ObjectiveThis project aims to use our robust women's health patient data to analyze the correlation between cytology and high-risk human papillomavirus (Hr-HPV) testing, study the performance of Hr-HPV testing for detecting cytology lesions, and examine epidemiologic measures of human papillomavirus (HPV) infections in the women's veteran population.MethodsWe collected patient data from 2014 to 2020 from our computerized patient record system. We performed HPV assays using the cobas® 4800 system . The cobas HPV assay detects HPV 16, HPV 18, and 12 other HPV types . We organized cytology results and Hr-HPV assays with Microsoft Access and Microsoft Excel  for analysis.ResultsA total of 9437 cervical specimens were co-tested. High-grade cytology lesions - high-grade intraepithelial lesion (HSIL) or higher and atypical squamous cells, cannot exclude HSIL (ASC-H) - were overwhelmingly positive for Hr-HPV . Low-grade cytology lesions - low-grade squamous intraepithelial lesion ((LSIL) and atypical squamous cells of undetermined significance (ASC-US) - were positive for Hr-HPV in lower percentages . Hr-HPV testing had a sensitivity of 91.3%, a specificity of 93.1%, a positive predictive value of 16.4%, and a negative predictive value of 99.8% for detecting high-grade cytology lesions. Hr-HPV testing had a lower performance for detecting low-grade cytology lesions. Ten cases had high-grade cytology and negative Hr-HPV test. Out of 10 such patients, nine showed no dysplasia (six) or low-grade dysplasia (three) on subsequent biopsy. Overall, 14.4% of tests were positive for Hr-HPV. The highest positive Hr-HPV test rates were in the third and eighth decades of life, 25.1% and 22.0%, respectively. However, the eighth decade consisted of a small sample of only 50 women. In women over 30 years of age with Hr-HPV infections, HPV types 16 and 18 were present in 11.7% and 6.4% of tests, respectively. Other HPV types were present in 82.3% of tests.ConclusionsHr-HPV testing has a high performance in detecting high-grade cytology lesions and a lower performance for detecting low-grade cytology lesions. However, studies show that LSIL rarely progresses to cervical intraepithelial neoplasia grade 3 or higher (CIN3+), suggesting minimal to no impact on cervical cancer screening. We believe our findings are in accordance with recent studies and affirm the guidelines that recommend primary Hr-HPV testing as the preferred screening method. The percentage of positive Hr-HPV tests and rates for age and HPV types 16 and 18 in our women’s veteran population suggest similar HPV prevalence to that of the general US population. Human papillomavirus (HPV) is one of the most potent carcinogens in humans, with almost 5% of all new cancers diagnosed worldwide attributable to HPV . These cHPV infects epithelial cells, promoting cellular proliferation, blocking apoptosis, and evading the immune system ,5. PersiSince the 1950s, for most of this period, the basis of cervical cancer screening has relied on the revolutionary Papanicolaou test and, later, liquid-based cytology. As cervical screening technologies evolved and knowledge of the natural history of cervical cancer grew, so did the recommendations for screening and management.One of the most substantial changes in screening and management guidelines was the incorporation of Hr-HPV molecular testing into screening protocols for cervical cancer by the American Society for Colposcopy and Cervical Pathology (ASCCP) in 2012 . At thatIn 2015, after growing evidence of the high performance of primary Hr-HPV testing -14 and tIn 2020, the American Cancer Society (ASC) updated the cervical cancer screening guidelines. They recommended primary HPV testing as the preferred screening method, with co-testing and cytology alone being acceptable . They alDuring the last decades, the Veterans Health Administration (VHA) has seen a significant increase in its women patient population. The growing numbers of women participating in the US military have made this subgroup the fastest growing subgroup of US veterans . The VHAAlthough recent cervical screening guidelines shift towards primary HPV screening as the main method for cervical cancer screening, we use co-testing at James A. Haley Veterans Affairs Hospital. Co-testing provides an excellent opportunity for comparing and correlating cytology and Hr-HPV testing results. Studies that compare cytology testing to Hr-HPV testing in the US women's veteran population are lacking. As the gradual shift towards primary Hr-HPV screening occurs, we believe more studies will compile in favor of the performance of Hr-HPV testing in different scenarios.Female veterans have a higher prevalence of interpersonal trauma due to their military service, affecting their healthcare needs -21. AlthThis project aims to use our robust women's veteran health data to analyze the correlation between Hr-HPV testing and cervical cytology. In doing so, we measure the performance of Hr-HPV testing for the detection of high-grade versus low-grade lesions diagnosed by cytology within this specific population. We also calculate the percent of positive Hr-HPV tests among US veteran women, a population in which these studies are scant.A total of 9,437 cervical specimens of women veterans were co-tested by Hr-HPV testing and cytology from 2014 through 2020.The Hr-HPV testing was done through the cobas HPV Test using the Roche cobas 4800 System. The cobas HPV Test detects HPV 16, HPV 18, and 12 other HPV types . We divided cytology results into two main diagnostic categories: high-grade cytology lesions, including high-grade intraepithelial lesion (HSIL) or higher and Atypical squamous cells, cannot exclude HSIL (ASC-H), and low-grade cytology lesions, including low-grade squamous intraepithelial lesion ((LSIL) and atypical squamous cells of undetermined significance (ASC-US). Results of cytology and Hr-HPV assays were sorted, organized, and analyzed using Microsoft Access and Microsoft Excel .We calculated percentages of Hr-HPV positive cases for each cytologic diagnostic category. We evaluate sensitivity, specificity, positive predictive value, and negative predictive value of the Hr-HPV test for detecting each cytologic diagnostic category. We further analyzed cases that showed high-grade cytology but resulted in a negative Hr-HPV test looking for common findings and possible causes of discrepancy. We calculated the total percentage of Hr-HPV positive cases within the population. We divided women by age groups  and calculated the percentages of positive Hr-HPV in each age group. In women over age 30 with Hr-HPV infections, we determined the rate of positive tests for HPV types 16, 18, and other types precisely. We did not determine the specific rates for Hr-HPV types in women under age 30 because we do not report specific Hr-HPV type results in this younger age group. We only report Hr-HPV type results in women over age 30 with a cytology result of ASC-US, LSIL, or higher.Of the 9,437 cervical specimens of women veterans co-tested during 2014-2020, the Hr-HPV test results for high-grade cytology lesions (HSIL or higher and ASC-H) were overwhelmingly positive for Hr-HPV  .Low-grade cytology lesions (LSIL and ASC-US) were positive for Hr-HPV in lower percentages   of 16.4%, and a negative predictive value (NPV) of 99.8% for detecting high-grade cytology lesions. However, it had a lower sensitivity of 58.9%, a specificity of 93.1%, a PPV of 56.2%, and an NPV of 93.8% for detecting low-grade cytology lesions. Figure A review of medical records of patients with high-risk lesions on cytology and negative Hr-HPV showed that nine out of 10 patients had either no dysplasia (six) or low-grade dysplasia (three) on subsequent biopsy. Two of these cases showed microglandular hyperplasia; one of these simultaneously with low-grade dysplasia. The remaining case was diagnosed cytologically as ASC-H but was lost to follow-up and did not undergo biopsy. Cytology review of most of these cases identified significant background inflammation complicating cytologic interpretation.Out of the 9437 cervical specimens, 1359 cases were positive for Hr-HPV, constituting 14.4% , 66 contained HPV type 18 (6.4%) as a single or coinfection, and 852 contained Hr-HPV types other than 16 and 18 (82.3%) . Hr-HPV testing was highly sensitive and specific for detecting high-grade cytology lesions, 91.3% and 93.1%, respectively. It also had an NPV of 99.8%, which gives high reassurance to those women with a negative Hr-HPV result. A low PPV of 16.4% is obvious since HPV types 16 and 18, together, have a three-year cumulative incidence risk (CIR) of only 21.16% for developing CIN3+, and the other Hr-HPVs have a three-year CIR of 5.4% for developing CIN3+, according to the ATHENA study . This meWhen reviewing positive high-grade cytology lesions that were negative for Hr-HPV testing, we found that the majority had significant background inflammation complicating cytologic interpretation. On subsequent biopsy, nine out of 10 were either negative for dysplasia (six) or had low-grade dysplasia (three). Two of the revised biopsies showed microglandular hyperplasia, one of them with simultaneous low-grade dysplasia. Microglandular hyperplasia is a benign alteration of the endocervical epithelium in which the endocervical cells can show reactive changes. These changes can be confused with a wide range of differential diagnoses during cytological interpretation, including LSIL, HSIL, AIS, and invasive cancer . These aA concerning finding in our study is the low sensitivity of Hr-HPV testing for detecting low-grade cytology lesions. One cannot help but ask: What is the impact of missing low-grade lesions? LSIL diagnosed by cytology can be caused by Hr-HPV types or Lr-HPV types. A study from the Netherlands showed that, over four years, all women with LSIL and a negative Hr-HPV test regressed to normal cytology, as did 85% of those with HSIL and a negative Hr-HPV test . AnotherOur results show that 14.4% of all Hr-HPV tests were positive in our women's veteran population. Our literature search for the overall prevalence of Hr-HPV types in the US general population found variable results. A study carried out by Monsonego et al. used extensive data from the ATHENA trial with over 40,000 women screened in 23 states. They showed the lowest overall Hr-HPV prevalence, 13.4% , which iWhen analyzing age-specific rates of Hr-HPV positive tests, we found them very similar to the rates of the women’s general public calculated from the ATHENA study results (See Table When comparing the percentage of HPV types 16 and 18 positive cases between our population and that of the general US female population analyzed from the ATHENA study data by Monsonego et al., HPV type 16 had a lower percentage in our population, 11.7% versus 18.9%, and HPV type 18 had a similar rate in our population, 6.4% versus 7.2%. Our percentages fall very close to that of the general US female public in a study by Dunne et al. , it is 1According to our data, Hr-HPV testing shows high-performance measures for detecting high-grade cytology lesions in our women's veteran population. However, it will miss a significant number of low-grade lesions. Studies have shown that LSIL rarely progresses to CIN3+, primarily when Lr-HPV types cause it. These studies suggest that not detecting a percentage of these lesions has minimal to no impact on cervical cancer screening. We believe our findings are in accordance with recent studies and guidelines that recommend primary Hr-HPV testing as the preferred screening method. The total percentage of positive Hr-HPV tests, rates for age, and rates for HPV types 16 and 18 in our women's veteran population suggest similar HPV prevalence to that of the general US population.


It has been more than 10 years since the human papillomavirus (HPV) vaccination program was initiated in most advanced countries. Thus, it seems necessary to change the uterine cervical cancer screening strategy. Molecular-based tests are considered essential in this scenario.We aimed to review the distribution of the HPV genotypes after the introduction of the vaccination program with Cervarix® and Gardasil 4® in two autonomous communities in Spain, looking for possible changes in distribution and the occurrence of a herd effect.A cross-sectional study was performed in 45,362 samples that were processed in the Cantabria and Aragon communities during the period from 2002 to 2016. We compared the genotype distribution before and after the vaccination program was initiated.Genotypes HPV6 and HPV11 have decreased significantly after the introduction of the vaccine. HPV16 has had a decrease, but not a significant one in the statistical analysis. However, HPV31, HPV52, and HPV45 have increased in percentage. A replacement phenomenon with other genotypes not included in the vaccine has been observed in our population.Continued surveillance is needed to provide further indication of any changes over time in the genotypes in circulation. This will be facilitated by monitoring the genotyping results from the new model of cervical screening using primary HPV DNA testing. Human papillomavirus (HPV) is responsible for one of the most common sexually transmitted infections in the world . Its impIn the field of primary attention care, there are two complementary developments that have changed the cervical cancer prevention protocols in the Western world: firstly, the implementation of vaccination programs in 2007 in 65 countries  and, secIn 2007, the Interterritorial Spanish Council of the National Health System  approved the systematic vaccination against HPV in a single cohort of girls aged from 11 to 14 years. Vaccination started in 2008 using the bivalent vaccine until 2014. From 2014 onwards, the quadrivalent vaccine is administered. In the Aragon community, vaccination was established in schools and that in Cantabria in health centers. In 2015, the overall coverage in Spain, for the complete vaccine regimen, was 77.8% (range = 65.6%–93.4%), while in Aragon it was 88.3% and in Cantabria 89.7%. The last data published from the Spanish Ministry of Health are from 2019; the complete regimen was 79.0% with a target population of 171,929 women. For the first dose, the Aragon coverage is 94.1% and that of Cantabria was 90.6% . UnfortuThe vaccination program was established with two commercially available inactivated vaccines: Cervarix® and Gardasil®. They were synthesized from non-infectious structural proteins obtained by genetic recombination. Cervarix® is active against the HPV16 and HPV18 genotypes and Gardasil® against the HPV6, HPV11, HPV16, and HPV18 genotypes, with some differences also in the adjuvant molecules . It is eWhile the effectiveness is not discussed in terms of the genotypes included in the vaccines, a number of different questions are raised about the cross-protective effects between the genotypes not included in the vaccine, a possible replacement of genotypes ; a generThe importance of HPV vaccination has increased because of the high prevalence of HPV-induced oropharyngeal cancers. In fact, this location has superseded the uterine cervix as the most prevalent site of papillomavirus-related neoplasms .Therefore, our aim in this study was to review the distribution of the HPV genotypes after the introduction of the vaccination program in two autonomous communities in Spain: Cantabria and Aragon. In both communities, HPV genotyping was performed as a routine molecular technique. Data of the genotyping prevalence from the previous years before the start of the vaccination (pre-vaccination) were compared with those from the years after implementation of the vaccination program (post-vaccination).Our study populations before and after implementation of the HPV vaccine were recruited from the same geographic locations and category of service provider in order to minimize changes in the HPV-risk-related characteristics between the two periods.A repeat cross-sectional study was performed in 45,362 samples that were processed in both communities during the period from January 2002 to May 2016. Of these, 17,472 were in Hospital Lozano Blesa (Aragón) and 27,890 were in Hospital Marques de Valdecilla (Cantabria). The aim of the study was to compare the prevalence of HPV along the years of opportunistic screening.t-test to find out whether there are remarkable differences between the averages pre- and post-vaccination, i.e., whether those differences may have happened by chance or not. A more complex statistical analysis was not performed because of the lack of enough data associated with the HPV results.Specifically, we compared the HPV prevalence in the two populations by assessing the differences in any one of the 35 HPV genotypes tested (see below). Three HPV types that are genetically related to the vaccine-targeted HPV types—i.e., HPV45 (related to HPV18) and HPV31 and HPV33 (related to HPV16)—against which cross-protective antibodies have been detected in response to HPV vaccination, were the most closely studied. We also report prevalence individually for HPV52 and HPV58, which are also, but less closely, related to HPV16. We performed a All the data were anonymized and no relationship with clinical records was obtained. Approval from the Ethics Committee for Clinical Investigation was obtained.From an analytical point of view, cervical swabs were analyzed with a CLART HPV2 and HPV4 genotyping test , which is based on PCR followed by low-density microarray for the determination of genotypes from specific HPV L1 fragments from 35 individual HPV genotypes .A sample collected with the cervical swab was resuspended in 1 ml saline solution immediately before processing. The resuspension was vortexed thoroughly for 1 min. DNA extraction was done using an automatic extractor following the manufacturer’s instructions: COBAS AmpliPrep  was used in Lozano Blesa Hospital and QIAcube  was used in Marqués de Valdecilla Hospital.®  with 5 μl of the denatured PCR products. The precipitate was analyzed on a Clinical Array Reader  with the CLART Human Papillomavirus 2 and 4 software.Of the extracted DNA, 5 μl was used for PCR amplification. Amplification was performed on Eppendorf Mastercycler EP gradient S  and Veriti . Automatic visualization was performed using AutoclartThe results were expressed in absolute values and in median and averages of positive HPV tests related to the total of tests analyzed.There were 27,890 patients from the Cantabria autonomous community and 17,472 patients from the Aragon autonomous community evaluated for the period between January 2002 and May 2016. A total of 3,395 HPV-positive women were studied from the pre-vaccination period and 17,648 from the post-vaccination period. The average age of these HPV-positive women was 37.3 years, with a median of 36.3 years . The proportion of patients with a positive test for HPV infection was 46.38% .Upon verifying the distribution of the HPV genotypes over the years, it was observed that most of the 35 genotypes analyzed in the PCR system did not show temporal differences (p = 0.069) (p = 0.007) , and HPV45 (p = 0.01) and HPV52 (p = 0.001) , although this was non-significant in the case of HPV16. It is important to note that the coverage of the second dose is lower, at least in Cantabria. We have not observed the same effect in the HPV18 genotype, perhaps due to the low prevalence of this virus in the Spanish population. These data are comparable to those obtained in other series .As for data referring to the possible replacement of HPV31 and HPV45, it should be noted that an Australian study also found increases in the prevalence of both viruses in the non-vaccinated population , althougAccording to the principles of ecology , severalOn the other hand, there is what is called the “herd effect,” which provides indirect protection for those who have not been vaccinated because of a reduced prevalence of HPV in the population. In this sense, we have detected a decrease in the genotypes included in the vaccine. Therefore, it might be appropriate to consider this effect when establishing policies for early detection in the non-vaccinated population.The herd effect that has already begun to be detected in some populations  may haveA final topic that we consider necessary to discuss is the technique used for the molecular diagnosis of HPV infection. All of the data obtained in our study and all the questions posed about the replacement of genotypes and herd effect would not have been determined and answered if not for the use of a genotyping technique. In different countries, there is a trend toward the use of techniques based on PCR and genotyping for diagnosis . In factFinally, the intrinsic biological malignant potential of the different genotypes is another influencing factor to favor genotyping. In fact, it is well known that the risk of the HPV16 or the HPV18 genotype is higher than that of the rest .We acknowledge that our study has several limitations. Firstly, we have no access to the clinical data of all the patients as we do not know the vaccination status in all cases. Secondly, our only aim was to present a description of real-world data in order to best decide on appropriate strategies for vaccination and screening.In conclusion, continued surveillance is needed to provide further indication of any changes over time in genotypes in circulation. This will be facilitated by the monitoring of the genotyping results from the new model of cervical screening using primary HPV DNA testing.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Comité de Ética de la Investigación con Medicamentos de Cantabria. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JF-S: Design, writing, and technical support. RB: Design and writing. AA: Writing and technical support. JG: Technical support. CM: Technical support. MN: Technical support. PG-B: Technical support and statistical analysis. SA: Technical support. JG-R: Design and writing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Cervical cancer is the predominant cause of female cancer deaths in Sub-Saharan Africa. Chronic infection of the uterine cervix by the human papillomavirus (HPV) is the most important factor for the development of cervical cancer. HPV screening may be used to screen out women at risk of cervical cancer; however, the majority of HPV infections will eventually heal, and at present, there are no screening methods to detect which HPV infections that will become chronic. In the present study, we followed HIV-negative and HIV-positive Rwandan women with cervical HPV infections for two years with repeated samplings from the uterine cervix. We identified protein biomarkers that correlate with the potential risk for women to develop cervical cancer. By including the identified biomarkers in cervical screening programs, we are able, potentially, to identify those women with cervical HPV infections, who should be carefully monitored in the future.Background: Effects on the proteome when a high risk (HR)-HPV infection occurs, when it is cleared and when it becomes chronic were investigated. Moreover, biomarker panels that could identify cervical risk lesions were assessed. Methods: Cytology, HPV screening and proteomics were performed on cervical samples from Rwandan HIV+ and HIV- women at baseline, at 9 months, at 18 months and at 24 months. Biological pathways were identified using the String database. Results: The most significantly affected pathway when an incident HR-HPV infection occurred was neutrophil degranulation, and vesicle-mediated transport was the most significantly affected pathway when an HR-HPV infection was cleared; protein insertion into membrane in chronic HR-HPV lesions and in lesions where HR-HPVs were cleared were compared; and cellular catabolic process in high-grade lesions was compared to that in negative lesions. A four-biomarker panel  was identified, which was able to distinguish chronic HR-HPV lesions from cleared HR-HPV/negative lesions (sensitivity 100% and specificity 91%). Another four-biomarker panel  was identified, which was able to distinguish high-grade lesions from low-grade/negative lesions (sensitivity 100% and specificity 81%). Conclusions: We have identified the biological pathways triggered in HR-HPV infection, when HR-HPV becomes chronic and when cervical risk lesions develop. Moreover, we have identified potential biomarkers that may help to identify women with cervical risk lesions. Cervical cancer is the most important cause of cancer death among women living in sub-Saharan Africa . ChronicDifferent approaches have been tested to reduce the number of cases of cervical cancer in developing countries. Cytology as a screening method is difficult to implement in developing countries due to a limitation in the number of cytologists. We and other research groups have shown that HPV screening may be used to identify women with high-grade cervical lesions in Rwanda ,6. WhileProteomics has been used for identifying biomarkers correlating with the presence of premalignant lesions and cancer of the uterine cervix ,8. BiomaThe present study was conducted in HIV positive and HIV negative women in Rwanda, where women were sampled from the uterine cervix at repeated occasions during a two-year period. The study had two general aims. First, we wanted to assess what happens in the uterine cervix when a cervical HR-HPV infection occurs and is eventually eradicated, when an HR-HPV infection becomes chronic and when high-grade intraepithelial lesions (HSIL = CIN2+/CIN3+) and cervical cancer are developed. Secondly, we wanted to identify biomarker panels that could discriminate between high-grade and chronic HR-HPV positive lesions and benign cervical lesions.® . The initial intent was to do both transcriptomics and proteomics; however, the concentrations of RNA in the samples were too low to do transcriptomics. Participating women underwent the same sampling procedure as described above after 9, 18 and 24 months. Possible high-risk (HR)-HPVs were grouped together with HR-HPVs. The women categorized as having an HR-HPV chronic infection were those presenting with HR-HPV infections at baseline that were still present at follow-up after 24 months (n = 14). Women categorized as HR-HPV cleared were, at first sampling, HR-HPV positive and, at follow-up, were HPV negative at two sampling occasions (n = 9). Women categorized as HR-HPV incident were, at first sampling, HPV negative and, at the next follow-up, HR-HPV positive (n = 7). Average time span from baseline sampling to follow-up sampling for HR-HPV cleared and HR-HPV incident groups was 8.1 ± 0.4 months (n = 7 + 9). HPV negative women were defined as women who were HPV negative at all sampling occasions and with no cytological changes . The HR-HPV chronic group was subdivided into high-grade and low-grade lesions (n = 5), adenocarcinoma in situ  or squamous cell carcinoma  were defined as high-grade lesions, and, where cytology was graded as low-grade squamous intraepithelial lesion , atypical squamous cells, undetermined significance  or normal cytology (n = 2), they were grouped and defined as low-grade lesions (table). Age, HIV status, cytology and HPV status and HPV types are described in the table. The description of the present cohort has been presented in detail in our previous study . In brie lesions . SamplesFirst, we wanted to assess whether the proteome changed in response to the development of the HR-HPV infection and what happens in the proteome when the HR-HPV infection is cleared  analysis and proteomic data analysis, are described in The statistical analyses and software used for statistics as well as Venn diagrams and volcano plots are described in Squared Euclidean distance-based hierarchical clustering analyses were performed with Perseus software (v1.6.14.0) for either all changed proteins between groups or the 40 most changed proteins according to the absolute fold-change .The Search Tool for the Retrieval of Interacting Genes/Proteins (String) software (version 11.0) was used for protein-protein network analysis . The conThe Institutional Review Board at the College of Medicine and Health Sciences, University of Rwanda and the Regional Ethical Review Board in Gothenburg approved the present study. Written informed consent was provided by each participant in the study. The code is 642-15 for the Swedish approval and 081/2015 for the Rwandan approvaln = 7). In paired samples between uninfected at baseline and HR-HPV infected at follow-up, 181 proteins were up-regulated, and 133 proteins were down-regulated at follow-up ; Protein-protein network analysis of the 40 most changed proteins in the HR-HPV incident group showed that 27 of these genes were related to neutrophil degranulation , 133 proteins were significantly more expressed and 57 proteins significantly less expressed, as compared with the negative group (n = 14), and 91 proteins were significantly more expressed, and 24 proteins significantly less expressed, as compared with the low-grade lesion group , β (subunit 2) and γ (subunit 3). Studies show that eIF2 counteracts viral infections, and phosphorylation of eIF2α leads to the inhibition of HPV18 E6 protein synthesis . The eukFew biological pathways could be identified changing in the cleared HR-HPV group vs. the chronic HR-HPV group. Among the biological pathways identified, pathways regulating how proteins were established in membranes were affected. There was also a limited number of biological pathways changed between the cleared HR-HPV group and the negative group. The time span between the paired samplings was eight months, and the results may indicate that the establishment of HPV infection takes place during a longer period of time than the period of time for clearance of HPV infection. The biological pathways that changed in response to HR-HPV chronicity were regulating metabolism. The organonitrogen compound metabolic process had low FDRs both in comparisons between the cleared HR-HPV group and the negative controls as well as between the chronic HR-HPV group and negative controls. LIMCH1, SGTA, BLOC1S5, EIF1, GRPEL1, optineurin and ezrin were proteins identified as potential biomarkers to screen out HR-HPV lesions. LIMCH1 was recently identified as a biomarker for aggressive cervical cancer . The samWe found evidence that pathways regulating RNA were the most important pathways for distinguishing high-grade lesions from other cervical samples. Alternative splicing is important for the life cycle of HPV . Our finThe two-four protein biomarker panel gave a high accuracy in predicting that the sample was a high-grade lesion among other lesions. Combining DNAJA4 with IGKV2-30 gave an AUC of 0.95 of the ROC curve. Also including ERH and TMEM97 in the biomarker panel only increased the AUC to 0.97. While the proteins in the biomarker panel have not been identified in the pathogenesis of cervical dysplasia and cancer, the proteins are identified as regulators of dysplasia and cancer in other tissues. The heat shock protein (HSP) family member DNAJA4 is induced in T-cells in heat shock and in HIV-1 infection . The V rThe weakness of the study is that the number of women assessed was low, and for the chronic HR-HPV group, we only assessed HIV positive women. Due to a limited number of chronic HR-HPV samples, we could not group according to cytological categories, and therefore, one limitation is that the HR-HPV chronic group constitutes a mixed group for cytology. Studies show that HIV positive women have more CD8+ lymphocytes in HPV-positive cervical lesions, compared with HIV negative women ,46. TherWe have identified biomarker panels that may potentially distinguish high-risk cervical lesions from low-risk lesions. Moreover, we found evidence for the involvement of neutrophils in the development of HR-HPV infection. The panels of biomarkers are currently validated in a new cohort of HIV-positive women in Rwanda and will also be validated in a cohort of HIV-positive women in Ethiopia.


We estimated and compared the travel related carbon emissions of the annual meeting of the Canadian Association of Gastroenterology between the two most common geographical locations of the meeting.We modelled the car, train and flight travel journey of each registrant to two annual meetings. One was held in Toronto, close to where the majority of Gastroenterogists live, the other in Banff in the west of the country. We used validated carbon emission outputs per kilometer of travel.2equivalent (CO2e) emitted per person. When the meeting was held in Banff emissions were 41% higher than those in Toronto with an average distance travelled of 3949 km and 0.760t of CO2e emitted per person. Almost all of the travel related carbon emissions for both meetings were generated by flying.The average per capita distance travelled to the Toronto meeting was 2845 km, resulting in 0.540 tonnes (t) of COEven when held close to the largest population centre, there is a large environmental impact from travel to annual meetings. Importantly, choice of meeting location has a very big impact on difference in carbon emissions. Societies need to consider the site of meetings and reduce the number of in-person attendees if they wish to reduce their carbon footprint. Hybrid models participants should be considered. Our analysis also suggests, other medical societies who wish to model their annual meetings can use a simplified model, using flying distance only, to estimate travel-related emissions. Climate change has been described as the greatest public health threat of the 21st century . Travel, with its associated carbon emissions from driving and flight, is a significant contributor to GHG emissions (It is primarily caused by rising atmospheric greenhouse gas (GHG) concentrations as a result of combustion of fossil fuels. There are many different GHG such as CO2, methane and nitrous oxide. Each has a different atmospheric warming potential and duration of effect. COmissions .Health care providers and scientists have a role to play in mitigating the effects of climate change through education, advocacy, and changes in personal and professional behavior, including travel which can make up a significant portion of an individual’s annual carbon footprint .The Canadian Association of Gastroenterology (CAG) consists of over 1000 members, health care providers and scientists, who are involved in digestive disease and health. An annual meeting, Canadian Digestive Disease Week (CDDW), is held for the purposes of promoting the objectives of the Association. Most of the membership (approximately two thirds), live in the Provinces of Ontario and Quebec , which aThe objectives of this study were twofold. Firstly, to determine the travel related carbon emissions of the annual CDDW meeting. Secondly to compare the magnitude of the effect of holding the meeting close to where most gastroenterologists live (Toronto) to that in a more scenic site . The last two meetings have been held in these two locations. Our hypothesis was that holding the meeting in a location closer to where most members of the CAG live, namely Toronto in the east-central zone, is associated with reduced travel related carbon emissions, but were surprised at the magnitude of the effect we found.The Canadian postal code is alphanumeric and consists of six digits, for example, B3H 2L0. The first digit (letter) denotes a Province with the exception of the Provinces of Quebec (which has three codes) and Ontario (which has five codes). There is a specific digit for the cities of Toronto (M) and Montreal (H). The second digit (number) represents a specific rural region, an entire medium-sized city, or a section of a major metropolitan area. The third digit (letter) represents the postal district in the rural region/city. For example, the code B3H represents the Province of Nova Scotia (B), the city of Halifax (3) and the postal district within Halifax (H). The last three digits of the postal code allow location of a street address. In order to preserve confidentiality, we did not review the data for these final three digits.We consulted with the Capital Health ethics board in Halifax. The study falls under Tri Council Policy Statement section 2.4 on secondary use of anonymous information. It did not require a research ethics board review.We obtained the data from the Canadian Association of Gastroenterology on the attendees at the last two in-person meetings. The inclusion criteria included the following:Attended CDDW in Toronto (2018) or Banff (2019)Canadian postal code availableMember (Regular or Trainee of the CAG)International participantIndustry/sponsor participantWe determined the originating site of travel, from the first three letters of the postal code of residence, of attendees at the Toronto and Banff Meetings.The total distance for each person was calculated from three components.A. Distance to departure: If the attendees needed to fly to the conference and there was an airport within 50 km of the residence, we discounted this distance because we could not accurately determine the point of departure. If the attendee needed to drive, or take a train, more than 50 km to the airport the round-trip distance to the departure airport was calculated. If the attendee did not need to fly, no distance charge to an airport was added.B. Flight distance. We calculated the distance from the departure airport, if one was likely used, to the arrival airport in Toronto or Calgary (the airport for Banff).C. Finally, we added the travel distance from Calgary airport to Banff; a round trip of 240 km. The conference centre in Toronto is located in the centre of the city, 30 km from the airport. We did not add this distance to the travel distance.Calgary is the major airport for Banff and also has an academic centre. There is a second major urban area in Alberta, Edmonton, 300 km north of Calgary which also has a medical faculty. We assumed that all of the Gastroenterologists in the two major urban areas of Alberta drove to the meeting, that they drove alone, and used a medium-sized car. We assumed that all attendees from outside Alberta flew to Calgary and then travelled the 240-km round trip by coach to Banff.Participants who lived within the metro Toronto area , were not given a mileage charge to the Toronto meeting.There are nine academic gastroenterology centres, with significant numbers of CAG members, within potential driving, or train, travel distance to Toronto. All, with the exception of McMaster, have flight connections to Toronto. Attendees from these centres have a choice of travel modes which include road, rail and air. Based on input from educators at these centres, we modelled travel patterns  from theWe used Google maps to calculate driving distance, Via Rail comparison tool to determine train distance, and airport.globefeed.com/Canada  to measu2equivalents (CO2e). We used the following estimates. Short-haul flights were defined as those less than 1500 km one-way, long haul were greater than 1500 one way  of total travel. The travel distance of attendees who drove to the Toronto meeting was 2.4% of all travel, and train travel was 1.9%. Ninety-six per cent of travel to the Toronto meeting was flight related, 91% of this was related to long-haul flights in excess of 1500 km per flight segment. With regard to carbon emissions, 96% of the emissions were related to flying. The total CO2e was over 380t, which is equivalent to 0.760t of CO2e per attendee.The total distance travelled by attendees at the Banff meeting was nearly 2 million km, averaging nearly 4000 km per attendee. Travel to reach the departure airport was 1% of total, similar to the Toronto meeting. The travel distance of attendees who took a car or coach to the Banff meeting was more than the Toronto meeting at 7.6% of all travel. This reflects both travel from Edmonton and the return coach journey to Banff of arrivals at the airport in Calgary, which generated 4.4% of all travel kilometres. There is no effective train connection between Calgary, Edmonton and Banff, so train travel was not a factor. Over 92% of travel to the Banff meeting was flight related, 93% of this was related to long-haul flights. With regard to carbon emissions 92.4% of the emissions were related to flights. The total CO2e emissions 220 kg higher per person.The average distance travelled to the Banff meeting was 1104 km more than that of the Toronto meeting and the COThe estimated travel distances to the Toronto meeting by attendees from parts of Quebec and Ontario was based on expert opinion on the percentages who might have travelled by road, rail or air. Using the expert opinion model, the distance flown was 61,079 km by Ontario and Quebec attendees. In a sensitivity analysis, we estimated the flight travel distance if all of these travelled by air as opposed to travelling by a mixture of road, rail and air. If all attendees from Ontario and Quebec flew, we estimated the flight distance at 113,876 km, a difference of 52,797 km. from the expert opinion model. Given the total distance traveled to the Toronto meeting was 1,519,294 km, the difference between expert opinion and possible all flight model is 3% and not likely a major source of error.We did not add a travel cost for attendees from the Toronto area, postal code M, to the Toronto meeting as we did not know their departure point. The maximal distance within this area to the convention centre is 50 km return. There were 60 registrants from postal code M. If we assigned a 50 km travel distance to each, the total travel contribution would be 3000 km daily, or 9,000 km for the 3-day meeting, an insignificant contribution given the total meeting travel of over 1.5 million kilometers.2e/km for short-haul flights and 195 g CO2e for long-haul flights. These values represent the average passenger. Short haul was defined as <1500 km, long haul >1500 km. However, it is likely that some attendees flew business class. As shown in Air travel represented 92% of travel to the Banff meeting and 96% of travel to the Toronto meeting. We chose carbon emission values of 158g COIf all attendees flew in economy, emissions would be reduced by 22%. If all attendees travelled in business class, the flight-related emissions would more than double. We do not know what percentage of attendees flew in economy or business.2e per attendee. Emissions were estimated to be 41% higher when the meeting was held distant from the largest Canadian population centres. Thus, choice of meeting location is extremely important with regards to the carbon footprint of the annual society meetings. Meeting organizers should consider this when choosing a venue. We are not aware of any other estimates of environmental impact of Canadian medical meetings and suggest all societies should include such estimates when planning their meetings.When the annual CAG meeting was held in the vicinity of where most attendees live, the Toronto – Montreal axis, we estimated the travel related carbon emission total was 288t, nearly 540 kg of CO2 is equivalent to 600 L of CO2 gas, therefore each attendee at the Banff meeting results in nearly a half million liters of travel related CO2 being released into the atmosphere where it persists indefinitely and will contribute to warming of the atmosphere for millennia. The average distance driven of a car in Canada is 20,000 km per year with a fuel efficiency of 9 L/100 km. The annual fuel consumption will be 1800 L of gasoline , but they are likely to be similar to Toronto. With regard to decreasing attendance, we need to understand which objectives are best served by face-to-face meetings and which can be met online. For example, nearly half of the attendees were trainees. It may be that the benefits of bringing members of the profession together at earlier stages of their career to encourage networking and build professional identity outweigh the negative environmental impact. Conversely, there may be some members of the profession who do not need to attend in person. Future needs analysis needs to include the traditional educational objectives as well as other domains, such as professional development, and networking, which are not always explicit.In addition to modifying the location of the meeting and who needs to attend in person, there are other options to the traditional format. These include holding a simultaneous western and central meeting perhaps with faculty representatives at both sites. The difference in travel emissions between the meetings in Banff and Toronto may be less than expected for some readers. The explanation appears to be that when the meeting is held in Ontario, the second largest block of gastroenterologists  fly to Toronto and when the meeting is held in Alberta the largest block of gastroenterologists  fly to Calgary. Moreover, the number of attendees from Ontario and Quebec are almost equal to those from prairies/western provinces . Given that the round-trip distance from Calgary to Toronto is 5400 km, it is inevitable that a single meeting will generate considerable carbon emissions. A two-site concurrent meeting would provide an in-person meeting for the majority of Gastroenterologists while minimizing long-haul flights. Canada has a large geographical distribution and hence innovative travel, and meetings options need to be considered to reduce our carbon footprint. France has recently banned short domestic flights, where the alternative is 2.5 hours or less by train. Such an initiative may have limited impact in a large country such as ours.A biennial meeting would reduce emissions by 50% with no change of venue. Virtual meetings, and hybrid meetings where some attend in person, may also have a role , 20. EmiA reduced number of attendees may make the traditional attendance of industry at medical conferences cost ineffective. Clearly, this requires discussion and planning with industry supporters. Alternative virtual presence or distributed numbers at two sites should be considered.If in-person meetings are required, then there are guides which will help reduce the carbon footprint and steps which can easily be taken by meeting planners. These include planning for waste management, changes to catering and choosing venues which are energy and design environmentally friendly , 22. Enc-6 of annual national emissions. The impact of the leadership shown on this health emergency, and the message sent with regard to the climate crisis, to attendees and all other partners in the annual meeting is likely to be far more impactful.The COVID pandemic has shown that it is possible to continue the activities of medical societies online. Given the emerging climate crisis, we believe that societies should look at their annual conferences, and other programs which involve travel, not only from a financial cost-benefit perspective but also with regard to the environmental cost. The reduction in Canada’s annual GHG emissions of 729 million tonnes  by movin


A subset of carcinomas that arise in the head and neck region show a viral etiology. In fact, a subgroup of oropharyngeal cancers are caused by some types of human papillomavirus (HPV), so-called high-risk (HR)-HPVs, whereas undifferentiated nasopharyngeal carcinomas are etiologically related to Epstein–Barr virus (EBV). However, studies have reported the presence of both HR-HPV and EBV in some types of head and neck cancers. In this review, we discuss the potential contribution and role of HR-HPV/EBV coinfection in head and neck carcinogenesis, as well as the mechanisms that are potentially involved. In addition, HR-HPV/EBV interaction models are proposed.High-risk human papillomaviruses (HR-HPVs) and Epstein–Barr virus (EBV) are recognized oncogenic viruses involved in the development of a subset of head and neck cancers (HNCs). HR-HPVs are etiologically associated with a subset of oropharyngeal carcinomas (OPCs), whereas EBV is a recognized etiological agent of undifferentiated nasopharyngeal carcinomas (NPCs). In this review, we address epidemiological and mechanistic evidence regarding a potential cooperation between HR-HPV and EBV for HNC development. Considering that: (1) both HR-HPV and EBV infections require cofactors for carcinogenesis; and (2) both oropharyngeal and oral epithelium can be directly exposed to carcinogens, such as alcohol or tobacco smoke, we hypothesize possible interaction mechanisms. The epidemiological and experimental evidence suggests that HR-HPV/EBV cooperation for developing a subset of HNCs is plausible and warrants further investigation. Head and neck cancers (HNCs) encompass tumors of a variety of subsites, including the lips, oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, and salivary glands. Head and neck squamous cell carcinomas (HNSCCs) constitute more than 90% of all HNCs . These mEpithelial tissues are susceptible and permissive to both HPV   and EBV EBV exhibits a similar epithelial tropism, although EBV cell entry occurs through both apical and basolateral routes in mucosal epithelia , and thiAs in epidemiological studies, the cellular location of viruses is generally not considered, and the term “copresence” is assumed when HPV and EBV are both detected in tumors. However, copresence in tumors is not synonymous with coinfection, which occurs when both HPV and EBV infects the same epithelial cell. Molecular methodologies, such as a polymerase chain reaction (PCR), cannot determine the coinfection or coexpression of viral products, although this test is frequently used in epidemiological studies. HPV/EBV copresence has been evidenced in 31.2% of HNCs, which includes larynx, lip, and nasopharynx malignancies . SimilarMore than 90% of oral tumors are squamous cell carcinomas (OSCCs), which arise from the mucosal epithelium lining the lips, anterior tongue, gingivae, floor of mouth, palate, and other areas of the mouth . In 2020Nasopharyngeal carcinoma (NPC) is a HNC with an estimated 133,354 new cases and 80,008 deaths in 2020 . AccordiAn estimated 98,412 new cases and 48,143 cancer deaths worldwide were attributable to oropharyngeal tumors in 2020 . EtiologHNCs also include tumors arising from the hypopharynx, larynx, paranasal sinuses, nasal cavity, and salivary glands. However, data regarding HPV/EBV coinfection in these neoplasms are scarce. HPV/EBV coinfection was reported in 25% and 33.3% of hypopharyngeal and paranasal sinus carcinomas, respectively . In addip = 0.0194), although no difference was observed between HPV+/EBV+ NPCs and those harboring EBV or HPV single infections [The cluster of differentiation 21 (CD21), also known as the complement receptor type 2 (CR2), is considered to be the major attachment receptor for EBV in B cells . Howeverfections . Furtherfections . In addifections . Similarfections . These ffections . HoweverCultures of normal epithelial cells in which the EBV lytic cycle is preferentially established appear unable to sustain latent EBV infection ,127,128.Both HPV and EBV demonstrate a broad range of mechanisms to evade both the innate and adaptive antiviral host response for virus replication . InAn increased expression of TLR3, TLR7, and TLR8 has been associated with HPV16 clearance/control in cervical specimens . HoweverIFNs constitute one of the first lines of host defense against virus infections. The production of IFN-α and IFN-β is activated mainly by the IRFs 3 and 7 (reviewed in: ). The reThe host innate response to viral infection is composed of the production and release of pro-inflammatory cytokines, which are also hijacked by viral proteins. For instance, HPV E2, E6, and E7 oncoproteins induce the production of interleukin-10 (IL-10), which, in turn, activates the Janus kinase-1/tyrosine kinase-2/signal transducer and activator of transcription 3 (JAK1/Tyk2/STAT3). The stimulation of the STAT3 pathway inhibits macrophage activation and the production of some inflammatory cytokines, such as TNF-α, IL-6, and IL-1β . Other pIt has been reported that HPV16 E7 decreased the activity of the IKK complex (α and β), which induces the IκBα phosphorylation and degradation of the NF-κB inhibitor . FurtherIt has been reported that the HR-HPV E5 oncoprotein can disrupt antigen presentation by downregulating MHC/HLA class I membrane expression with accumulation in the Golgi’s apparatus ,212. ThiIt has been proposed that HR-HPV and EBV interactions could contribute to cancer EMT and cancer progression, including HNC ,215. HowAl-Thawadi et al. found an association between the LMP1/E6 co-expression and upregulation of the inhibitors of DNA binding 1 (Id-1) in cervical carcinomas . Indeed,An increased frequency of TP53 promoter methylation was evidenced in HR-HPV/EBV-infected OPSCCs compared to HR-HPV or EBV infection alone . AdditioIn OPSCC, the activity of glutathione peroxidase (GPx) and superoxide dismutase (SOD) antioxidant enzymes was significantly decreased in patients with HPV/EBV coinfection when compared with HPV or EBV infection alone. A low GPx and SOD activity was observed in HPV/EBV-coinfected patients with poorly differentiated tumors and an advanced stage of disease .Sharma et al. (2019) studied the association of the TLR 9 (−1486 T/C) genotype, and wild (TT), hetero (CT), and homozygous (CC) allele, with HPV/EBV coinfection in pre-malignant and OSCC samples . InteresSingle HR-HPV or EBV infections are insufficient for carcinogenesis, suggesting the involvement of additional factors. Both HR-HPV and EBV have been detected in HNCs, most notably in oropharyngeal tumors. The HPV/EBV copresence in HNCs is highly variable worldwide, ranging from 6.5% to 37.5% of OSCCs, 15% to 47.7% of NPCs in endemic regions, and 53.3% to 86% of OPSCCs. Potential mechanisms for HPV/EBV cooperation remain unclear, although some possibilities have been suggested. First, HPV could facilitate EBV entry by promoting an increased expression of integrins and CD21. Second, HPV could facilitate EBV latency establishment by promoting genetic alterations due to HR-HPV genome integration into the host genome. Third, local immune evasion promoted by HPV infection could facilitate secondary EBV infection in epithelial cells. Additionally, HPV and EBV viral oncoproteins can synergistically cooperate for head and neck carcinogenesis. Additional studies are warranted in order to evaluate the mechanisms involved in the cooperation between HPV and EBV for head and neck carcinogenesis.


We aimed to assess awareness, knowledge, and attitudes of healthy pregnant women towards human papillomavirus (HPV), to estimate factors associated with a positive attitude towards HPV immunization and to assess the uptake of the vaccine among their children. A cross-sectional study was conducted at the University Clinic of Gynecology and Obstetrics, Belgrade, Serbia among pregnant women attending their regular gynecological check-ups at the 12th gestational week. Knowledge about HPV and HPV vaccine was assessed using a specifically designed 12-item and 5-item questionnaires. Out of total 265 included women, 79.3% had heard of HPV, and 37.5% knew that HPV vaccine exists. HPV vaccine knowledge score was associated with higher odds for a positive attitude towards vaccination of both female  and male  child. The number of children  and high vaccine knowledge score (OR = 1.64 95% CI 1.13–2.39) were independent predictors associated with willingness to vaccinate child against HPV. The gynecologist was the preferable point of reference for information seeking about the HPV vaccine. Despite relatively high HPV awareness and knowledge among pregnant women in Serbia, about one-third of them are HPV vaccine aware, and are willing to vaccinate their children against HPV. Human papillomavirus (HPV) is considered to be the most common sexually transmitted infectious agent today . The estCervical cancer in Serbia is the fourth leading cancer among women and the second most common cancer among women aged 15–44 . Many efThree types of HPV vaccine are available in Serbia, bivalent, quadrivalent, and nine-valent HPV vaccine . The volAccording to the guidelines, it is recommended for all children aged 11 and 12, teenagers who have not been vaccinated, and young women up until the age of 26 and young men up until the age of 21 . Yet, thExcept mother’s educational level and parental acceptance of the vaccine in general ,13, the The aim of this study was to examine the HPV and HPV vaccine-related knowledge among healthy pregnant women in Serbia, to assess factors associated with willingness to vaccinate their children, and to estimate the uptake of at least one dose of vaccine received by their children.This was a cross-sectional study, conducted in February 2020 among healthy pregnant women who attended the regular prenatal check-ups for the screening of fetal aneuploidies and morphological anomalies (“double-test”) performed at the 12th–14th gestational week at the Clinic of Gynecology and Obstetrics, Clinical Centre of Serbia, Belgrade. This University Clinic is one of the three Gynecology and Obstetrics clinics in the capital of Serbia. They are available for all pregnant women because the mandatory social security insurance, which exists in our country, allows access to any of them. The double test screening is recommended for all pregnant women in Serbia and, in Belgrade, is being done in tertiary institutions only. A total of 256 consequent women who attended the check-up at the time of the study were included.http://www.batut.org.rs/download/aktuelno/rgm2019/Brosura%20HPV.pdf, accessed on 1 March 2021). We previously used this questionnaire in our study on women referred to colposcopy and/or HPV testing and on a sample of medical students ) for continuous variables, depending on the normality of data distribution, and number (percentage) for categorical variables. Differences in knowledge scores between the categories of patients’ characteristics were assessed using the Mann–Whitney U test. A Chi-square or Fisher’s exact test was used for the analysis of categorical data, where appropriate. Univariate logistic regression analyses were performed for HPV awareness, HPV vaccine awareness, HPV vaccine knowledge, and willingness to vaccinate themselves as an outcome. The multivariable logistic regression model was performed to identify factors associated with the willingness to vaccinate their child against HPV. Variables that were significantly associated with these outcomes at the significance level <0.1 in the univariate logistic regression analysis and based on clinical significance were entered into the multivariable logistic regression model. Odds ratios (OR) with 95% confidence intervals (CI) were computed and the Hosmer–Lemeshow goodness-of-fit test was performed to assess overall model fit. The statistical analysis was performed using SPSS version 23.0 software .The average age of the pregnant women included in the study was 33 ± 7.1 years . SlightlOut of a total of 256 women included in the study, 203 (79.3%) had heard of HPV while substantially fewer women, 96 of them (37.5%), knew that the HPV vaccine exists. Odds ratios with 95% confidence intervals along with median knowledge scores about HPV and HPV vaccine are presented in Factors associated with the highest odds of having heard of HPV vaccine were older age , university degree compared to high school graduation , urban compared to rural residence , while having had one or more abortions was associated with a lower chance of having heard of HPV vaccine .Twelve questions used to assess HPV knowledge are presented in About two-thirds (64.6%) of vaccine-aware women knew that the vaccine was available in Serbia. Most of them knew (70.8%) that the vaccine was recommended before the first sexual intercourse and that vaccinated women should continue undergoing cervical cancer screening even after vaccination (72.9%). About half of women (56.3%) knew that vaccines cannot cause cervical cancer. One-third (32.3%) of respondents knew that the vaccine was also recommended for men. The median knowledge score about HPV was 3.0 (IQR = 2).The majority of women used Internet sites of official organizations and this source of knowledge was significantly more often reported by women who had a score of HPV knowledge greater than seven while women who had a score of HPV knowledge ≤7 used other sources of information in larger numbers . Gynecolp = 0.120).Only 7 out of 232 women (3%) responded that their child had been already vaccinated against HPV with at least one dose of the vaccine, without a significant difference between low and high HPV knowledge groups (2.1% vs. 5.3%, Willingness to vaccinate themselves or their children against HPV increased substantially with increased awareness that vaccine exist and with a higher score of knowledge about HPV vaccine . HPV vacMultivariate logistic regression with OR and 95% CI for factors associated with willingness to vaccinate child against HPV among pregnant women is presented in The present study examined the awareness and knowledge of healthy pregnant women in their first trimester of pregnancy in Serbia on HPV, along with their attitudes on vaccination, factors associated with willingness to vaccinate their children, and actual uptake of the HPV vaccine.Our study showed that almost 80% of our participants stated that they have heard about HPV before, but much less, only just over a third was aware that there is an HPV vaccine. In our previous study, conducted seven years before the current, among women with positive PAP smear test obtained at the primary care facilities and referred to the hospital for further examination, it was found that 60.5% of women had heard of HPV . The intHPV awareness was significantly associated with educational level in our study, as women with secondary education had more than 6.5 times higher likelihood to have heard about HPV and those with tertiary education had 17.2 times higher likelihood to be aware of HPV compared to participants with primary education only. Serbia has a well-developed network of primary health care centers with gynecological health care services and routine pregnancy counseling sessions for pregnant women. These sessions could include the provision of information on HPV with a special focus on the provision of proper, detailed, and tailored information such that even women with lower education could benefit from.It has been more than ten years since the HPV vaccine was introduced in EU countries . In SerbThe trust in the vaccine safety is considered one of the main factors influencing the vaccination uptake. Unfortunately, recent analysis showed the decrease in the belief that vaccines are safe in Serbia and that general trend may have influenced the willingness for uptake of HPV vaccine as well. This presents the rising global public health issue and calls for joint public health action .Women with a higher number of children had 1.32 times higher likelihood to be willing to vaccinate a child against HPV, while with each point increase in the vaccine knowledge score, the likelihood for willingness to vaccinate increased by 64%. These results also strengthen the importance of adequate educational programs and as multiple previous studies have shown ,26 higheAlmost 90% of the participants reported that they would be seeking information on HPV vaccination from their gynecologist. This is a good indicator of the trust between pregnant women and their chosen gynecologists, which was also shown previously, as frequent prenatal visits improve the relationship between patients and physicians .Given the fundamental role of parents in HPV vaccine uptake of their children, public health strategies should address modifiable factors that influence parents’ uptake, in particular increasing women’s awareness of the vaccination benefits and addressing their fears about vaccine safety. Particular clinical importance reflects in the role of gynecologists in offering the vaccine and communicating its benefits to pregnant women for their female and male children. Motivation and education of the clinicians to promote and offer the HPV vaccine to the pregnant women together with other public health strategies to educate women on this topic could have an important role in accelerating the vaccine uptake.The main limitation of this study is that it was conducted in only one university obstetric clinic. However, all three obstetric clinics in Belgrade are close to each other and are all accessible to women due to public social security. Moreover, the study was conducted at the largest clinic for gynecology and obstetrics in the capital of Serbia. Besides, the double test is mandatory for all pregnant women at the end of the first trimester of pregnancy and it is available only at university clinics in our capital, and not in primary health care centers, which are the most common centers for other examinations during pregnancy. Another possible limitation is that this cross-sectional study was conducted during the first trimester. Expectant mothers may think more about the vaccination of their child before the end of pregnancy and ask for more information about all vaccines, which would increase their level of knowledge about the HPV vaccine. However, it was found that the prevalence of HPV is higher during pregnancy, due to hormonal changes in the body of expectant mothers. The viral replication is very high during the second trimester when the highest prevalence of HPV was observed . For thaOur study showed that about 80% of pregnant women in Serbia are HPV aware, but almost two-thirds of them are not HPV vaccine aware. Concerningly, only one-third of them are willing to vaccinate their children against HPV. As vaccine knowledge level is the independent predictor of vaccination willingness of currently pregnant women who are soon to be mothers of youth for whom the HPV vaccine is intended, there is a necessity for the introduction of the educational programs that would include wide populations of current and future mothers.


Background: Racial/ethnic minorities generally have a lower knowledge of human papillomavirus (HPV) and the HPV vaccine than non-Hispanic Whites. They are also less likely to have a regular healthcare provider (HCP). Given the role of HCPs in disseminating health information, we evaluated whether racial/ethnic disparities in HPV knowledge are moderated by regular HCP status. Methods: Data from the Health Information National Trends Survey Five (HINTS 5) Cycles One and Two (2017–2018) were analyzed. HPV and HPV vaccine knowledge were compared by regular HCP status across race/ethnicities. Independent partially-adjusted multivariable logistic regression models were used to assess the association between race/ethnicity and knowledge after controlling for sociodemographic characteristics. The resulting adjusted odds ratios were compared to those from fully-adjusted models that included HCP status. Results: After adjusting for regular HCP status, differences in knowledge persisted between racial/ethnic groups. Compared to Whites, Hispanics and Other race/ethnicities had significantly lower odds of having heard of HPV. Blacks, Hispanics, and Other race/ethnicities had significantly lower odds of having heard of the HPV vaccine. Conclusion: Racial/ethnic minorities had significantly lower levels of knowledge despite HCP status. These data suggest the need to address disparities in health information and strengthen provider–patient communication regarding HPV and the HPV vaccine. Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (U.S.), with nearly 80 million Americans currently infected and 14 million new infections expected each year . Over 45Racial/ethnic minority populations, particularly non-Hispanic Blacks and Hispanics, are disproportionately impacted by HPV and certain HPV-associated cancers. For example, non-Hispanic Black women have a 25% higher incidence of cervical cancer compared to non-Hispanic White women and are almost twice as likely to die from cervical cancer . Among HVaccine and other preventive care uptake is a complex, multilayered phenomenon influenced by factors at the personal, interpersonal, structural, and societal level . KnowledHCPs play an important role in the acceptance and uptake of the HPV vaccine and cervical cancer screening ,19. A hiGiven the role of HCPs in recommending HPV prevention services, we hypothesized that having a regular healthcare provider may attenuate racial/ethnic disparities in knowledge of HPV and the HPV vaccine. Here we examine racial/ethnic differences in knowledge of HPV and the HPV vaccine and assess how they are moderated by having a regular healthcare provider.Cross-sectional data were obtained from the fifth iteration of the National Cancer Institute’s (NCI) Health Information National Trends Survey (HINTS 5), Cycles 1 (2017) and 2 (2018). HINTS is a nationally representative random-digit dial telephone survey of non-institutionalized U.S. adults to monitor data on health-related behaviors, knowledge, and attitudes ,29. DataHave you heard of HPV?” and “Have you ever heard of the cervical cancer vaccine or HPV shot?” Having a regular healthcare provider was assessed through the item, “Is there a doctor/nurse/health professional that you see most often?” Sociodemographic variables were race/ethnicity , gender, age, education, and household income. Census region  and geographic area  were also available in the HINTS data files. Discussion of the HPV vaccine with a healthcare provider for the ad hoc analysis was assessed through the item “Has a doctor ever talked with you about the HPV shot?” This item was only asked to those individuals who reported having an immediate family member between the ages of 9 and 27 years old.Knowledge of HPV and the HPV vaccine were assessed based on the items, “p-values were used for comparisons by race/ethnicity, both overall and stratified by HCP status. Independent, partially-adjusted multivariable logistic regression models were used to examine the association between HPV and HPV vaccine knowledge and awareness in each racial/ethnic group after adjusting for sociodemographic characteristics. A second, fully-adjusted model for each outcome, which included sociodemographic characteristics and regular HCP status, was used to determine whether the latter had an impact on the association. All statistical tests were considered significant if the p-value was less than 0.05. An ad hoc analysis was conducted to examine the receipt of a provider recommendation among individuals with a regular HCP who were themselves or who had a family member who was age-eligible for the HPV vaccine . To account for the complex survey design and provide representative estimates of the U.S. population, data from Cycles 1 and 2 were weighted based on the analysis recommendations given by the HINTS investigators [Descriptive statistics were used to describe within-group frequencies and between-group comparisons. Wald chi-square tests and adjusted tigators ,31. Thistigators ,29. Datatigators ,31. All tigators .Of the 6552 respondents, 4093 were non-Hispanic White, 1057 were non-Hispanic Black, 778 were Hispanic, and 624 were of Other race/ethnicity. The results of the partially-adjusted multivariate logistic regression models (Model 1) comparing odds of HPV and HPV vaccine knowledge while adjusting for sex, age, education, income, census region, and geographic area, are presented in Racial/ethnic differences in knowledge of HPV-associated cancers were mostly non-significant except for cervical and oral cancer . In the In ad hoc analyses examining receipt of a provider recommendation among individuals with a regular HCP who were themselves or who had a family member who was age-eligible for the HPV vaccine, individuals of Other race/ethnicity had lower odds (OR = 0.44 (0.20–0.95)) of receiving a provider recommendation compared to non-Hispanic Whites . Odds ofThe findings of this nationally representative analysis show that racial/ethnic minority groups in the U.S. have significantly lower knowledge of HPV and the HPV vaccine compared to non-Hispanic Whites. Furthermore, certain minority groups also had significantly lower knowledge of the causal link between HPV and cervical cancer (Other races) or oral cancer (non-Hispanic Blacks) compared to non-Hispanic Whites. Given that a regular healthcare provider is more likely to recommend preventative services  and counsel patients during preventative service encounters ,19, we hWe hypothesize that the null effect of regular HCP status on the association between race/ethnicity and knowledge of HPV and the HPV vaccine is due to the general low prevalence of HPV and HPV vaccine discussion between HCPs and patients. While a strong recommendation by a provider is a prominent predictor of HPV vaccine uptake , many HCIn our ad hoc analysis of individuals with a regular healthcare provider who were themselves age-eligible for the HPV vaccine or had an age-eligible family member, we found that the prevalence of HPV vaccine discussion with a provider was not significantly different for non-Hispanic Blacks and Hispanics compared to non-Hispanic Whites. Our ad hoc analysis had a relatively small sample size and was underpowered to detect meaningful differences. However, prior studies have reported significant racial/ethnic disparities in provider HPV vaccine recommendations . While fOur findings suggest that having access to a regular HCP does not mitigate disparities in knowledge of HPV or the HPV vaccine among racial/ethnic minority populations. This informs future opportunities to explore other options that may contribute to disparate knowledge such as the communication strategy used for patient–provider discussions regarding vaccination  especialThere are limitations to this research that should be considered when interpreting these results. As with all survey data, there is room for recall bias, particularly when reporting provider HPV vaccine recommendations. However, we are unaware of any data indicating that recall bias is differential across race/ethnicities. Our ad hoc analysis had a small sample size resulting in its low power to detect differences in HPV vaccine recommendation by regular HCP. Finally, while HCP status is a common marker of healthcare access and utilization , the varIn conclusion, having a regular HCP does not seem to attenuate the significant racial/ethnic disparities in HPV and HPV vaccine knowledge. Further research is needed to understand factors contributing to HPV knowledge differences and the subsequent development of targeted interventions to mitigate racial/ethnic disparities in knowledge and awareness of HPV and the HPV vaccine.


Men who have sex with men (MSM) and transgender individuals are at higher risk of genital warts and anal cancer due to sexually transmitted human papillomavirus infection. This study explores MSM and transgender women’s perceptions of Human papillomavirus (HPV) infection and HPV prevention strategies (screening and vaccination) in Pakistan.A qualitative study using focus group discussions (FGD) with self-identified MSM, male sex workers and transgender women were conducted between March 2019 to August 2019 in Karachi, Pakistan.Participants were recruited from community-based organization (CBO) working for MSM and transgender women. A total of 38 men and 10 transgender women took part in 6 FGDs. Discussions were recorded, translated, transcribed verbatim and analyzed using content analysis.Three themes were identified from the emerging analysis. These are, 1) Knowledge and risk perceptions about STIs and HPV, 2) Beliefs and attitudes towards HPV prevention, 3) Participant’s recommendations for HPV vaccination and anal Pap screening. Participants described lack of knowledge of HPV and its health consequences as HIV is the only focus of attention of the government and the local CBOs. None of participants had heard about HPV prevention including vaccination and anal Pap screening for men but expressed a positive attitude towards prevention. Genital warts and anal cancer were perceived as severe potential consequences of a known risk behaviors. All participants stated they would be interested in taking an HPV vaccine but acknowledged that the provision of services for sexually transmitted infections (STI) are inadequate to meet the needs of key populations and are not prioritized by the government. The main perceived barriers to access HPV prevention included cost and challenges to access public health care services or openly discussing one’s sexual orientation with health care providers. Participants generally preferred the CBO for more professional, unbiased staff attitudes that respect patients’ integrity, confidentiality and privacy. Most participants thought that in case the government is non-cooperative, CBOs should work in the interest of HPV eradication and generate funds through international funding.The findings from this study can help public health policy and researchers to understand this minority’s perspective on HPV prevention. Given the low level of knowledge about HPV infection and its negative health consequences there is a need of HPV education combined with STI education and awareness through HPV brochures to educate the target population effectively.The online version contains supplementary material available at 10.1186/s12889-022-12775-z. Human papillomavirus (HPV) infection is the most common viral sexually transmitted infection (STI) worldwide  and clasPersistent infection with high-risk HPV type most notably HPV type 16 is the major cause of anal cancer  and has The most effective strategy available to prevent HPV and related diseases in heterosexual and MSM populations is prophylactic vaccination. The Advisory Committee on Immunization Practices recommends vaccinating all MSM up through age of 26 years due to the increased risk of anal cancer in this key population  A recentFurthermore, anal Papanicolaou (Pap) screening for the precancerous HPV anal lesions as a secondary prevention may have greater utility in preventing future anal cancer –31 and iHPV vaccination is limited in Pakistan. HPV vaccine is available to private health care providers and pharmacies but is not yet part of national immunization programs targeting heterosexual or Lesbian, Gay, Bisexuals, Transgender and Queer (LGBTQ) populations. Before establishing vaccination and screening programs targeting LGBTQ populations, the health system needs to assess what factors exist that can hinder or facilitate the implementation of such programs among sexual and gender minorities.Previous studies done in Pakistan on HPV vaccine knowledge, attitudes and barriers among adults have found the low knowledge among men, moreover exorbitant cost, inaccessibility and misconceptions around vaccination were the barriers , 36 Thesattitudes and beliefs are meaningful predictors of human behavior  community, considering it as the most common STI, but then after knowing that HPV is the most actual common STI maybe I should prevent myself from getting it” .This limited knowledge translated into poor recognition of STIs symptoms. STIs symptoms were sometimes misunderstood by study participants as generated by other causes such as weather.“[LGBTQ people] think having itching, burning, redness of skin in sensitive areas is because of hot weather [We] can’t appreciate having gonorrhea – for example”. .During the FGDs they acknowledged that certain sexual practices put them at risk of contracting STIs. For example, they identified that having multiples sexual partners, sex with an HIV positive partner, sex work and condom less sex due to avoiding missing sexual encounters or due to fearing having less pleasure were sexual risk-taking behaviors among their community.“We are more adventurous when it comes to sex and [we] follow multiple routes, pleasure matters to [us], opportunity matters to [us]”. .“Vulnerability of a sex worker for STI is due to his sexual attitude – [We] do sex with multiple men, 4 to 5 times in a day, obviously, we are at risk no matter how much safe we make it. [We] are always at risk”. As sex workers, we are exposed to HPV more, clients do not use condoms, we [sex workers] get more money if we let [clients] do it without condom, that put us at more risk of getting HIV/HPV and other diseases!” .Although, participants had difficulty associating HPV infection with anal warts and sometimes warts were confused with other anal problems such as hemorrhoids. However, after discussing Ali´s vignette, participants were not only surprised to learn that nearly everyone who is sexually active will be exposed to HPV in their lifetime, but that also helped them estimating their self-risk for HPV. In addition, participants had never heard of anal cancer, the link between anal cancer and HPV infection or the need to screen for both.I am very scared of it [HPV]. I wasn’t this scared before, but now, I am very scared, I am worried as I am a gay like Ali [in the vignette]!! Here we think it [STI] is not a disease of the Muslims and why is its vaccination being done? [They] are destroying us, [we] are unable to access health care facilities” .“Furthermore, MSM recognized their increased susceptibility to HIV, and after learning from the Ali’s story (vignette) the similar route of transmission for HPV also, the participants realized that susceptibility chances may also be comparable to HPV since both diseases follow similar transmission pathways. Study participants seemed to be more aware of the implications of their risky behavior in terms of having unprotected sex with multiple sexual partners.Participants expressed a positive attitude toward HPV vaccination and screening. They believed that both vaccination and periodic anal screening were critical for their health in particular for those who were HIV positive. Having personal history of anal warts was the motivating factor towards receiving HPV vaccination. Although they might have been infected with the HPV before, however, spirits were high that vaccination could benefit them from other HPV types to which they had not yet been exposed. Moreover, peace of mind and protecting partners were other motivational reasons for HPV vaccine uptake.“Vaccine and screening are as if a drowning man catches a straw! I suffered warts multiple times, such a scary experience, when my partner moves on with someone else… having emotional trauma, anal warts is a huge problem, so after vaccination, I would have no fear of being thrown from the community, besides its your moral duty to save others after you save yourself!!” .“Until now, we didn’t have knowledge. Since now we do, we will get them somehow. One must get them in any way. One must somehow arrange for it. Sex workers earn meager money …would be difficult for us! However, it's about [our] health, I will make adjustments in my spending to spare some money for it. After knowing so much…I will not delay it!”Acceptability is associated with the knowledge and risk-perception, one of the participants vowed his concern as follow.HIV infection makes MSM pay more attention to their health, one of the participants who was newly diagnosed with HIV showed his acceptance and willingness for HPV prevention.“I am glad that the vaccine would wards off the risks of HPV and also helps improve one’s condition if he is suffering from the disease, getting vaccinated has its own set of benefits like protection from cancer, warts and other skin diseases I can see the future generations safe and healthy” .Informants who were sexual workers were supportive of prevention strategies because it would allow them to keep their clients, avoid losing income or being victims of violence.“We are unable to retain our clients, news spreads …as a result we are disowned by our guru… feeling of worthlessness… not bringing money in! so not only having lost means of bread but also being kicked out by our gurus so we lose the roof also and are on streets with no money and no food to eat….so now knowing about prevention we would be happy if this [CBO] or government can make arrangements for the prevention or even you[ME] itni bari dactor (well-known doctor) can arrange vaccine for us as a sadqa-e-Jariyah .Financial barriers were mentioned as key factors impairing access to HPV vaccination and screening. This was discussed to be especially true to poor LGBTQ people and those involved in subsistence sex work.“The one who has money will get them, but what about ones who can’t afford, people like us what should we do?” .Another important barrier mentioned was fear of discrimination by health workers due to their sexual orientation or their involvement in sex work. This perceived stigma made them uncomfortable disclosing their sexual orientation to health care providers, suggesting that they would be very selective about answering questions regarding their sexual behavior. Moreover, apathy and discourtesy from the doctor’s side may also discourage patients from attaining HPV immunization.“The biggest issue is that we are not socially accepted, [we] cannot openly discuss our issues with healthcare providers (HCPs) due to our social exclusion. [Our] social exclusion precludes disclosing health issues to HCPs” .“We [Sex workers] are reprimanded and mocked by physicians for our choice of life, I [Sex worker] feel so much disrespect—I won’t go to him [doctor] again” .The participants were unanimously of the view that we must always strive to educate and motivate others to get vaccinated and get the screening services. This will subsequently kick-start an ongoing cycle of raising HPV awareness- giving a deathblow to all the rumors and misconceptions attached with the side effects of the vaccine. Spreading the information forward to create a domino effect can help raise HPV awareness. They were of the view that CBOs and print and social media can also play a crucial role in creating awareness about essential knowledge of HPV.“Attempts to publicize HPV must be implemented by conducting such seminars to promote informed, healthy choices. Needless to say, this lack of awareness is responsible for the widespread, unchecked transmission from one individual to another.” .“A day should be dedicated to HPV to help raise awareness in Pakistan. This is going to encourage a culture of preventive care!” .The participants of a view that somehow disclosure of their sexuality become part of discussion in the context of requesting an STI testing. Some study participants shared stories of health care providers seeming uncomfortable or awkwardly asking questions, whereas others described situations in which they felt stigmatized or judged. One of the participants shared his views.“Health professionals under training should be exhorted (encouraged) to treat the patient irrespective of his sexual identity which is unfortunately not practiced. Thereafter, it creates a social stigma that establishes a communication gap during doctor-patient consultation.” .They very boldly recommended a need for more education of health care providers to reduce the perceived stigma for seeking health care services.“rampant homophobia makes the testing and screening for STIs difficult in our society, raised eyebrows and endless questions from the health care providers enables telling lies as this is the easy way out!…moreover doctors don’t understand unique needs of our community, there is a need to educate doctors and increase their competency to deal with LGBTQ health needs” and ‘‘I think it’s kind of the doctor’s job to make sure that you’re comfortable and speaking to them about whatever”. .When asked where the services should be provided, almost all participants unanimously thought that public hospitals are poorly adapted to offer HPV preventive services as without any a political will and proper attitudes towards the LGBTQ population, the patient fails to receive any substantial treatment at these sites.Participants prefer the community-based organizations for provision of these services because of the professional, unbiased treatment that incorporates maintaining the patient’s confidentiality and privacy. Moreover, they were of the view that these CBOs have always been at the forefront of providing myriad services in the past.Furthermore, while overall participants expressed their mistrust for the public hospitals however, showed their acceptability for the services to be provided at STI clinics being run by National AIDS Control Program of Pakistan as a second choice. They thought that the government as is in the other parts of the world must take HPV vaccination seriously.“Vaccine can be added in childhood immunization schedule because don’t know the future sexual life to be tested for HPV routinely as we go or HIV every second month, injections should be free or subsidized for people of the community who are needy, i.e., free for non- affording people as we get the services for HIV or else price should be subsidized. The price should be set to 1/4th of what it is now.” .Our main findings from this theory-guided qualitative inquiry showed that our study sample had low knowledge of STIs in general and HPV in particular, as well as had low self-risk perception of contracting HPV. Moreover, cost and revealing sexual orientation to the health care provider were the main barriers for electing for the prevention services.Up until our study participation in this study, most of the MSM and all transgender women were neither having any awareness or knowledge of HPV infection, which are generally consistent with the studies done in the US, UK Canada, Peru and different parts of Asian continent –53 nor wRisk perceptions are perhaps more important for attitudes and behaviors, for instance HPV vaccination and periodic anal Pap screening, that are intended to reduce a specific health threat such as anal warts and anal cancer and thus have a positive association between risk likelihood and subsequent action . Once thMoreover, many of the study participants related their poor awareness about HPV as STIs to the societal sex-adversity for discussion on sex-related issues in our country . The matAs suggested by others, , 63 we iAll participants expressed apprehensions, fear, worry, unease, and distress when given information that HPV is the most common sexually transmitted infection, most of them realized that they are at risk to acquire HPV as they are at risk of acquiring HIV as both share the same route of transmission. Moreover, HIV positivity increases individual self-care awareness and prompting them to seek knowledge and that increases willingness to adopt preventive behaviors . In our Of note, acquired HPV knowledge from the discussions, their estimated self-risk perception and HIV status were endorsed facilitating factors for the vaccination and periodic screening in our studied sample of MSM and transgender women which is in line with other studies being done in China and the United States , 65. PreHowever, one of the barriers being identified by our study participants was revealing one’s sexuality i.e., sexual identity or sexual orientation to a health professional to access these preventive services which is in agreement with other studies , 68 The Consistent with other studies , 74–78, Moreover, study participants expressed frustration and disappointment about the inability to get screened for HPV neither in the CBO nor is any set-up in any of the health care center by the government. This suggests that this minority group is receptive to HPV prevention and recommended to have the preventive services including anal Pap screening made available either in CBO or should be integrated in the HIV care and treatment program keeping the convenience and respect for their integrity and confidentiality in mind. To fit less educated targeted members of the community, another recommendation from the participants was to make the promotion material simple i.e., avoiding technical terms for greater understanding and reception.To the best of our knowledge this is the first study on this understudied, underserved priority population on the relatively naive phenomena of HPV. This qualitative inquiry provided a more nuanced picture of the issue and explored this group’s thoughts about HPV and its preventive strategies in a more microscopic manner. Trustworthiness of the findings was ensured by PI (ME) during data collection process who spent lengthy periods of time with the study participants and maintained prolonged and trustable engagement with them to build trust so that to have a grasp of the true reality of the issue. Moreover, during entire data analysis the discussions of the findings by ME with MS was an ongoing process to enhance the credibility of the study findings. Furthermore, ME maintained a log of reflexive notes after every FDG to become aware of personal biases, personal feelings, and pre-conceived notions. Throughout the data collection process in each FGD, the PI (ME) used to share with the participants the summary statements at the end of each point before moving to the next point of discussion. Moreover, at the end of each FGD, PI (ME) conducted a wrap-up session with the recruited participants whereby summarization of the entire discussion was done to have participants validation, in order to minimize the potential for researcher bias by actively involving participants in checking and confirming the salient features of the discussion. However, our study indeed has few limitations also. Although forty-eight members from sexual and gender minority participated in the six focus group discussions, we believe that we reached the point of saturation as no new comments, ideas or themes were generated. Secondly, only a few study participants were more involved or vocal in the discussions than others; however, we tried our best to encourage others who were quiet to share their thoughts and views also. Moreover, most of our study participants were poor and had no formal education which might lead to difference in response regarding knowledge attitudes and practices. Of note, this study was conducted in an urban city in which most participants were residents. Consequently, our study results may not be applicable to those living in rural areas.The findings from this study can help public health policy and researchers to understand MSM and transgender women’s perspective on HPV prevention. The demonstrated lack of appropriate knowledge of HPV infection in this study may potentially influence the priority populations’ perception of the need to adopt preventive behaviors which are often influenced by the perceived vulnerability and severity of a condition. These findings could provide the focus points towards building culturally relevant HPV prevention interventions including HPV awareness through social and print media and CBO promotions more specifically for sexual and gender minorities.Attempts to publicize HPV must be implemented by conducting seminars to promote informed, healthy choices. Moreover, health care providers need to widen their clinical lens so that it focuses not only on the diagnosis and treatment of illness but also on health promotion of sexual and gender minority. The Pakistani government could promote a policy to pay for the vaccination of population of sexual minorities as is already covering HIV care and treatment. Creative use of technology, bundling of HPV preventive services with other types of health visits, i.e., for HIV infected MSM and transgender women, HIV clinics would be a good starting point for promoting HPV knowledge and prevention. Moreover, strategies to initiate anal Pap screening will need to improve knowledge and understanding of risk for anal cancer in this at-risk group.Additional  file 1. FGDs Interview guideAdditional  file 2. Ali's Story