potential adverse effects, and suspecting vaccine safety, and negative news on all vaccines prevented the generalization of the HPV vaccination ,17,18. IThis systematic review was registered on the International Prospective Register of Systematic Reviews system . This systematic review was conducted based on PRISMA reporting method and includes community-based, descriptive cross-sectional and cross-sectional studies published between 2009 and 2019.The investigated studies, which were about protection methods against cervical cancer in Turkey published in the last 10 years, were focused on individuals’ knowledge, awareness, attitude, and behaviors on HPV and HPV vaccine. In the literature, no systematical national research report was found on individuals’ knowledge, awareness, attitude, and behaviors on HPV and the HPV vaccine . In thisst and 4th, 2019.Studies included in the systematic review were obtained as a result of comprehensive review of EBSCO, Google Scholar, Proquest, PubMed, Springer, and TR index databases between March 1Keywords in English used in the review were “Turkey”, “HPV”, “Human Papilloma Virus”, “HPV vaccine”, “knowledge”, “awareness”, “attitudes”, “behavior”; and “Türkiye”, “İnsan Papilloma Virüsü”, “Human Papilloma Virüsü”, “HPV aşısı”, “bilgi”, “farkındalık”, “tutum” and “davranış” words were used in the Turkish database.In this systematic review, as a result of comprehensive scanning of the databases, 118 research reports were identified according to the titles and abstracts that met the eligibility criteria. It was observed that there were 43 recurring studies among this research. In the assessment according to title and abstract after the recurring researches were identified, studies conducted by healthcare professionals/students (n=47), intervention studies (n=3), scale validity reliability studies (n=2), and studies conducted on immigrant Turks (n=1) were eliminated because they did not fit the purpose of the systematic review. After this stage, the full texts of the studies were reviewed (n=25). Studies for which the full text was not available were excluded from the systematic review (n=2). Following the assessments, it was determined that there were 23 studies that met the eligibility criteria for this systematic review .Evidence centers such as the Cochrane Library and Joanna Briggs Institute (JBI) recommend that the studies addressed in systematic reviews are assessed using standardized critical instruments to determine their scientific value and bias risk according to their objectives, design, and method properties . It is rA data collection form developed by the researchers based on the literature was used to collect the data of the scanned studies included in the systematic review. The data collection form includes the author, year, subject, location, sample size and properties, method, main findings, conclusion, and suggestion titles of the study. Researchers reviewed the full texts of 23 studies in detail and recorded in the data collection form under titles independently from each other. Data collection forms of each study were reviewed by all researchers and the data of the systematic review were established.The collected data was merged under the titles of “Author”, “Year”, “Location of the Research”, “Age Range”, “Health Center”, “Number of Participants”, “Properties of Sample”, “Hearing of HPV”, “Hearing of HPV vaccine”, “Vaccination Rate”, “Willingness to Vaccination for Own Self”, “Willingness to Vaccination for Daughter”, “Willingness to Vaccination for Son”, “Barriers of HPV Vaccine”, “Source of HPV Knowledge”, “Willingness to have Education about HPV”, “Factors in relation to HPV and Vaccine Knowledge” and “Suggestions” , 3.In this systematic review, 5132 studies from six databases were scanned in total. It was determined that there were 43 recurring studies out of 118 studies identified according to the titles and abstracts. Number of identified studies was determined as 78. Fifty-four studies that were determined to be beyond the purpose of the systematic review based on the title and abstract were eliminated. Out of the 25 studies whose full texts were to be assessed for eligibility, two studies were excluded because their full texts were not available. The full texts of 23 studies that met the eligibility criteria were included in the scope of the systematic review .In the assessment of the studies according to the JBI-Critical Appraisal Checklist for Analytical Cross-sectional Studies, it was determined that eligibility criteria were defined clearly in the sample in 95.6% (n=22) of the studies, and the study subject and methods were explained in detail in 56.5% (n=13) of the studies. It was observed that the researched case was measured in a valid and reliable manner in only 4.3% (n=1) of the studies included in the systematic review, but all of the studies (n=23) used objective criteria for measuring the researched case. It was determined that confounding factors were not identified in 82.6% (n=19) of the studies, and also strategies for coping with confounding factors were not specified. It was determined that the results of all studies (n=23) were assessed using objective criteria and suitable statistical analyses were conducted .It was determined that 56.5% (n=13) of the studies included in the systematic review were published between 2009 and 2013 and 56.5% (n=13) were published in international indexed journals. In the studies that were assessed, the age range of the participants varied between 13 and 87 years. The number of participants in the studies was between 229 and 1808. Sixty-five percent (n=15) of the studies addressed only adult women; 21.7% (n=5) addressed adult men and women; 8.6% (n=2) addressed female adolescents and young females; 4.3% (n=1) addressed only males, and 4.3% (n=1) addressed female adolescents and their mothers. In terms of the location of the studies, it was observed that 65.2% (n=15) of the studies were conducted at tertiary healthcare institutions. Studies were conducted in 13 different provinces in total .In the studies, it was determined that the rate of “Hearing of HPV before” was 3.8% at the lowest and 57.0% at the highest, and the rate of “Hearing of HPV vaccine before” was 2.2% at the lowest and 74.7% at the highest. In the assessed studies, it was reported that the parents’ willingness to have their daughters vaccinated with HPV vaccine varied between 14.4% and 68.0%, whereas their willingness to have their sons vaccinated with HPV vaccine varied between 11.0% and 62.0%. In addition, it was reported that the lowest rate of vaccination with HPV vaccine among the participants was 0.3% at the lowest and 6.0% at the highest . Two of In nine studies conducted on in HPV vaccine barriers (43.4%), it was reported that the first three barriers identified were lack of knowledge about HPV and vaccine (40.9% to 76.6%), adverse effects concern (0.9% to 64.5%), and the price of HPV vaccine (0.2% to 49.5%), respectively. According to data obtained from the studies, it was observed that the information source of the participants about HPV and vaccine was healthcare personnel at the rate of 12.3% to 72.2%, and media  at a rate of 23.5% to 88.8% . In the When the reporting properties of 23 cross-sectional studies included in this systematic review were assessed, it was observed that most of them explained the eligibility criteria in the sample (95.6%) and objective measurements were performed with appropriate statistical analyses and results were reported objectively in all of them. Taking confounding factors under control is quite important in terms of the reliability of the results in cross-sectional studies ,23. In mIn information and awareness studies on HPV and the HPV vaccine that were conducted in developed countries, it was reported that HPV knowledge and awareness were at low-to-moderate levels, and vaccination rates (26%-55%) were not at desired levels, although the willingness for vaccination was high ,32,33,34Although HPV immunization willingness was high, various barriers made it difficult to raise vaccination rates to the desired level. HPV vaccination barriers in developed countries were listed as doubts about vaccine safety and efficiency, adverse effect concerns, lack or inconsistency of information about HPV and the HPV vaccine, and the price of the HPV vaccine ,32,34. IThe most frequent source of healthcare information in developed countries was healthcare professionals, and media  at a lower rate . In deveIn the literature, it was reported that level of knowledge on HPV vaccine increases as people’s education levels and income levels increase ,39,40,47In that respect, it was suggested that groups with lower education and income levels should be addressed primarily in programs in relation to HPV and the HPV vaccine. Consistent with the literature, it was determined that most of the studies addressed in this review recommended health education for increasing knowledge, awareness, and positive behaviors towards HPV and the HPV vaccine . SystemaThe systematic review was limited to the studies published in EBSCO, Google Scholar, Proquest, PubMed, Springer, and TR index databases for which full texts could be accessed. There full text of two studies were not accessible.It is considered that conducting common, systematic, and continuous health education programs aimed at both sexes and including both parents, which would increase knowledge and awareness on HPV and the HPV vaccine, and provide positive attitudes, will be effective in protecting people against HPV-related cancers ,34,36,38


Numerous programs exist to support veterans in their transitions to civilian life. Programs are offered by a host of governmental and non-governmental stakeholders. Veterans report encountering many barriers to program participation. This study identified barrier reduction strategies offered by programs that new post-9/11 veterans reported using, determined which strategies veterans use and value, and examined veteran characteristics that impact their odds of using programs that offer barrier reduction strategies.This study reflects findings from the first wave of data collection of The Veterans Metrics Initiative (TVMI), a longitudinal study examining the military-to-civilian reintegration of new post-9/11 veterans. The websites of programs used by respondents were coded for barrier reduction components. Veterans also indicated which barrier reduction components they found most helpful in meeting their reintegration goals.Of 9566 veterans who participated in Wave 1 data collection, 84% reported using a program that offered at least one barrier reduction component. Barrier reduction components included tangible supports , increased access to programs, decreased stigma, and encouraged motivation to change. Although only 4% of programs that were used by veterans focused on helping them obtain Veterans Administration benefits, nearly 60% of veterans reported that this component was helpful in reaching their goals. Access assistance to other resources and supports was also reported as a helpful barrier reduction component. For instance, approximately 20% of veterans nominated programs that offered transportation. The study also found evidence of a misalignment between the kinds of barrier reduction components veterans valued and those which programs offered. Veterans from the most junior enlisted ranks, who are at most risk, were less likely than those from other ranks to use barrier reduction components. Study limitations and ideas for future research are discussed.Despite the evidence that barrier reduction components enhance access to programs and contribute to program sustainability, many programs used by post-9/11 veterans do not offer them. There was also a misalignment between the barrier reduction strategies that veterans value and the strategies offered by programs. Veteran serving organizations should increasingly implement barrier reduction strategies valued by veterans. Very little is known about how the transition from active duty service to civilian life unfolds among post-9/11 veterans. While a plethora of programs and supports are offered to veterans, many report difficulties accessing them.To increase the penetration and reach of programs and services targeted to veterans, barrier reduction efforts are needed, and they must align with what veterans’ report valuing in reaching their reintegration goals.This study demonstrated that barrier reduction efforts are recognized and needed by veterans, but they are somewhat misaligned with what veterans need, are generally under-used, and special efforts need to be made to target barrier reduction to veterans from the most junior enlisted ranks.Currently, there are 2.6 million post-9/11 military veterans in the United States. This population is projected to grow to 3.5 million by 2019 [Some of the most common challenges experienced by post-9/11 veterans occur within four domains of well-being: ; legal, Despite the well-documented needs of post-9/11 veterans and the plethora of programs available to them , many veCurrently, there are over 40,000 programs in the United States purporting to assist veterans with transitioning to civilian life . VeteranTheory and research in the area of implementation and dissemination science indicates that effective program implementation requires four essential elements:  relevantTangible supports are the physical resources, assistance, and/or monetary supports provided to veterans to directly assist them in meeting their basic and higher-order needs [er needs , 29. To er needs , 29. TheProgram access components typically provide logistical supports that make it easier for veterans to engage with programs. The VA healthcare system is offered at no cost for veterans, which is a critical program access barrier reduction component. Transportation is also sometimes provided by the VA to veterans who live far from a VA clinic, which makes it easier for them to attend appointments [intments . In addiintments , 32. OutIntra-individual change component involves: [nvolves:  promotinnvolves:  decreasinvolves: . Veterannvolves: . Effortsnvolves:  and contnvolves: –38 to deTo our knowledge, this is the first study to describe the barrier reduction components that veterans encounter in the VA and non-VA programs that they use. Extant research has focused primarily on barrier reduction related to the use of VA mental healthcare. Many veterans use non-VA programs in support of employment, education, financial, health, and social goals . Recentln = 48,965). Detailed information on the sample, procedures, and participant demographics have been published elsewhere [n = 9566). The majority of the veterans were male 82% (n = 6734), White, Non-Hispanic 64% (n = 5215), and from the enlisted ranks (77%).The population of veterans who had separated from active duty service or de-activated from active duty status in the prior 4 months between June–September 2016 were identified from Veterans Affairs and Department of Defense Identity Repository (VADIR) and were invited to participate in the study , food, clothes or other physical objects, legal advice, access to benefits, among others. Second, veterans were asked if any of the programs they used made it easier to access the program by providing transportation, insurance, child care, stigma reduction strategies or messaging, bolstering motivation to change, and others. Finally, veterans were asked the extent to which barrier reduction strategies helped them achieve their reintegration goals.). The websites were coded for the presence of barrier reduction components using a distilling process [A list of barrier reduction components was derived from a review of the research literature using grounded theory. Rotheram-Borus et al. (2009) provided a framework specifically for barrier reduction components . Veteran process . Tangiblexpert coder check coding consistency, discussing discrepancies, and coming to agreement on the final codes and definitions of each component.Coding was conducted using qualitative software NVivo 12 . Two independent raters coded programs by indicating whether each component was either present or absent for each program. Coders applied all relevant codes to a program; therefore, codes were not mutually exclusive. Reliability among coders was established by having a third In survey studies that do not use random sampling, there is always a question regarding the degree to which the responses may be biased because participants in the study may not fully represent the population from which the sample was drawn . In the n = 8010) reported using at least one program or VA benefit. Approximately, three-quarters of the respondents nominated a VA benefit. Nearly half (43%) of post-9/11 veterans reported using educational benefits. Approximately 34% used the Post-9/11 GI Bill, while 9% used the Montgomery GI Bill, and 32% of veterans used the VA home loan program. Nearly 35% of veterans used VA hospitals, clinics, and/or Vet Centers.The vast majority of veterans , which resulted in 656 unique programs being coded. In addition, 239 programs were identified by coders from nominations. However, these only included a program type  not a specific program that was able to be identified via a web search.n = 895); (b) veterans who self-reported using a barrier reduction component that helped them achieve their goals (n = 4308); and (c) the alignment among programs that offered a program component and the proportion of veterans who self-reported using it.Table Fifty-six percent of programs offered a tangible support component. The first column of Table The second column represents the self-report of veterans who nominated at least one program to describe in detail and who used a barrier reduction component and reported that the component helped them achieve their goals. The most commonly mentioned barrier reduction components that helped veterans reach their goals were assistance for obtaining VA benefits , increasing motivation to change , provision of non-VA insurance or free medical care , and non-VA tuition discounts or scholarships . The remainder of barrier reduction components were not or were rarely mentioned as being used and having helped veterans achieve their goals.The final column in Table Looking across the columns of Table VA-sponsored tangible supports included the Montgomery GI Bill or Post-9/11 GI Bill; VA home loan program; and use of VA hospitals, clinics, or Vet Centers. Veterans from the Air Force were less likely to utilize any GI Bill compared to Army veterans; however, veterans from the National Guard or Reserve were two times more likely to utilize the GI Bill than veterans from the Army  were all more likely to utilize the VA healthcare system compared to White, Non-Hispanic veterans. Veterans working full-time were less likely to utilize the VA healthcare system.Additional analysis was conducted on the sub-sample of veterans who reported using tangible support components outside of the VA . Relative to veterans from the most junior enlisted ranks, those from most of the higher ranks were significantly less likely to utilize programs that provided a housing benefit. Hispanic veterans and veterans who identified as Non-Hispanic multi-racial were two times more likely to report using programs that provided legal advice compared to White, Non-Hispanic veterans. Finally, veterans with a probable diagnosis of PTSD were 85% more likely to use programs that provided legal advice compared to those without PTSD.Table Table To our knowledge, this was the first study to examine barrier reduction components present in programs that are designed to assist post-9/11 veterans as they transition from military to civilian life. Perhaps most striking was the finding that the vast majority of programs did not offer any barrier reduction components. This is a problem from practical, theoretical, and policy perspectives. Practically, many post-9/11 veterans report barriers to programs that they need , 17–19. The study also revealed that a low proportion of new post-9/11 veterans report using and benefiting from barrier reduction components. The most commonly mentioned barrier reduction component that was both used and helpful  was mentioned by less than 25% of the sample. Seven components coded from websites were not mentioned by any veterans, and a sizeable number of barrier reduction components were only mentioned by less than 10% of them. The most parsimonious explanation for this finding is that recently separated post-9/11 veterans do not need to use programs or take advantage of barrier reduction components. A number of studies have shown that most veterans make a healthy transition from military life to civilian life .From a policy perspective, VA and non-VA program providers should consider enhancing veteran awareness of their programs, providing clear explanations as to eligibility requirements, offering strategic referrals to programs for which veterans are eligible, and prioritizing barrier reduction strategies in their strategic plans. Given limited resources, efforts should be made by programs to include barrier reduction components. For new post-9/11 veterans, the current study suggested that providing assistance with obtaining VA benefits, increasing motivation to change, provision of non-VA insurance or free medical care, and non-VA tuition discounts/ scholarships are the most important barrier reduction components in helping them reach their goals. Unfortunately, very few programs offer these components. For example, while only 6.3% of programs offered an increased motivation to change component, 17.5% of veterans reported using and benefiting from this type of component. Because veterans value the increased motivation to change component, programs should consider adopting this component . Just as importantly, a low proportion of veterans report using and benefiting from barrier reduction components. Thus, not only are barrier reduction components not offered enough, but the quality and/or impact of these components may be suspect. Indeed, research on the impact of barrier reduction components is lacking, and future research should address this gap. Research in this area would provide needed information for developing policies to assist veterans make healthy transitions to civilian life.The results of this study also demonstrate that there is often a misalignment among the barrier reduction components offered by programs and the components that veterans reported as being most helpful. For example, while increased motivation to change was coded in only 6.3% of programs, 17.5% of veterans reported using and benefiting from this component. In addition, among programs offering this component, 29.3% of veterans reported using it. While there is no research related to barrier reduction misalignment, it seems reasonable to think that lack of alignment is a problem. From a practical and policy perspective, alignment among what components are offered, used, and are helpful would be ideal in terms of meeting veteran needs. It is possible that alignment improves over time; however, this assertion has yet to be examined.For new post-9/11veterans, tangible support components were the most widely used, and this was particularly true for VA programs. Three-quarters of new veterans reported using at least one VA program. VA benefits are a unique tangible support component because they are offered at no cost and directly enable a person to obtain a desired outcome . VA-sponsored education was used by 43% of the sample. This assistance enables veterans or their family members to achieve a higher level of education. Education is, of course, positively associated with a host of health and well-being outcomes . The VA home loan benefit was used by 32% of veterans. Veterans whose military occupation was combat arms and combat support were more likely to utilize educational benefits because their military occupations may not translate directly to civilian occupations; thus, additional training could be needed to find employment within the civilian population.Three additional commonly reported tangible support barrier reduction components were directly related to meeting a veteran’s economic needs . A subset of post-9/11 veterans struggle financially, and this is particularly true for veterans who have health problems , live inIn comparison, very few veterans (16%) utilized the access barrier reduction components for non-VA benefits . One potential reason may be that veterans may not be eligible for all barrier reduction components available within a program. It is also possible that veterans are unaware of the resources available to them when using a program. For example, income guidelines or minimum credit scores may need to be met before a veteran can access certain benefits.The barrier reduction component of access assistance was also found to be a helpful tool that veterans used. For instance, approximately 33% of veterans report utilizing at least one VA healthcare service . Moreover, as consistent with previous research , veteranThe majority of programs were found to make access easier by making some of their materials available online (97% of programs). For example, the VA is widening its access to veterans by providing more administrative support and clinical care via the web. Implementation science theory and research supports the idea of making access to information and resources more widely available. However, navigating the internet to find the specific program may still be troublesome for some veterans. In this ever advancing technological world, web access will play an increasingly important role in the lives of veterans; however, rural dwelling and older veterans often have poor or no access to the internet . Thus, pTransportation appears to be a key access assistance component particularly for veterans with serious injuries or disabilities that prevent them from getting around by themselves or for those who do not have the financial means to purchase and maintain their own transportation . HoweverAccess to child care can be a barrier reduction component as it provides service members free time to utilize programs or pursue employment or educational opportunities . HoweverThe barrier reduction components related to intra-individual change  were present in a low proportion of programs. However, these components were used and viewed as helpful by 17.5% of veterans. Among those programs that offered this component, 29.3% of veterans reported using it. Military and veteran cultures foster norms that stigmatize help seeking, particularly for mental health problems . Active As with any study, there were some limitations with the current investigation. The most significant limitation of the study is that the sample was not drawn at random. As a result, the degree to which the findings were biased is not known. Also, participation in the study was voluntary and it is likely that respondents who participated felt strongly about the topic in question and may favor certain responses . While tTo expand the reach and penetration of programs and services to post-9/11 veterans, barrier reduction efforts should be robust and align with what veterans report valuing as they transition from active duty to civilian life. Currently, with the exception of tangible supports, the barrier reduction efforts that veterans appear to value  are rarely offered and they are under-utilized by veterans. Veterans who are at most risk for poor civilian reintegration are also least likely to engage programs that offer barrier reduction components. Veterans serving organizations should consider bolstering their efforts at providing barrier reduction efforts, particularly with respect to better alignment with veterans’ needs.