CADM1, MAL, and miR124-2 genes as triage tests in assaying self-collected cervical samples positive for high-risk HPV on primary screening, and to review the literature regarding host cellular gene methylation analysis of self-collected cervical samples.To assess the feasibility of partial HPV genotyping and methylation analysis of Women residing in North-East Italy who had failed to respond to the invitation to participate in an organized population-based program were invited to provide a self-sample. Their stored baseline (self-collected) and follow-up (clinician-collected) cervical samples were included in the study. DNA was extracted from HPV-positive  samples. Partial genotyping with separate detection of HPV types 16 and 18 was performed with a hybrid capture-based method and a quantitative PCR assay. Methylation was assayed with a quantitative methylation-specific PCR.miR124-2). Invalid quantitative PCR results were recorded in 5% of self-collected samples. The specificity of miR124-1, MAL, and CADM1 methylation was 84%, 94%, and 98%, respectively, and the specificity of the three markers combined was 84%. Sensitivity was not estimated due to the lack of CIN2+ samples. The systematic review showed that different methylation assays yield different accuracy values.High-risk HPV infection was detected in 48% of baseline and 71% of follow-up HC2-positive samples. Methylation was demonstrated respectively in 15% and 23.5% of baseline and follow-up samples and chiefly involved a single gene (Self-collected samples are suitable for methylation assays included in reflex triage testing. The reproducibility and accuracy of the methylation tests described in the literature should be improved. Cervical screening performed in the framework of organized population-based programs has reduced cervical carcinoma incidence and mortality . Key strCervical cancer is etiologically associated with human papillomavirus (HPV), in particular with persistent infection with high-risk types (hrHPV). Large, randomized, longitudinal clinical trials comparing cytology with hrHPV testing used as primary screening test have clearly demonstrated that HPV DNA testing (where hrHPV types were detected as a pool) was more effective than cytology in reducing the incidence of invasive cancer in women aged 30 years and older .Over the past few years, several trials have explored strategies to increase screening participation and primary screening test performance . In partCADM1 (cell adhesion molecule 1), MAL (T-lymphocyte maturation-associated protein), and miR-124-2 (microRNA-124-2) oncosuppressor genes, which are functionally involved in cervical carcinogenesis [A fundamental step of HPV testing strategies is the triage of hrHPV-positive women, to discriminate those at higher risk, who need immediate colposcopy, from those at lower risk, who are invited for re-evaluation . Self-collected samples are not suitable for cytology (the most widely used triage test), but can be used in molecular testing . Severalogenesis ,9. HPV togenesis  combinedogenesis ,12.CADM1-m18, MAL-m1, and hsa-miR-124-2. A systematic review of the literature on the analysis of host cellular gene methylation in self-collected specimens was also performed.In the present study, self-collected samples provided by Italian women who had failed to respond to the invitation to participate in an organized screening program were analysed for HPV DNA. Positive samples were subjected to viral DNA genotyping and tested for the methylation of host cellular genes www.clinicaltrials.gov (NCT 01647724).Organized, population-based screening programs of Este-Monselice and Pieve di Soligo Local Health Authorities in Veneto Region . At the end of 2012, women aged 30–64 years who had failed to respond to the call-and-recall strategy were invited to provide a cervical sample using a second-generation lavage self-sampling device  delivered at home or picked-up at a reference pharmacy [Women with a positive hrHPV test were invited for immediate colposcopy and followed-up according to standard protocols, which involve hrHPV testing of a clinician-collected sample a year later. The subsequent screening round for women who tested negative was at 3 years, either by HPV testing (Este-Monselice) or by cytology .The self-collected samples were delivered to the laboratory, processed as previously described , and anaDNA was extracted from all specimens after completion of recall sample collection  using Qiagen’s QIAamp DNA mini kit according to the manufacturer’s recommendations, where an aliquot of cells collected before denaturation was resuspended in standard transportation medium , and collected at -80°C.Partial HPV genotyping was performed on HC2-positive samples using two different assays:the HPV Genotyping PS test , where type-specific primers allow individual detection of HPV types 16, 18, 45. The test was performed within 4 months of sample collection by applying the hrHPV HC2 assay procedure to the residual denatured samples; test procedure and data interpretation were according to the manufacturer’s recommendations;E7 gene of 12 hrHPV types  and the (probably) high-risk types 66, 67, 68, which uses fluorescent probes to detect PCR products. Four different fluorescent dyes provide for individual detection of HPV 16 and 18, while the Other HPV types are detected as a pool; the internal control for sample adequacy is the human β-globin gene [the HPV-Risk assay , a multiplex, real-time PCR-based assay directed against the bin gene . The assA sample was considered positive if it was positive on at least one of the two assays. A concordant result was one where both methods yielded positivity for HPV 16 or 18  or else for type 45 using the PS test and for Other HPV types using the HPV-Risk assay. Samples testing negative on the PS assay and yielding an invalid result on the HPV-Risk assay were considered to be negative for HPV types 16, 18, and 45.CADM1-m18, MAL-m1, and hsa-miR-124-2 using the PreCursor-M kit . This is a quantitative multiplex methylation-specific PCR (qMSP), based on the TaqMan technology. Samples were run in single, separate reactions on an ABI 7500 Fast Real-time PCR system (Applied Biosystems) following the manufacturer’s instructions. According to the manufacturer’s indications, samples with DNA concentrations < 10 ng/μl were excluded from the analysis (n = 3). In each run, 2 additional control samples were included, the HPV 16-positive SiHa cell line and a clinical sample  from a CIN3 case obtained in a previous study [DNA was subjected to bisulphite treatment using the EZ DNA Methylation kit  and tested for methylation of the promoter regions of the cellular genes us study . Data anPapers to be included in the systematic review were sought in the MEDLINE, EMBASE, Scopus, Clinicaltrial.gov, Web of Science, and Cochrane Library up to September 2016. The search strategy used the following terms: self-sampling AND cervical cancer; Uterine Cervical Neoplasms AND self-sampling AND methylation; Uterine Cervical Neoplasms AND self-sampling AND gene methylation; cervical cancer AND self-sampling AND methylation; cancer cervix AND self-sampling AND methylation. Papers were selected using the PRISMA flow-chart  and the Baseline (self-collected) samples were provided by 454 women, of whom 60 (13.2%) were hrHPV-positive with the HC2 test. Follow-up (clinician-collected) samples were available for 70% (42/60) women, of whom 25 had a negative HC2 test result and 17 (40.5%) had a persistently positive HC2 test result. Their baseline and follow-up data are reported in Partial genotyping was performed in all baseline and follow-up HC2- positive samples using both the PS test and the HPV-Risk assay (for the latter assay one self-collected sample was not available and could not be tested).At baseline, hrHPV infection was detected by one or both genotyping assays in 29 cases (48%): HPV 16 in 2 cases, HPV 18 in 2 cases, and Other HPV types in 25 cases, respectively. Two baseline samples that tested negative with the PS assay gave an invalid result on the HPV-Risk assay, whereas a negative result with both assays was recorded in 29 cases (48%).Genotyping of all 17 HC2-positive follow-up samples was performed with both assays. Infection clearance was documented in 5 women, who at baseline had tested positive for Other hrHPV types. HrHPV infection was detected in 12 cases (71%), a woman whose baseline sample could not be analysed and 11 women who had tested positive at baseline. Among the latter, a concordant result for Other hrHPV types was obtained in 7 cases; HPV 16 was detected in addition to HR in 2 cases and alone in one case, and a mixed infection (HPV 16 at baseline and HPV 18 at follow-up) was found in one case.CADM1, MAL, and miR124-2, respectively), whereas the DNA from the control clinical sample was consistently negative for CADM1 and positive for MAL and miR124-2 .SiHa DNA was consistently positive for all 3 markers  was detected in 15% (8/54) of the valid samples; 5 samples were positive for a single marker (miR124-2), 2 samples were positive for 2 markers (MAL and miR124-2), and only one was positive for all 3 markers; the latter sample showed the highest ratio values for all markers .A valid methylation analysis result was obtained in 54/60 (90%) self-collected samples at baseline; 3 samples could not be analysed due to insufficient DNA, and 3 samples gave an invalid result. Overall, DNA methylation of at least one locus (miR124-2 and one for MAL) and one sample was positive for 2 markers (MAL and miR124-2). MiR124-2 was the most frequently methylated locus also in follow-up specimens. Its median ratio value in samples positive for a single marker was 1.68. The ratio values of specimens positive for 2 markers were 11.26 and 9.67 . Of the specimens from the 15 women whose baseline and follow-up samples could both be evaluated, 10 were consistently unmethylated, whereas two different methylation patterns were detected in the two specimens in 5 cases: negative / single-positive , negative / double-positive , and double-positive (MAL + miR124-2) / negative (1 case).Analysis of the methylation markers of all follow-up samples from the 17 HC2-positive women gave valid results. Methylation of at least one locus was detected in 23.5% (4/17) of samples; 3 samples were positive for a single marker  baseline and 3/17 (17.6%) follow-up samples.miR124-2) to 98% (CADM1). All marker combinations had the same specificity as the least specific test, since the only CADM1-positive case also showed methylation of the other 2 loci, and the 3 cases showing MAL methylation also exhibited miR124-2 methylation , HPV immunization n = 8), HPV infection (n = 6), or described other biological samples (n = 5), were reviews (n = 18), were related to other topics (n = 5), or described screening techniques and screening diffusion (n = 72). Examination of the remaining 20 papers in the second stage of the PRISMA flow-chart led to the exclusion of 16 studies for the following reasons: 1 regarded self-sampling in HPV detection –25, 2 we, HPV inf9, HPV imCADM1, MAL, and miR124-2 cellular genes. The present findings confirm the adequacy of self-collected cervical samples to be used in molecular assays suitable for hrHPV triage, even though the absence of high-grade CIN samples in this population limits the significance of our results; in particular, only the specificity of the methylation of our target genes could be calculated.In this study, self-collected cervical samples provided by Italian women aged 30 to 64 years who had failed to respond to the invitation to participate in an organized population-based screening program and clinician-collected follow-up samples were subjected to partial HPV genotyping and investigation of the methylation pattern of Similar to a previous study , hrHPV iPartial HPV genotyping with separate identification of types 16 and 18, performed in HC2-positive samples using two different assays, detected an hrHPV type in 48% of the baseline self-collected samples and in 71% of the persistently HC2-positive clinician-collected samples obtained 12 months later. It has been reported ,35 that Partial HPV genotyping has been assessed, alone or in combination with other methods, as an assay to triage hrHPV-positive women ,36,37. SmiR124-2) was methylated; in addition, ratio values were considerably lower than those of SiHa cells and the CIN3+ control case, and were lowest in those that were positive for a single gene marker. Methylation of all three genes with high ratio values was recorded only in a 34-year-old woman who moved abroad and was lost to follow-up.Methylation of the cellular genes investigated in the study was detected in a small percentage of self-collected and clinician-collected samples ; these data are consistent with the 19.2% reported by De Strooper et al  in self-The combination of HPV genotyping and methylation assay data showed a higher frequency of positive results at 12-month follow-up than at baseline (17.6% vs. 7.4%), consistent with a higher rate of persistent HPV infections during follow-up.In the study, only the specificity of the methylation assay could be analysed due to the absence of CIN2+ or CIN3+ samples, although more than 1000 women were invited to screen with self-sampling.MAL/miR124-2 combination was less than 50% [The specificity values found in this study were much higher than those reported by other studies. In fact, according to the systematic review, the specificity of the than 50% . Clearlythan 50% ; this enFinally, as regards the accuracy values of cytology and other candidate triage biomarkers, i.e. p16 and E6-E7 mRNA in clinician-collected samples, sensitivity ranges from 60 to 90%  and specSelf-collected samples are suitable for methylation assays that could be employed in reflex triage testing. The reproducibility and accuracy of the methylation assays described in the literature needs to be improved before their clinical value can be assessed.S1 Table(DOC)Click here for additional data file.S2 TableQUADAS-2: Risk of Bias assessment according to QUADAS-2 scale available from: .(DOCX)Click here for additional data file.


The use of high-risk human papillomavirus (HPV) testing for surveillance and clinical applications is increasing globally, and it is important that tests are evaluated to ensure they are fit for this purpose. In this study, the performance of a new HPV genotyping test, the Papilloplex high-risk HPV (HR-HPV) test, was compared to two well-established genotyping tests. Preliminary clinical performance was also ascertained for the detection of CIN2+ in a disease-enriched retrospective cohort. A panel of 500 cervical liquid-based cytology samples with known clinical outcomes were tested by the Papilloplex HR-HPV test. Analytical concordance was compared to two assays: a Linear Array (LA) HPV genotyping test and an Optiplex HPV genotyping test. The initial clinical performance for the detection for CIN2+ samples was performed and compared to that of two clinically validated HPV tests: a RealTime High-Risk HPV test  and a Hybrid Capture 2 HPV test (HC2). High agreement for HR-HPV was observed between the Papilloplex and LA and Optiplex HPV tests , with kappa values for HPV16 and HPV18 being 0.90 and 0.81 compared to the LA and 0.70 and 0.82 compared to the Optiplex test. The sensitivity, specificity, positive predictive value, and negative predictive value of the Papilloplex test for the detection of CIN2+ were 92, 54, 33, and 96%, respectively, and very similar to the values observed with RealTime and HC2. The Papilloplex HR-HPV test demonstrated a analytical performance similar to those of the two HPV genotyping tests at the HR-HPV level and the type-specific level. The preliminary data on clinical performance look encouraging, although further longitudinal studies within screening populations are required to confirm these findings. The use of high-risk human papillomavirus (HR-HPV) testing for the identification of women at risk of developing cervical cancer and for the management of women who have received treatment is increasing globally . In addiThe Papilloplex HR-HPV test  is a commercially available HPV genotyping test that performs quantitative multiplex detection of 14 HR-HPV types, together with an endogenous human control target, in a single tube  and the Optiplex HPV genotyping kit . Preliminary insight into clinical performance of the assay is also presented through its ability to detect CIN2+ in a disease-enriched sample compared to two well-established clinically validated HPV assays: the Hybrid Capture 2 HPV DNA test  and the RealTime High-Risk HPV test .www.shine.mvm.ed.ac.uk/archive.shtml), which is a biobank designed to support HPV Research. The East of Scotland Research Ethics Service has given generic approval to the Scottish HPV Archive as a research tissue bank (REC Ref 11/AL/0174) for HPV-related research on archived samples. The Scottish HPV Archive is also registered with National Research Scotland (NRS) Lothian Bioresource. Samples were made available for the present project through application to the archive steering committee (HPV Archive Application Ref 0016).A total of 500 liquid-based cytology samples (LBCs) were obtained from the Scottish HPV Archive . Routine cytology classification was according to British Society for Clinical Cytology criteria . CytologSamples were retrieved and aliquots prepared for HPV testing with the Papilloplex HR-HPV test, HC2, Optiplex HPV genotyping test, LA, and RealTime HR-HPV test. The Papilloplex test was performed in Genefirst laboratories . All other tests were performed at the Scottish HPV Reference Laboratory and HPV Research Group (Edinburgh). All tests were performed according to the manufacturer's instructions, although a brief description of assay characteristics is provided in 6–The Papilloplex HR-HPV test was performed on DNA extracted using two different methods. Half the samples were extracted using a QiaAmp DNA minikit  and half using the automated Nuclisens EasyMag system . The method of extraction was randomly allocated to samples.2+), master mix  and working mix (primers and probes) to obtain a final volume of 20 μl per PCR. The PCR was performed on ABI 7500 Fast real-time PCR systems . The thermal profile was set as follows: amplification stage 1, 50°C for 2 min, followed by 95°C for 3 min; amplification stage 2, 9 cycles of 95°C for 6 s, followed by 66°C for 45 s; and amplification stage 3, 42 cycles of 95°C for 3 s, followed by 60°C for 33 s, and 63°C for 15 s. Fluorescence measurements in the ROX, FAM, HEX (JOE), and CY5 channels were recorded during step 2 of amplification stage 3 (60°C for 33 s). A preset dissociation stage (stage 4) was included following the final PCR cycle of amplification (stage 3). The postamplification melting profile protocol comprised 95°C for 15 s, 25°C for 1 min, 75°C for 15 s, and 60°C for 15 s. The fluorescence emission data were continually collected during the temperature increase. The negative derivative of the emission reading, with respect to temperature, was plotted against the temperature to form melting curves (per fluorescent channel) generated during the dissociation stage of the reaction (from 25 to 75°C).A total of 2 μl of DNA was added to the PCR amplification reaction mix (18 μl) containing buffer . For each sample, the internal control (CY5 detection channel) and all 14 HR-HPV types, corresponding to the ROX , FAM , and HEX channel  were simultaneously evaluated. Samples were considered positive for HR-HPV DNA types if a TC value was <38 for cellular DNA and <36 in any of the ROX, FAM, and HEX fluorescent channels. A sample was considered invalid if the TC value of cellular DNA was >38. The change in the characteristic melting profile(s) in the sample was compared to the negative-control reference melting profile to identify the genotypes present. Samples were tested in batches of 96 samples (including controls) per reaction.For consistency between experiments, the following threshold values for Type-specific positivity for each HR-HPV type included in Papilloplex was compared to the Optiplex and LA. Concordance, proportional agreement with accompanying 95% confidence intervals (CI) have been presented, along with kappa statistics and the McNemar test. The Papilloplex was also compared to the above-described tests at the level of HR-HPV positivity (for the types covered by Papilloplex only).n = 87), whereas no disease was defined as histologically confirmed CIN1 or less or a sample being associated with two consecutive negative cytology results at least 1 year apart (n = 349). Pathology data were incomplete to allow this categorization for 64/500 samples so clinical performance assessment was performed on 436 samples.Clinical performance of the Papilloplex test was measured as sensitivity, specificity, positive predictive value, and negative predictive value for the detection of cervical CIN2+ with 95% CIs around the percentages. The clinical performance of the HC2 and RealTime HPV test was also performed and presented alongside the Papilloplex results. Disease cases were defined as CIN2+  compared to both LA (n = 108) and Optiplex (n = 146). Similarly for HPV59, Papilloplex detected fewer samples as positive (n = 20) compared to LA (n = 73) and Optiplex (n = 28), which is reflected in the aforementioned kappa value. Conversely, Papilloplex detected a higher number of HPV31 (n = 64) infections compared to the LA (n = 54) and Optiplex (n = 40) tests, and a higher number of HPV33 (n = 44) infections versus Optiplex (n = 36). Papilloplex also detected a higher number of HPV56 (n = 32) infections compared to LA (n = 22), but this was lower than those detected by Optiplex (n = 43) .Type-specific concordance between the Papilloplex and the two genotyping assays for HR-HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68 is shown in Of the 500 samples in the panel, 87 were associated with CIN2+. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) results of the Papilloplex test for the detection of CIN2+ are summarized in The Papilloplex HR-HPV test is a single-tube test for the quantitative multiplex detection of 14 HR-HPV types, together with an endogenous human control target. This study provides the first analytical assessment of the Papilloplex test compared to two commercially available HPV tests that offer extended genotyping capability: LA and Optiplex. Further, to gain insight into the potential clinical performance of the assay, a preliminary evaluation was undertaken to determine its ability to detect CIN2+ in a disease-enriched population.Papilloplex showed high concordance to the Optiplex and LA tests at the level of overall HR-HPV positivity with a proportional agreement of 95 to 97% and a kappa of 0.90 to 0.93. Type-specific proportional agreement for all 14 HR-HPV types covered by Papilloplex was generally high, although there were some type-specific differences. Papilloplex showed moderate concordance to LA and Optiplex for HPV types 16 and 59, detecting less infection, and clearly, HPV16 is an important type for both epidemiological and clinical applications. On the other hand, Papilloplex detected more HPV31 infections compared to both comparator genotyping tests. Type-specific differences between genotyping tests have been reported previously , and sucThis said, we accept that the clinical evaluation performed in this study was preliminary and that the sample used was enriched in nature and did not represent women from a cross section of the screening population. Consequently, the clinical performance observed in this study is not representative of performance in a screening population. Nevertheless, determining initial sensitivity (the key measure of performance for screening applications) of a novel HPV test for CIN2+ using a sample with high disease prevalence has precedent , 11 and The variety of HPV tests available with their different scopes and capabilities provides users with options to choose the most appropriate test for a particular context and population. Papilloplex HPV is a single-tube assay that identifies 14 HR-HPV types. The ability to perform individual genotyping within a single closed-tube format reduces time and the risk of contamination associated with more “open” genotyping systems. The assay is amenable to several DNA extraction chemistries, requires a small amount of input DNA, and can be performed with existing real-time 96-well PCR platforms that are available in routine research and clinical laboratories. In terms of analytical performances, we have shown that this assay compares favorably to existing, more-established extended genotyping assays. Although initial data on clinical performance are encouraging, further longitudinal assessments will determine its potential use for screening and disease management.


Due to the arrival of multi-valent HPV vaccines, it is more and more important to have a better understanding of the relationship between vaccination and screening programmes. This review aimed to: (1) collect published evidence on the cost-effectiveness profile of different HPV prevention strategies and, in particular, those combining vaccination with changes in screening practices; (2) explore the cost-effectiveness of alternative preventive strategies based on screening and vaccination.A systematic literature review was conducted in order to identify the relevant studies regarding the cost-effectiveness of prevention strategies against HPV infection. Analysis comparing the modelling approaches between studies was made along with an assessment of the magnitude of impact of several factors on the cost-effectiveness of different screening strategies.A total of 18 papers were quantitatively summarised within the narrative. A high degree of heterogeneity was found in terms of how HPV prevention strategies have been assessed in terms of their economic and epidemiological impact, with variation in screening practice and valence of HPV vaccination found to have large implications in terms of cost-effectiveness.This review demonstrated synergies between screening and vaccination. New prevention strategies involving multi-valence vaccination, HPV DNA test screening, delayed commencement and frequency of screening could be implemented in the future. Strategies implemented in the future should be chosen with care, and informed knowledge of the potential impact of all possible prevention strategies. Highlighted in this review is the difficulty in assessing multiple strategies. Appropriate modelling techniques will need to be utilised to assess the most cost-effective strategies. Cervical cancer is now the fourth most common type of cancer among women worldwide, and second most common cause of death among women aged 15 to 44 , 3. CervTo prevent cervical cancers, screening programmes have been introduced in many countries around the world. These programmes have noticeably reduced the incidence of cervical cancer , 10. NevThe Pap smear is an essential cytological test and its introduction has led to a high reduction in cervical cancer incidence , 15. GibHPV DNA testing is a recent development in the management of HPV and is much more sensitive when compared to the Pap smear . The impWhereas screening detects diseases at an early stage (precancerous lesions) leading the treatment of these lesions prior to cancer development, vaccination prevents HPV-related disease and the burden related to treatment.HPV vaccination has been implemented in Europe since 2007, in addition to the existing cervical cancer screening programmes. Available vaccines at that time aimed to prevent ~70% of cervical cancers and ~50% of precancerous lesions, related to HPV 16 & 18 HPV , 22. TheThe vaccine was approved by the Food and Drug Administration (FDA) in 2014 for use in girls aged 9 to 26 and males aged 9 to 15. Similarly, in 2015, the Committee for Medicinal Products for Human Use (CHMP) recommended the vaccine for use in boys and girls from 9 years of age to protect against cervical, vulvar, vaginal and anal cancers, and pre-malignant cervical, vulvar, vaginal, and anal lesions and external genital warts . This vaThe vaccination of successive cohort of girls has the potential to reduce the average lifetime risk of developing cervical abnormalities and cervical cancer in the population; hence, the predictive value of cytology will decrease as well as the effectiveness of most screening modalities . TherefoSeveral systematic reviews, including the recent review by Mendes et al., 2015 , have asCollect published evidence on the cost-effectiveness profile of different HPV prevention strategies and, in particular, those combining vaccination with changes in screening practicesExplore the cost-effectiveness of alternative preventive strategies based on screening and vaccination.The current study aimed to review the published literature to:The study focussed on key European markets , Australia, Canada and the USA.A systematic literature review was conducted in order to identify the relevant studies regarding the cost-effectiveness of prevention strategies against HPV infection. The study question was formalised according to the PICOS framework see .We searched the following electronic databases for studies published up to April 2014: MEDLINE and MEDLINE-IN-PROCESS , on EMBASE , and the NHS Economic Evaluation database (via cochrane.org on 15th April 2014). Search terms are included in Cost-effectiveness analyses based on mathematical modellingPresentation of a health economic endpoint  and clinical outcomes (cancers/cases avoided)We included original research articles that met the following criteria:After running the searches on the electronic databases, the citations were screened by two independent reviewers, with study selection based on the pre-specified inclusion/exclusion criteria in Upon the completion of publication selection, relevant data were extracted according to a pre-specified template, which included authors, year of publication, country, period of analysis, mathematical model used, vaccine, price per dose and schedule, discounted rate, population, age of vaccination and catch-up, comparator, clinical outcomes considered, vaccine efficacy, duration of protection, assumptions on vaccination coverage, screening status, sensitivity analysis conducted, economic outcomes  and cost per life-year gained (LYG)). Data was then quantitatively summarised within a narrative review. Different scenarios on screening strategy and frequency from included studies were synthesized and plotted against changes in cost and QALY.A total of 1,188 papers were identified following removal of duplicates. Of the papers screened 115 were deemed eligible for full-text review. Following exclusion, a total of 18 papers were quantitatively summarised within the narrative review using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram. see Fig. .Fig. 1PRAnalysis comparing the modelling approaches between studies was made along with an assessment of the magnitude of impact of several factors on the cost-effectiveness of different screening strategies. Strategies which were only assessed as part of sensitivity analyses were also compared. The impacts of several factors on the cost-effectiveness of the HPV prevention strategies were assessed such as modelling approach, prevention strategies assessed, screening technique, screening frequency, age at first vaccination, screening coverage and compliance, number of vaccine valences and cross-protection, vaccine efficacy, efficacy waning effect and vaccine cost.Vaccination strategies varied considerably in terms of cost-effectiveness both within and between studies through both age of vaccination and number of doses received, as well as booster Tables  and 2.TaSixteen studies focused on the vaccination of pre-adolescent girls; the remaining 2 , 40 on cVaccination coverage was seen to differ across studies from 70 to 100% in base case, and varied in sensitivity analyses.Bivalent vaccine efficacy was reported to be greater than 75%, 90% and 95% versus HPV types 16/18 in 2 , 38, 8 , 40, 43 Cross-protection against other high-risk HPV types was considered in 7 , 39, 41 The majority of studies (17/18) focused on a bivalent (HPV16/18) or a quadrivalent vaccine (HPV6/11/16/18) Table . Only onCost of vaccination was another variable between studies with bivalent and quadrivalent 3-dose vaccine cost varying from €147.00–402.00 and €264.00–360.00, respectively.Costs were seen to have an important effect on the ICER of optimal strategies and significantly affect the cost-effectiveness result of vaccination strategies. Demarteau et al., 2011  reportedPap smear test alone : detection of cervical precancerous lesionsHPV DNA test alone: detection of HPV infections and HPV typesPap test + HPV DNA triage for Pap positive patientHPV DNA test + Pap triage for HPV DNA positive patientCombined Pap test + HPV DNA test.Various HPV prevention strategies were assessed in the included studies  , 40. GolOne study  reportedA strategy of HPV DNA testing was assessed in 5 studies , 38, 44 Combined screening strategies in combination with vaccination were seen to offer large clinical benefits, at little extra cost in studies including non-conventional techniques when compared to strategies of vaccination only.After the introduction of HPV vaccination, screening still needed to be continued, and strategies that incorporated HPV testing were more effective and cost-effective than those with cytology alone . strategThree modelling approaches were used for assessment in the included studies: 9 studies reported using a standard Markov model , 39, 41;Cervical cancer screening is one of the cornerstones of cervical cancer prevention in association with HPV vaccination. This study explored the cost-effectiveness of alternative HPV prevention strategies that combine screening with vaccination, drawing on 18 publications in order to inform and improve knowledge of the potential impact of the next generation of HPV vaccines.Among the strategies modelled, HPV DNA testing followed by cytological triage of HPV positive women in combination with HPV vaccination was found to be the optimal strategy, with a comparable cost to other screening strategies and also a greater QALY gain. An increasing vaccine valence counterbalanced the detrimental effects of delayed and less frequent screening Fig. . StrategIn our review, only 1 study considered changes in screening programs in a context of vaccines that covered than 2 oncogenic HPV types (HPV16/18), with the change in benefits gained from a vaccine of increasing valence offsetting the change in costs associated with a shorter interval between screenings . A nonavSimms et al., recently concluded that countries with high vaccination coverage with HPV9 such as Australia and England will require less intensive screening . At thisOne of the main limitations of this review was to exclude models that estimated clinical outcomes alone, instead focusing on economic models estimating clinical and economical outcomes. Nevertheless, economical consideration are rarely disconnected from clinical outcomes in the decision making process. Economic models which make use of the best available data can provide an assessment of the long-term impact of vaccination and screening against HPV and guide decision makers into making a better informed decision regarding which prevention strategy to employ.The above graph presents a plot of the incremental costs and QALYs of each vaccination strategy with increasing valence. The impact in terms of increasing costs and QALYS on cost-effectiveness results of decreasing the screening interval for each vaccination from no screening to annual screening can then be seen by moving rightwards on each curve. From the above figure, increasing valence is shown to generate additional health benefits at with cost savings versus decreasing the screening interval, which is associated with sharp cost increases for the additional health benefit generated.Although the conclusions of our review may appear limited because of the time span (until April 2014) and the fact that they do not consider the new nonavalent vaccine, they provide important insights into the methodological challenges in assessing vaccination and screening. Firstly, the choice of the model can limit the scope of the analysis. Most of the models presented in our review are static Markov models and considered only vaccinated women. These models have the advantages of assessing various screening components . Static Markov models cannot adequately take into account herd immunity, age distribution shifts, waning effects, nor do they provide a population-based perspective, therefore do not perfectly reflect disease transmission. In many countries, policy makers will have to consider an existing mix of vaccinated and unvaccinated women.Static models cannot adequately take into account herd immunity nor age distribution shifts. Risk of infection in susceptible individuals is constant in static models, while in dynamic models, it is a function of the proportion of the population infected (which changes over time). Hence, when intervention uptake is very low , is targeted at groups that do not have an impact on overall transmission, or does not prevent circulation of the pathogen, static and dynamic models produce similar results.To assess the change of screening in unvaccinated women, a cohort-based model can be used. Naber et al., 2016    demonstrAnother difficulty in assessing the best preventive strategies is the number of strategies that can potentially be assessed, and this can quickly become huge if different age intervals, different tests and different algorithms are evaluated. Sander et al. 2016 recently considered 900 combinations of vaccination and screening strategies . The mosRegarding the long term impact of HPV vaccines, the scientific community acknowledges that protection against HPV associated diseases related to vaccine types has been demonstrated for at least 10 years and that and long term follow up studies does not show any decrease in efficacy over time . In addiA single programme of vaccination and screening will need to be deliberated when considering further reduction of the cervical cancer burden , 53. AddSome governments, such as in Australia, have already adapted their screening programme, accelerating the implementation of HPV DNA testing, due to the success of vaccination . MoreoveExisting analyses in this article, and the recent ones not included in our review , 50, focAs referred to by Mendes et al., 2015 the choice of optimum cervical cancer screening strategies will be highly complex due to the number of criteria to consider from a policy viewpoint and especially relevant in countries with high vaccination coverage rates .Further research on country-specific data for HPV vaccination and screening as well is the corresponding economic impact should be conducted to generate evidence which can assist policy-makers in finding a more systematic and tailored approaches to HPV prevention.This review has highlighted how HPV prevention strategies have been demonstrated to show both an economic and epidemiological impact. The arrival of a new HPV vaccine has the potential to dramatically alter the epidemiological outlook of HPV, and, as a consequence, current screening programmes may need to be rethought. The need to re-assess current prevention programmes is increasingly highlighted .This review has demonstrated synergies between screening and vaccination. New prevention strategies involving multi-valence vaccination, HPV DNA test screening, delayed commencement and frequency of screening could be implemented in the future.HPV prevention strategies implemented in the future should be chosen with care, and informed knowledge of the potential impact of all possible prevention strategies. Availability of a nonavalent vaccine will allow a complete review of current strategies, offering an opportunity for a more efficient and affordable approach to HPV prevention.Also highlighted in this review is the difficulty in assessing the interaction between screening and vaccination and in assessing multiple strategies in general. Appropriate modelling techniques will need to be utilised to assess the most cost-effective strategies, with recommendations made based on analysis of efficiency frontiers and similar techniques.


HPV) is being incorporated into the cervical screening programme, with the probable future introduction of HPV as a primary test and a possibility of HPV self‐sampling. In anticipation of this development, we sought to inform future policy and practice by identifying potential barriers to HPV self‐sampling.Testing for human papillomavirus , lower education  and lower perceived importance of HPV as a cause of cervical cancer . Interviews revealed personal and system‐related barriers. Personal barriers included a lack of knowledge about HPV self‐sampling, women's low confidence in their ability to self‐sample correctly and low confidence in the subsequent results. System‐related factors included a lack of confidence in the rationale for modifying the current cervical screening programme, and concerns about sample contamination and identity theft.Most survey participants  intended to HPV self‐sampling and to help inform future policy and practice. Personal and system‐related barriers including low confidence in the reasons for changing current cervical screening provision need to be addressed, should HPV self‐sampling be incorporated into the cervical screening programme.Insights gained from this research can be used to guide further enquiry into the possibility of  HPV testing as “test of cure” following treatment and to triage women with borderline and low‐grade dyskaryosis for high‐risk HPV is currently being incorporated throughout the UK,Due to growing evidence of superior sensitivity and negative predictive value compared to cervical cytologySelf‐sampling methods are increasingly advocated in tests for sexually transmitted infections.Self‐efficacy—an individual's belief in their capability to exercise control over challenging demands—is considered to be one of the most powerful predictors of health behaviour.This study used mixed methods to understand women's attitudes and intentions regarding HPV self‐sampling, and in particular the influence of self‐efficacy on intentions to HPV self‐sample. The overarching aim was to generate recommendations to inform future policy and practice in relation to the possible introduction of primary HPV self‐sampling.22.1Women aged 20‐64 years who were resident in South East Wales and gave written informed consent were approached to take part in the study during 2012‐2013. The main recruitment source was Cervical Screening Wales, with supplementary recruitment through primary care and sexual health clinics, local community groups and snowball sampling. Supplementary recruitment was needed to ensure that the target sample size was achieved and to help increase sample heterogeneity. It was calculated that a survey sample size of 172 participants would achieve 90% power to detect an odds ratio of 2 for the effect of self‐efficacy on intention to self‐sample. Survey respondents who indicated willingness to participate in a further interview were purposively sampled for a lower intention to HPV self‐sample, based on their survey responses.2.2The study received approval from the South East Wales Local Research Ethics Committee C (REC: 11/WA/0213) and Public Health Wales Research and Development (REF: 2012PHW0023).2.3A mixed‐methods design was adopted using a cross‐sectional survey and semi‐structured interviews, in which HPV self‐sampling was presented as a hypothetical cervical screening method. Women who were recruited through Cervical Screening Wales were sent an invitation leaflet and freepost envelope with their standard cervical screening invitation letter inviting them to express interest in the study. Women who were interested in participating were instructed to fill in their details on the reverse of the recruitment card and to return it using the supplied prepaid envelope. Women who returned the completed recruitment card were then sent the full participant pack and survey.For the supplementary recruitment, women were approached to participate at the additional recruitment sites. Survey respondents were purposively sampled for lower intention to HPV self‐sample and were invited to take part in a semi‐structured interview conducted in their homes or at a suitable alternative venue. All interviews were audio‐recorded with consent, anonymized and transcribed verbatim.33.1A theoretically based (HBM) survey was developed to measure women's attitudes and intentions regarding HPV self‐sampling, in order to examine the determinants of anticipated uptake. Content validity analysis with health research experts facilitated the development of the survey. The use of patient and public involvement (PPI) of women eligible for cervical screening through cognitive interviews helped to ensure that the format of the survey was accessible and that individual items were easily and correctly understood. Overall, the survey was well received by participants. Survey measures included HPV and cervical cancer knowledge, HPV self‐sampling intention, self‐efficacy in relation to HPV self‐sampling, perceived susceptibility to and severity of HPV infection/cervical cancer, and perceived benefits/barriers to HPV self‐sampling. Cervical screening history and demographic variables were also included (see Data S1 for further details). All HBM items were scored on 5‐point Likert response scales. Reliable scales were identified through a principal components analysis of items relating to HBM a priori constructs. Five factors with eigenvalues >1.00 were extracted. As shown in Table 3.2Interviews were conducted by DW using a semi‐structured interview schedule (Data S2) and focused on understanding participant perceptions of primary HPV self‐sampling, if it was incorporated into the cervical screening system. The interview schedule was theory‐based and drew on the extended Health Belief Model constructs and concepts identified as significantly associated with intention to self‐sample during survey analysis. The interview schedule was divided into two sections which explored perceptions relating to (i) HPV self‐sampling and HPV in general, and (ii) experiences of cervical smear tests. Sampling continued until no new significant or relevant themes of interest to the study objectives were identified.3.3P<.05) were modelled to determine their effects on self‐sampling intention.Survey data were analysed using SPSS for Windows version 20. Participants with missing data were excluded from analyses. Descriptive statistics were used to characterize the sample, followed by univariate analyses to examine preliminary associations between intention to self‐sample, sociodemographic and HBM factors, HPV knowledge and past cervical screening history (chi‐square tests or independent t‐tests as appropriate). Logistic regression was used to identify the strongest predictors of intention to self‐sample, with a binary intention outcome measure entered as the dependent variable (higher intention versus lower intention to HPV self‐sample). Due to non‐normal distribution of the intention measure, a binary intention measure was created from participants’ Likert scale responses (1‐5). Those who were classified as having a higher intention to HPV self‐sample scored 4 or 5 on all three intention items, whilst those who scored 3 or under on any of the three intention items were classified as having a lower intention to HPV self‐sample (see Data S1 for details). Statistically significant variables identified during univariate analyses  women who received a recruitment pack completed the survey. A further 57 women were recruited through GP surgeries, community groups and sexual health clinics to increase sample size and representation. The final survey sample therefore consisted of a total 194 participants, 137 (71%) of whom were recruited through Cervical Screening Wales and 57 (29%) from supplementary recruitment sources. Nineteen women who had consented to be contacted for an interview and who were classified by the survey as less likely to HPV self‐sample were interviewed. Figure 4.1Most survey participants were of White ethnicity, in the 31‐ to 49‐year age group, were highly educated and were home owners. The majority had attended a cervical screen within the last 4 years. Nearly half (43.0%) of participants had received an abnormal smear test result, and approximately a quarter 18.2%) had received treatment for cervical abnormalities. A small proportion of women knew a family member/friend diagnosed with cervical cancer (13.5%), and some had known someone who had died of cervical cancer (5.7%). Table % had rec4.2Overall, most women  reported high intention to HPV self‐sample. HPV knowledge was low: 31.4% of participants had not heard of HPV before participating in the study, 25% (N=41) believed that HPV could be transmitted by means other than sexual contact, 32.3% of women believed that HPV could be treated with medicines, and 51.6% believed that HPV could not clear up on its own.P<.05), White ethnicity (P<.01), lower self‐efficacy (P≤.001), fewer perceived benefits (P<.002) and more perceived barriers (P<.001) to HPV self‐sampling, fewer perceived benefits of smear tests (P<.028), low HPV knowledge (P<.02) and the perception that HPV is not an important cause of cervical cancer .Preliminary associations between independent variables and intention  indicated that lower intention to self‐sample was significantly associated with lower educational attainment , indicating that it was able to distinguish between women who had a lower or higher intention to HPV self‐sample. The model correctly classified 83.3% of cases and explained between 43.1% and 61.2% of variance in intention to self‐sample. Self‐efficacy in relation to HPV self‐sampling had the strongest influence on intention . Higher educational level was also associated with higher intention to self‐sample . Women with a lower intention perceived HPV as less important in causing cervical cancer  and perceived more barriers  and fewer benefits to self‐sampling  and cervical smear tests  than women with a higher intention to self‐sample I think it's more a genetic thing and passed down (P17)lifestyle and your diet and um stress I guess, all sorts of things Most women did not know what caused cervical cancer. Some attributed cervical cancer to lifestyle factors, genetic factors or something that just happens.(P4)I don't know nothing at all about it (P11)I'm a bit embarrassed that I don't know more about it Consequently, women had very little knowledge of HPV and reported embarrassment about their lack of knowledge.(P10)basically my generation was never educated in anything like that, you know especially with school with sex education … so I think for me I'm a missed generation to understand what it is fully Women also discussed sex education and stated that they had not been taught about HPV or its link with cervical cancer. Some women acknowledged that they had been regular cervical smear attenders from a young age, but that the role of HPV in cervical cancer was never explained to them. Consequently, women felt that more education about cervical cancer and HPV was needed.(P17)my only concern would be am I putting it in far enough, because obviously when they do a smear test they open up your sort of cervix type thing and then they take, it's in quite deep to take the sample and it would be am I inserting it high enough?Women had a basic understanding of HPV self‐sampling, which was attributed to the description of what HPV self‐sampling would involve which was included in their participant information packs. However, women rationalized their understanding in the context of cervical smear tests and perceived similarities. Most women believed that the self‐sampling kit would involve collection of material from the cervix and some also believed that a speculum might need to be used. Primarily, women were concerned that this would be difficult to perform.(P1)if it was the only option that I had then I would do it… but if I had an option of having a smear test with the nurse, or doing it myself then I'd go with the nurse Availability of a cervical smear was an important influence on intention to self‐sample. Women stated that their intention would be highly influenced by the availability of an alternative, and often saw self‐sampling as an inferior method of cervical screening compared to cervical smears.(P3)you know if you were to use, use the self‐sampling would you still be able to go then to your GP Women's preference for cervical smear tests appeared to be linked to their confidence in the current form of cervical screening, and concerns about losing access to professional expertise.The habitual nature of cervical screening behaviour influenced women's intentions to self‐sample, with women who expressed a preference for the habitual behaviour reporting a lower intention.(P9).my concern would be if a medical person had been doing this for all this time, would your sample be good enough? Women were also worried about sample contamination due to sampling at home, which they saw as a non‐sterile environment. Women were concerned that they might not be able to carry out self‐sampling properly due to a lack of practice and medical expertise.“missed something” (P2), and some referred to carrying out self‐sampling incorrectly and receiving a false‐negative result as entering into a “life and death situation” (P1).Women reported a lack of confidence in self‐sampling results by saying that they might have (P4)if I was a post lady I wouldn't want to handle someone's thing that's been in places When discussing operational factors associated with HPV self‐sampling, operational themes emerged including women's concerns that postal workers might be unwilling to handle kits and worry about identity theft, because self‐sampling kits would contain DNA and personal details.(P5).If there's nothing about acknowledgment of samples…it would make me have entirely less confidence in the whole process One of the most recurrent and unprompted operational barriers was concern that the laboratory would not confirm receipt of the self‐sampling kit, which affected women's confidence in the set‐up of a new screening process:“politically motivated” and “rushed through” (P5) to cut costs for the NHS. Consequently, concerns were raised about withdrawal of service: “Are they taking away my rights to have a smear test?” (P13). Barriers identified from the initial framework included worry about the self‐sampling kit getting lost or contaminated in the post.Finally, women felt that the imperative for self‐sampling might be (P17).they can help someone who needs more crucial help than doing a sample (P9).it's worthwhile because the funds would then go to… treating people with cervical cancer and then getting better careConvenience, speed and the perception that self‐sampling would be less embarrassing, uncomfortable and invasive than cervical smear testing were facilitators to self‐sampling. Women had altruistic beliefs and reported that participating in self‐sampling might release health practitioner appointments to others whose needs were more urgent. Some women also felt that self‐sampling would be a more cost‐effective form of screening and that saved funds could be distributed elsewhere5In the event that HPV self‐sampling is incorporated into UK cervical screening programmes, research examining barriers and facilitators will be important to highlight potential problems with acceptability and uptake and to direct service recommendations. The present study identified the impact of personal and system‐related barriers on women's attitudes towards primary HPV self‐sampling, and their intention to HPV self‐sample. In addition to identifying barriers and benefits associated with HPV self‐sampling, the study provided important insights into women's perceptions regarding a potential change from a familiar and established health‐care system  to a new and different type of cervical screening system (HPV self‐sampling). Public concerns about safety and acceptability should be addressed if primary HPV self‐sampling is to become incorporated into the cervical screening programme.“right” to receive a cervical smear test.Reflecting previous research,Operational and system‐related barriers to HPV self‐sampling included fears about sample contamination, loss and identity theft, and women wanted to receive an acknowledgement that their kit had arrived at the laboratory safely. Although women's preference for returning samples directly to health‐care providers rather than through the post has been identified in previous studies,The present study primarily investigated the attitudes of cervical screening attenders, many of whom had been identified as having a cervical abnormality previously and some of whom had received treatment for cervical abnormalities. By exploring the views of women who are engaged in the current screening programme, this research provided insight into the potential impact of modifying primary cervical screening on subsequent attendance. Ultimately, this research identified factors that might lead women currently engaged in cervical screening to drop out of cervical screening, should a new method be introduced.Study limitations are acknowledged. Individual survey items were combined to form scales based on the HBM constructs, with some exhibiting low internal reliability . This may have been due to the breadth, such as the possible benefits associated with self‐sampling or barriers associated with cervical screening, or the low number of items in the scale.The incorporation of HPV testing in the changing cervical screening programme within the UK presents an opportunity for future integration of primary HPV testing and the possibility of HPV self‐sampling. Evidence presented in the current study suggests that personal barriers such as lack of knowledge and low self‐efficacy in ability to self‐sample correctly, as well as operational and system barriers such as concerns about reasons for establishing a new method for cervical screening, are influential in determining intention to engage in HPV self‐sampling. The insights gained can be used to guide further enquiry into the possibility of HPV self‐sampling and inform future policy and practice. Should HPV self‐sampling be incorporated into the cervical screening programme, psycho‐educational interventions that increase HPV‐related knowledge, perceived capability to HPV self‐sample and confidence in the reasons for setting up a new programme will be needed.None. Click here for additional data file.


To characterize the vaginal microbiome and the rate of sexually transmitted infections (STIs) in the women of Príncipe (São Tomé and Príncipe). human papillomavirus [HR-HPV], N. gonorrhea [NG], T. vaginalis [TV], and C. trachomatis [CT]) were obtained. Cross-sectional study of 100 consecutive women, invited for a free appointment and cervical cancer screening. A vaginal slide (wet mount microscopy) and a cervical sample (ThinPrep®) . The association of abnormal Pap test with msAV was not significant (p = 0.08). TV, NG, CT, and HIV were found in 8.0%, 2.0%, 3.0%, and 2.0%, respectively, and were more prevalent in younger women. HR-HPV was positive in 36.7%; 2 were positive for HPV18, but none for HPV16. Coinfection of HPV with other STIs was 8.3%. Prevalence of abnormal vaginal flora (AVF) was 82.5%, mostly bacterial vaginosis (BV) 54.6%, and moderate/severe aerobic vaginitis (msAV) 25.8%. HR-HPV was not related to BV ( The prevalence of NG, CT, TV, and HR-HPV was according to expected, while that of HR-AVF was higher. The surprisingly low prevalence of HPV16 and HPV18 must be considered in the design of programs for prevention and vaccination; this setting can be useful as a model for postvaccination scenarios. Sexually transmitted infections (STIs) constitute a worldwide, major public health problem . Detaile Trichomonas vaginalis (TV) prevalence is highest in African and American regions, and the lowest rates are reported in the Western Pacific region , HSIL [n = 2], ASC-US [n = 1]) were HR-HPV positive. In 1 woman with HSIL we failed to get HR-HPV results due to technical difficulties. One of the HIV positive women had HR-HPV, but both had normal cytology.Seven of 8 women with abnormal cytology  . In the Prevalence of TV in Príncipe Island is lower than in mainland Southern Africa, where up to 25% 95% CI, 17.9–31.4) of women seem to be infected .9–31.4 o to 0.4% Despite the small size of the sample, we performed an analysis of the risk factors for acquiring STIs, such as condom use, pregnancy, and alcohol consumption. Only one woman used condoms, explaining a similar prevalence of STIs in pregnant and nonpregnant women. In Zimbabwe, lower use of condoms was associated with increased sexual risk behavior and higher pregnancy rates . Sex witp < 0.05), mainly due to an increase in ASC-US and LSIL, but not HSIL [Unlike other researchers, we did not find an association between the presence of NG, CT, or TV and HPV or abnormal Pap smear findings , 22. Allnot HSIL . The sizBesides the high prevalence of HR-HPV other than HPV16 or HPV18, another major finding of this study was the staggering prevalence of AVF and vaginal infections. Apart from BV, which is found to be highly prevalent in most sub-Saharan African countries , the preThe fact that free cervical cancer screening was being offered might have been a bias. However, the main limitation of this study is its small sample size, precluding sophisticated (multivariate) analysis to be performed, but given the difficulty to gather the samples, and the naïve status of this remote, isolated area, we decided to start off with an in depth analysis of a small group of women first, to get an idea of the prevalence of the most common STIs in general. Further study of a larger contingent of this population to confirm specific trends will be needed to direct further actions and measures. Hence, we aim to subtype the different HPV subgenera in this population to obtain a clearer picture of the precise HPV subtype prevalence in this low HPV16/HPV18 prevalent area and decide whether and if vaccination with a broad spectrum HPV vaccine would be achievable and wise. Further research is also necessary, in order to improve the vaginal microflora, which is one of the riskiest influencing factors for acquiring HIV and other STIs, as well as for negative obstetrical outcomes worldwide. Certainly, it would have a tremendous impact in an isolated community which will, inevitably, one day open up for influxes from the rest of the world. In Uganda we recently achieved a significant improvement of the vaginal microflora by self-screening and treatment with locally applied intravaginal antiseptics or antibiotics .Women from Príncipe Island have a very high prevalence of high risk AVF and HR-HPV, but not HPV16/HPV18. Despite that, the prevalence of classical sexually transmitted infections, such as NG, CT, and TV was similar to that in continental African regions. Prevalence data from isolated communities can be especially interesting for clinicians and policy makers, to tailor prevention and vaccination programs. Furthermore, the specific HPV prevalence characteristics in this population provide a platform for research to resolve scenarios that will ensue in the post HPV-vaccination with less or no HPV16 and HPV18 and potentially more other HR-HPV types.


The purpose of the study was to assess the knowledge, attitudes and beliefs of male and female college students in Kentucky about HPV associated diseases and vaccines, and to determine which parameters predicted self-reported uptake of HPV vaccination.A self-selected cross-sectional sample of college students completed an evidence-based online survey.Of approximately 1200 potential respondents, 585 completed the survey. The average age was 20.6 (SD 3.15) and 78% were female; 84% of the population had had one or more sexual partners. Concern for HPV vaccine safety and potential need for boosters did not significantly deter vaccine uptake. Likewise, knowledge about HPV associated cancers was not predictive of vaccine uptake. On the other hand, parental influence for vaccination was a strong predictor for vaccine uptake , and free vaccine nearly doubled the likelihood of being vaccinated . In addition, the strong preference for the respondent's partner to be HPV vaccinated predicted vaccine uptake , but the lack of preference for partner vaccination predicted an unvaccinated self .HPV vaccination has been successful in young adult college students in Kentucky. Young adults prefer their partners to be HPV vaccinated regardless of whether they themselves are vaccinated. Parental influence and free vaccine were positive predictors for vaccine uptake in this population. •Young adults have a very strong preference for their partner to be HPV vaccinated.•Doctors do not influence young college adults’ decisions to be HPV vaccinated.•Parents are a significant influencer for young adult HPV vaccine uptake.•Young adults realize need for cervical cancer screening regardless of vaccine. Additionally, the study initiates an assessment of the perceived influence the student felt he or she had in the vaccination decision.22.1Participants were recruited from a metropolitan research university in Jefferson County, Kentucky, with an undergraduate enrollment of more than 16,000 students. Students are largely in-state residents (74%) with roughly equal numbers of students from urban and rural areas of the state. African Americans make up 10.2% of enrollment with an additional 12.7% of students classified as other minorities.Undergraduate students enrolled in an introductory psychology course were eligible to participate in the study. Over the spring and fall semesters, approximately 1200 were eligible to enroll in the study via the department's research participation system, Sona Systems (Estonia). The research participation system, which lists several other studies from which the student could choose, described the current study, indicated the research credit hours (0.5 h) that could be earned, and redirected participants to the survey. The online survey was created and hosted on Qualtrics  and could be accessed only through the Sona System. Participants could complete the survey on a computer or mobile device.2.2Prior knowledge surveys about HPV vaccines, particularly to parents of children, do not have validation statistics associated with them, but rely on verifiable scientific knowledge for accuracy. Our research group developed a similar survey with input from medical and public health researchers of HPV associated cancers, HPV vaccines, sexually transmitted infections, shared decision making, and behavioral health/health promotion. We validated the questions with a process that involved an extensive review of the literature, a pilot test for face validity, and a Delphi method for content validity The final survey consisted of 30-items in four sections. The demographics section assessed race, ethnicity, sexual orientation, past sexually-transmitted infections (STIs) and number of lifetime sexual partners. Assessment of knowledge of HPV and HPV vaccination included responses to whether HPV leads to 12 health outcomes; knowledge of the vaccine's effectiveness, duration of immunization, and the need for continued cervical cancer screening. Assessment of attitudes included the importance of the protecting oneself versus protecting one's partner against STIs, perceptions of the safety of HPV vaccination and other vaccines, willingness to get a booster shot(s) after the initial HPV vaccination series, and desire for sexual partners to be vaccinated against HPV. If not a dichotomous answer choice, the responses were either 5 point scales  with an additional prefer not to answer option due to the sensitive nature of many of the questions; or an estimate of importance between 0 and 100 . Assessment of behaviors included HPV vaccine uptake (0–3 doses of either Gardasil™ or Cervarix™), discussion with partners about their vaccine status, use of condoms, and perceived involvement in the decision to be vaccinated. In addition, items assessed the perceived lifetime likelihood of becoming infected with HPV and/or developing an HPV-linked cancer on a scale from 0 to 100 .2.3Data were analyzed using SPSS V24  and Dell Statistica v13 . Extensive data cleaning methods, done by two of the authors, included removal of non-respondents, assessment for out-of-range values, unreasonably short (less than 2 min) response duration and visual evidence of patterned responding . Descriptive statistics, non-parametric statistics (chi-square) and binomial logistic regression were used to establish significant differences. Multivariate logistic regression provided adjusted odds ratios to predict vaccine uptake.3Of the 645 surveys initiated, 585 completed more than 95% of the questions. The majority of the respondents were female (78%), white (74%), and heterosexual (90%), who had 1–2 lifetime sexual partners (36%). Of the 84% of respondents who had reported having had sex, 76% said their partners were of the opposite sex.About 50% of respondents, regardless of vaccination status, said they were likely or very likely to discuss their vaccination status with a new sex partner. On the other hand, significantly more unvaccinated than vaccinated were unlikely or very unlikely to discuss HPV vaccine status prior to a new relationship ; and the vaccinated were significantly more ‘undecided’ about the discussion than the unvaccinated .The vaccinated expressed significantly higher strong or very strong preferences for their sexual partner to be HPV vaccinated compared to the unvaccinated . Conversely, the unvaccinated were neutral or had slight/no preference for partner vaccination significantly more often than the vaccinated .There was no difference between the vaccinated and unvaccinated in preference for preventive measures before having sex with a person: Over half of the vaccinated and unvaccinated would have sex with a person who was not HPV vaccinated; and about a third of the vaccinated and unvaccinated would have sex with a person without using a condom. Asking the negative question about who they would not have sex with, significantly fewer vaccinated would not have sex with a person who did not have HPV vaccination , and similarly, significantly fewer vaccinated would not have sex with a person not using condoms . Yet, the majority (88%) of respondents indicated a somewhat or very confident stance in preventing self from an STI during sex irrespective of protection by condom use or vaccination.Respondents were asked who was most important in making the decision to be vaccinated. Options included: “it was a shared choice between the doctor and me”, “myself”, “my doctor”, or “my parents or guardians”. Overall, 69% of respondents chose “myself” as the most important person in the decision whether to vaccinate; the unvaccinated chose “myself” more frequently  than the vaccinated. Overall, 13% indicated that participating in a shared choice was the most important influence to receive vaccination, and this rate was similar between the unvaccinated and vaccinated . Although “my parents or guardians” was selected by a small percentage , those choosing “my parents or guardians” were more often vaccinated than not . “My doctor” was chosen least often  and at a similar rate among the unvaccinated and vaccinated respondents .Finally, overall 65% of the respondents would get vaccinated if all doses and boosters were completely free of charge. For the unvaccinated, 44% remarked that free vaccine would not influence them, whereas for the vaccinated, 73% agreed/strongly agreed that free vaccine would facilitate their vaccination .3.1a); ovarian cancer was incorrectly attributed to HPV 93% of the time. Genital warts were correctly attributed to HPV in 66% of the respondents, and other HPV associated benign diseases, such as plantar and finger warts, were correctly identified in 34% and 26% of the respondents, respectively (b). There was minimal understanding of the lack of HPV association with other common diseases or conditions, except for pregnancy (c).Of the cancers presented to the respondent, cervical cancer most often was correctly attributed to HPV a; ovariaectively b. There regnancy c.Fig. 1Pknowledge sub-score for HPV associated diseases was 5 , a score that did not differ by vaccination status, gender, race or age.Out of 12 possible points for correct answers, the median and interquartile ranges for the total 3.2Overall, respondents had two dominant answers about the duration of vaccine efficacy: 29% responded that the vaccine protected for a lifetime, and 29% indicated that they did not know . The vacOverall, 93% of respondents correctly understood the need for cervical cancer screening with or without HPV vaccination. The vaccinated respondents understood significantly more than the unvaccinated about the need for continued cervical cancer screening regardless of whether vaccination occurred .knowledge sub-score for HPV vaccines was 2 . While both groups knew much about HPV vaccines, the unvaccinated knew significantly less about the vaccines than the vaccinated with 88% scoring a 2 or 3 compared to 95% by the vaccinated (p < 0.05).Out of 3 possible points for correct answers, the median and interquartile ranges for the total two sub-scores about HPV disease and HPV vaccines together resulted in a median correct score of 6 with interquartile ranges of 4 and 8 out of a possible 15 total correct. There were no differences between the two groups in knowledge by vaccination status, gender, race or age.Summing the 3.3Booster shots were acceptable to over 90% of the population . Annual Concerns about HPV vaccine safety were significantly higher among the unvaccinated than the vaccinated , yet over a quarter of the vaccinated agreed or strongly agreed with concerns about HPV vaccine safety. For childhood, adolescent and adult vaccines, in general, over half of all respondents believed they were completely safe, while nearly a third had no opinion.Most respondents agreed or strongly agreed that free HPV vaccine or booster doses would influence them to get vaccinated; and, those vaccinated were significantly more influenced than the unvaccinated .The perception of the likelihood of being infected with HPV was quite low for both groups, but significantly lower for the vaccinated than the unvaccinated  vs. 10 , p < 0.001). The perception of the likelihood of their HPV infection progressing to cancer did not differ by vaccination status , but was much higher than the actual risk [9]3.4In a univariate logistic regression analysis , all parMen were significantly less likely to be vaccinated than women , and those declaring Asian race/ethnicity were less likely to be vaccinated than whites . Number of lifetime sexual partners was not predictive of vaccination status, nor was confidence about protecting self from STIs.males only = 6.65, 95% CI: 2.32, 19.00, OR females only = 4.25 95% CI: 2.44, 7.42). On the other hand, vaccinated respondents compared to the unvaccinated were not more likely to care whether their partner used condoms.While the discussion with new sex partners about each having been vaccinated was not predictive of vaccination status, vaccinated respondents indicated a very strong preference for their partner to have been vaccinated compared to the unvaccinated respondent . This was reinforced by the vaccinated men and women stating that they were significantly more likely to not have sex with someone who has not had the HPV vaccine .Among knowledge questions, the vaccinated were significantly more likely to be unaware of the association of HPV with anal cancer . In addition, the vaccinated were also less aware of the lack of association between HPV and HIV  than the unvaccinated. HPV associated benign disease knowledge did not predict vaccine uptake.Understanding the need for continued cervical cancer screening did not significantly predict vaccination status.Belief in yearly or every 5 year booster doses was significantly associated with vaccine uptake, especially among the female responders . However, the knowledge about the duration of vaccine efficacy was not a significant predictor of vaccine uptake.The vaccinated respondents were significantly more likely than the unvaccinated to strongly/very strongly disagree with concerns about HPV vaccine safety , while at the same time having no difference from their unvaccinated respondents in agreement about the safety of childhood and adult vaccines. Finally, the influence of free vaccine/booster on vaccine uptake was significant .3.5The multivariate analyses considered all of the significant univariate predictors in an adjusted model . Older aSeveral other important results from this analysis also appeared. Lack of concern about HPV vaccine safety did not influence vaccine uptake in the adjusted model, neither did the need for boosters at any frequency. Knowledge in limited areas did predict vaccine uptake, though. Specifically, those who correctly answered that finger and genital warts were from different HPV types were twice as likely to be HPV vaccinated ); and those who correctly categorized plantar warts as caused by HPV were significantly less likely to be vaccinated.Being vaccinated was predicted by having a very strong/strong preference for the partner to also be vaccinated ; while having no or little preference for partner vaccination was significantly associated with less vaccine uptake.Significant influencers to be vaccinated were reduced to only parent/guardian influence in the multivariate model  with the opportunity for shared choice or the doctor's recommendation becoming not significant. Finally, free vaccine/boosters predicted an increased vaccine uptake by nearly two-fold .4This study is one of the larger studies to date to investigate the knowledge about HPV associated diseases and vaccines, attitudes and beliefs in college students since the implementation of the Patient Protection and Affordable Care Act (ACA) in 2010. The ACA makes it more likely that college aged adults can be vaccinated, regardless of ability to pay. Kentucky has had a significant Medicaid expansion through the ACA and has reduced the uninsured rates to less than 11% In 2014, the most recent report, 12.5% of females were first vaccinated at 18 years of age and 20% at 19 years or older; among males, 24.4% were first vaccinated at 18 years of age and 26% at 19 years or older, despite the target age for vaccination being 11–12 years old The young adults attending college in urban Kentucky have a higher rate of vaccination than is reported for the nation, but similar to the reports from the American College of Health Association The concept of free vaccine was associated with vaccine uptake in this college-aged survey, but real life free vaccine has not been significant for an increased uptake or compliance with HPV4 vaccine in a different young adult population One of the most important outcomes of this study was the finding that a very strong/strong preferences for their sexual partner to be vaccinated was a highly significant predictor of HPV vaccine uptake. This result is concordant with other work supporting the female's desire for her male partner to be HPV vaccinated Specifically, but contrary to many adolescent focused studies Parental influence (11%) was also a significant predictor of vaccine uptake as has been discussed in other similar communities Finally, we found little evidence that students were overly concerned with vaccine safety, especially among those who were vaccinated. This finding is consistent with a previous systematic review 5Increasing young adult vaccination rates may come with changing preferences and influencers. Finding mechanisms to move young adults to prefer partner vaccination may offer an increase in HPV vaccine uptake, similar to peer pressure or peer education for contraceptive choices. In general, to observe population effects in cervical cancer prevention, we must include post adolescent young adults in the vaccination drive. Co-messaging HPV vaccination and cervical cancer screening to young adults may be the best approach for reducing cervical cancer burden later in life 5.1NCT03180034], the behavioral health attitudes of reduced numbers of dosing in young adults may influence uptake that is not considered in this work.We did not address the number of doses that the young adults completed, nor the time frame in which they might have received more than one dose. With two dose regimens being promoted by the WHO This is a survey conducted from a convenience population sample. The survey was designed to incorporate self-validation for maximizing truthful responses with control questions, options to not answer a question, anonymity, and no signed consent form. Generalizability to other college aged populations cannot be verified. Respondents were all enrolled in college and, at minimum, had access to campus health services; these results, therefore, may not apply to young adults not in college, or those with limited access to health care. Future research among the vocational young adults is needed to understand how to reach others not in a collegiate setting. Additional studies are needed to assess how to teach strategies to young adults so that they can inform new partners of the expected protections  the young adult has of a new partner.No author has any conflict of interest for publishing this work.This research did not receive any specific grant from funding agencies in the public, commercial, or not for profit sectors.


Detection of genital HPV DNA is recommended as an important strategy for modern cervical cancer screening. Challenges include access to services, the reliance on cervical samples taken by clinicians, and patient’s preference regarding provider gender. The objective of this research was to determine the acceptability, feasibility and performance of alternative self-collected vaginal samples for HPV detection among Ghanaian women.careHPV brush and a clinician-collected (CC) cervical sample was obtained using a similar brush. Paired specimens were tested for HPV DNA (14 high-risk types) by careHPV assay (Qiagen) and by HPV genotyping .A comparative frequency-matched study was conducted in a systematic (1:5) sample of women attending HIV and outpatient clinics in the Cape Coast Teaching Hospital, Ghana. Participants were instructed on self-collection (SC) of vaginal samples using the p < 0.0001), showing excellent agreement. This agreement was similar between HIV positive (93.8%) and negative (94.7%) women. Sensitivity and specificity of SC compared to CC were 92.6% (95%CI: 85.3–97.0) and 95.9% (95%CI: 89.8–98.8) respectively. The highest sensitivity was among HIV positive women  and highest specificity among HIV negative women . Overall, 76.3% women found SC very easy/easy to obtain, 57.7% preferred SC to CC and 61.9% felt SC would increase their likelihood to access cervical cancer screening.Overall, 194 women of mean age 44.1 years (SD ± 11.3) were enrolled and 191 paired SC and CC results were analysed. The overall HPV detection concordance was 94.2% (95%CI: 89.9–97.1), Kappa value of 0.88 (careHPV support the use of this alternative form of HPV screening among Ghanaian women. This could be a potential new affordable strategy to improve uptake of the national cervical cancer screening program.The feasibility, acceptability and performance of SC using  In Ghana, as in many parts of sub-Saharan Africa, cervical cancer is the commonest cancer and the leading cause of cancer-related mortality among women, with an estimated 3052 new case and 1556 deaths in Ghana annually . InformaThe diagnosis of cervical cancer relies on the detection of precursor lesions using conventional cytology with pap smear, visual inspection using acetic acid or Lugol’s iodine (VIA/VILI) or colposcopy with histological confirmation, with varying performance characteristics for all of these tests and several limitations for implementation in low-resource settings .Detection of hrHPV types has important prognostic value for the detection of high-grade cervical squamous intraepithelial lesions (HSIL) or neoplasia (CIN) . DiagnosSince highly sensitive molecular testing for HPV does not necessarily require exact cervical location of HPV replication (i.e. the squamo-columnar junction or transformation zone) to be collected, contrary to what cervical cytology requires, an additional potential benefit of HPV testing is the possible use of self-collected cervico-vaginal samples. It has been shown that self-collection might be preferred by women as it addresses issues affecting clinician sample collection –13. TaylParticipants were recruited as part of a larger HPV and cervical cancer study conducted in the Cape Coast Teaching Hospital (CCTH), aiming at studying the epidemiology of, and diagnostic options for hrHPV and cervical lesions among HIV-1 seropositive compared with HIV-seronegative women. In the parent study, women attending the general medical outpatient and HIV clinics of CCTH were recruited. Every fifth woman aged ≥18 years was systematically selected from the list of daily attendants, starting with a randomly picked attendance number for the first woman. If a woman was deemed not eligible based on criteria for this study , or she did not accept to be part of the study, the next available patient was offered her place, and every fifth woman whence, to a maximum of 10 women per clinic day was recruited. For the current evaluation of self-sampling, we aimed to have about half the sample size and participants were recruited on alternate days.careHPV brush and to place it in the careHPV collection medium . Participants then underwent a speculum exam during which clinicians collected a cervical sample using the careHPV brush and transport medium. After sample collection, participants filled a short questionnaire to assess their experience and views of SC compared with CC. The questionnaire was administered by the clinician who collected the sample. Four questions were asked, with two using a Lichter’s scale of possible responses  following the manufacturer’s instructions. careHPV is a semi-rapid qualitative assay designed as a simplification of the Digene Hybrid Capture-II (HC2) test technology to detect the DNA of any of 14 hrHPV types  [careHPV has been favourably evaluated in comparison to HC2 and other HPV detection assays for the detection of high-grade cervical lesions [Paired SC and CC samples were tested using the  by HC2) –17. The  lesions .careHPV. This assay has been validated against an international reference method [In addition, HPV genotyping was done to verify type-specific concordance. An aliquot from each of the cervical and vaginal samples were tested using the Anyplex™ II HPV HR Detection assay  which detects 28 HPV types, including the same 14 hrHPV  detected by e method .A Kappa calculation was performed to determine the sample size needed for this sub-study. A Kappa value of 0.75 or higher was taken to indicate excellent agreement. Assuming a ≤ 10% difference in levels of detection between SC vaginal samples versus comparator standard CC cervical sampling, it was estimated that a total of 150 paired SC and CC samples were needed.careHPV results agreement between paired SC and CC samples was calculated using the Kappa statistic. Sensitivity and specificity of SC compared to CC as the gold standard were also calculated with their 95% confidence intervals (CI). A genotype level analysis of concordance was also conducted. To determine the acceptability of SC and CC, the proportions of responses to questions asked concerning the experience of participants was calculated.The proportion of overall Ethical approval for the parent and this sub-study was obtained from the Committee on Human Research Publications and Ethics of the School of Medical Sciences, Kwame Nkrumah University of Science and Technology (KNUST). Study participants were recruited to this sub-study after obtaining additional signed written informed consent.careHPV invalid results rate after retesting was 1.5% (n = 3) and results from these women were excluded from the analysis.Between July 2014 and August 2015, a total of 333 women were recruited to the parent study , of whom 195 eligible women were invited to be part of this sub-study. In all, 194 consenting women  provided paired SC and CC samples. careHPV concordance between the remaining 191 paired samples was 94.2%  showing excellent agreement with similar high agreement among HIV seropositive  and seronegative  women (Table p = 0.570), educational level (p = 0.482), or HIV status (p = 1.000).The overall careHPV, the positive agreement between SC and CC samples was 100%. For HIV negative women, the positive agreement between SC and CC samples was 100% for ten (10) hrHPV genotypes. The lowest positive agreement rates (50%) was among HIV negative women for HPV39  of the hrHPV types detected by  of the hcareHPV compared with genotyping for women with cytological endpoint is presented elsewhere [The performance of lsewhere . All womResponses showed that over three quarters 76.3%) of women felt it was easy or very easy to self-collect vaginal samples and 77.9% felt SC was very comfortable or somehow comfortable compared with CC. Given the option, the majority of women (57.7%) would prefer SC over CC and nearly two-thirds (61.9%) felt SC would increase their likelihood to access cervical cancer screening  and its performance to detect hrHPV infection, makes it a relevant approach for community level screening. In such campaigns, women could obtain samples at their homes, which could be brought to, or collected by, community health workers who would forward them to the laboratory. Results could easily and quickly be communicated back to the women without having to come to the health facility. With such a setup, only women who need follow-up tests like cytology or colposcopy would be invited to health facilities. This would alleviate the costs and burden on health services. The Community-based Health Planning and Services (CHP) concept, which already exists in Ghana, makes this a potentially easily adoptable strategy. Based on this concept, another research team is currently working on evaluating self-collection at the community-level in the Volta Region of Ghana.The study found that nearly all women could obtain a self-collected vaginal sample giving valid HPV results, and that they felt the method was acceptable and easy to use. Furthermore, the agreement between self-collected and clinician-collected samples for y others , 22–24, y others . Self-sacareHPV SC came at no additional cost - an important consideration in a developing country like Ghana.In this study SC samples were taken with the same brush as for CC sampling without the need to purchase additional devices specifically marketed for SC, including the Delphi® screener  and the Evalyn® brush . Thus, by using careHPV among 431 women in rural Thailand recorded over 90% acceptability with over 70% of respondents indicating a preference for SC [This study reported that three-quarters of women found SC to be more acceptable than CC. Having experienced both SC and CC, the participants could give a realistic account of their experience and determine their preference. Researches in other settings, including rural communities, have reported similar findings , 25. Troe for SC . Even ifThis study had some limitations. First, it used a quantitative approach to determine acceptability of self-collection. A complementary qualitative methodology would have enabled a better exploration of the women’s experience and potential difficulties. Second, women were recruited in a clinic setting, which increases the chances of participation, compliance with methodology and a positive outcome, as noted by others . A largecareHPV assay support it as a good alternative for hrHPV testing Ghana.This study therefore concludes that, the feasibility, acceptability and performance of vaginal self-collection using the