Cervical cancer poses a substantial burden in terms of morbidity, mortality, and economic losses, especially in low/middle-income countries. HPV vaccination and/or cervical cancer screening among females may reduce the burden of HPV-related diseases, including cervical cancer. However, limited funds may impede the implementation of population-based programmes. Governmental investments in the prevention of infectious disease may have broader economic and fiscal benefits, which are not accounted in conventional economic analyses. This study estimates the broader economic and fiscal impacts of implementing HPV vaccination and/or cervical cancer screening in Indonesia from the perspective of the government.A government-perspective quantitative analytic framework was applied to assess the Net Present Value (NPV) of investment on cervical cancer prevention strategies including HPV vaccination, cervical screening and its combination in Indonesia. All monetary values were presented in International Dollars (I$).Based on a cohort of 10,000,000 Indonesian 12-year-old females, it was estimated that HPV vaccination and/or cervical cancer screening result in a positive NPV for the Indonesian government. The combination of cervical screening and HPV vaccination generated a substantial reduction of cervical cancer incidence and HPV-related mortality of 87,862 and 19,359, respectively. It was estimated that HPV vaccination in combination with cervical screening is the most favorable option for cervical cancer prevention (NPV I$2.031.786.000), followed by HPV vaccination alone (NPV I$1.860.783.000) and cervical screening alone (NPV I$375.244.000).In addition to clinical benefits, investing in HPV vaccination and cervical screening may yield considerable fiscal benefits for the Indonesian governments due to lifelong benefits resulting from reduction of cervical cancer-related morbidity and mortality. High-risk human papillomaviruses (hrHPV), in particular HPV16 and HPV18, are responsible for cervical cancer and premalignant cervical disease among woman . AlthougSeveral health-economic analyses have shown that HPV vaccination combined with cervical cancer screening results in an efficient use of healthcare resources –19. SuchSJSN) for HPV prevention.HPV infection and cervical cancer disease pose a substantial morbidity and mortality burden. In 2012, there were over 20,000 new cases of cervical cancer and 9,000 cervical-cancer related deaths . The impThe natural history of cervical cancer for Indonesian women was modeled based on a previously published population-based Markov model . The cerThe fiscal analysis described here simulates the natural history and costs of cervical cancer patients in Indonesia. Susceptible, cervical cancer and death states were modeled and a simulation was run for a cohort of 10,000,000 Indonesian 12-year-old girls over their lifetime ,26. CervIn order to estimate the lifetime earnings and, thus, the lifetime tax revenues to be gained from the average Indonesian female, earnings distribution was categorized into three levels  and the average of each earnings level, based on the Indonesian Gross Domestic Product (GDP) using Gini index of 0.41 ,31, was et al. [Governmental transfers to citizens were estimated based on the national social and health security system. The benefits provided by the social security system are pension funds, and work-related accident and death-benefits ,45. Old-et al. . Costs wet al. . Direct The discounted cash flow method was used to obtain the present value of cash inflows and outflows. The results were presented in terms of the Net Present Value (NPV) of the investment decision for each of the cervical cancer prevention strategies under study as follows:t), including vaccine cost at t = 0 (K0) from incremental revenues (Rt) for each of strategy. Increments refer to the difference between the revenue and expenses with and without the HPV prevention strategy under consideration. All values were discounted (r) by 3% according to WHO recommendation and also consistent with previous cost-effectiveness studies on cervical cancer prevention programmes in Indonesia.NPVs were calculated by subtracting incremental expenses , tax compliance, membership of health and social security, percentage of earnings consumed and percentage of work-related accident premium. Inflation and discount rates were varied by the lowest and highest value of Indonesian inflation rate in 2014  and acceBased on a single cohort of 10,000,000 girls in Indonesia, our model showed that in the absence of any cervical cancer prevention strategy, 147,632 cases of cervical cancer will ultimately occur within the cohort. The implementation of cervical cancer prevention strategies, including screening alone, HPV vaccination alone, or cervical screening in combination with HPV vaccination were projected to prevent 15,641, 80,750 or 87,862 cases of cervical cancer, respectively. Furthermore, the combination of cervical screening and HPV vaccination generated the highest reduction of deaths caused by cervical cancer , followed by HPV vaccination alone  and screening alone  .The lifetime NPV for the study cohort of Indonesian 12-year-old females is illustrated in Implementation of population-based healthcare intervention unambiguously results in fiscal costs due to changes in morbidity and mortality that influence national accounts over the lifetime of the cohort. However, similar to other public investments, investment in healthcare interventions may also result in measurable, long-term fiscal benefits (i.e. tax revenue) attributed to changes in population health that may outweigh or considerably offset the costs . In thisThe main clinical benefit of cervical cancer prevention programmes is the reduction of morbidity and mortality ,53–55. IThe underlying assumption of taking a broader economic analytic perspective with emphasis on fiscal effects is that changes in health status or the prevention of infectious diseases have several external effects. The benefits of HPV prevention imply that more women who would be able to work thus, gain more earnings and pay more taxes and security premiums for the government. As a result of this, it is expected that the prevention of HPV infection and HPV-related diseases will yield increased governmental fiscal revenues from (direct and indirect) taxes and also  security insurance premium. Moreover, there are significant cost-savings resulting from reduced need for cervical cancer treatment which is captured in conventional cost-effectiveness analyses and also demonstrated by application of a “government-perspective” framework to assess different HPV investment strategies.A key limitation of this type of study is that it is largely dependent on the mathematical modeling of long-term clinical, economic and fiscal parameters. Although the population–based model included high-quality clinical-trial data, including vaccine and VIA screening efficacy on incidence and mortality, further model validation using observed-country-specific data could still further assure the outcomes of the model. However, the Indonesia-specific observational information is not available. Such further validation and comparing our model with more sophisticated models from other countries with better data availability remains an option for future research.Some of the key parameters dynamically change over time in the real life. Sensitivity analyses may address some of the uncertainty around these parameters. However, further observational data may be needed to assess the real-life fiscal effect of HPV prevention programmes. In addition, the current analysis does not take into account the effects of herd immunity, inequalities in access to health-care services due to socio-economic and regional differences, further distinctions in specific stages of both pre-cancer and cervical cancer, nor the benefits that HPV vaccination may have in terms of (i) protection of males and (ii) prevention of genital warts.By conducting a broader economic analysis, evidence is produced to inform analyses regarding the cross-sectorial allocation of resources and perhaps the transfer of funds from other sectors of the public economy to universal population-based vaccination and screening programmes. The evidence generated in this study may address the affordability of implementing an HPV prevention program in Indonesia. Our study results suggest that investments in HPV prevention programmes may generate epidemiological benefits that translate into health-economic and fiscal benefits for the Indonesian government that may fully offset the investment costs and thus may have a positive impact on national accounts in the long-run.


We also found that chicks exposed to higher blue component exhibited higher blood glucose levels. Furthermore, the glucose level was positively related to the final body mass  and food intake . These results demonstrate that spectral composition plays a crucial role in affecting growth and physiology in chicks. Moreover, consistent changes in spectral components might cause the synchronous response of growth and physiology.Despite the overwhelming use of artificial light on captive animals, its effect on those animals has rarely been studied experimentally. Housing animals in controlled light conditions is useful for assessing the effects of light. The chicken is one of the best-studied animals in artificial light experiments, and here, we evaluate the effect of polychromatic light with various green and blue components on the growth and physiology in chicks. The results indicate that green-blue dual light has two side-effects on chick body mass, depending on the various green to blue ratios. Green-blue dual light with depleted and medium blue component decreased body mass, whereas enriched blue component promoted body mass in chicks compared with monochromatic green- or blue spectra-treated chicks. Moreover, progressive changes in the green to blue ratios of green-blue dual light could give rise to consistent progressive changes in body mass, as suggested by polychromatic light with higher blue component resulting in higher body mass. Correlation analysis confirmed that food intake was positively correlated with final body mass in chicks ( Although the widespread use of artificial light has enhanced the quality of human life and is positively associated with modernity, wealth and security, the rapid global increase in artificial light has fundamentally transformed the light environment over the past six decades in both quantity  and quality (light composition) Therefore, interest has been rising around the mechanisms of individual response to artificial light Housing animals in controlled light conditions is useful for assessing the effects of light in animal models. Chickens are one of the best-studied animals with respect to the impact of artificial light. First, the avian retina possesses one of the most sophisticated cone photoreceptor systems among vertebrates. Birds have five types of cones, including four single cones that support tetrachromatic color vision and one double cone, which is thought to mediate achromatic motion perception. Tetrachromatic color vision is mediated by four types of single cones that are maximally responsive to violet, blue, green and red light Therefore, in this study, the chicken was selected as the object, and polychromatic light with various green and blue components was selected as the treatments to evaluate the effect of polychromatic light on the growth and metabolism indicators of chickens. In addition, most previous studies focus on a very short time exposure to domestic animals, neglecting the long-term dose of artificial light. As domestic animals are exposed to artificial light throughout their life, chickens were exposed to artificial light treatments from birth to the end of this study.2 . The dry bulb temperature and relative humidity were measured once every day, using data loggers  to ensure that the temperature and relative humidity conditions were similar in all compartments. The average environmental temperature and relative humidity were 25.3°C and 67.5%, respectively.Female chicks , purchased from a commercial hatchery , were randomly assigned to five lighting treatments of 30 birds in two replicates of 15 birds. The genetic performance of this medium-growing broiler strain is very stable, and it is certified by the China Agricultural Ministry as one of the two national gene pools of native broiler libraries. All birds were weighed individually at 30 days of age, and the average body mass was calculated immediately for each treatment. To maintain uniformity, 5 birds  were eliminated per treatment, and 10 broilers from each replicate without creating a deviation from the original average data (20 birds in two replicates of 10 birds from each light treatment group) were reared until the end of the experiment (81 d of age). All chicks had ad libitum access to food and water, and their diets were formulated to meet the nutrient recommendations for poultry . All groups were housed in five independent compartments, each of which contained only one light treatment. The independent compartments were divided into 2 sealed cells (replicates) of 1 m2 of irradiance using a radiometer  in each cell at 5 locations at cell floor level. Surroundings were covered with fluorescent fabrics to avoid pollution from other light sources. The light scheduled was 23∶1 light/dark cycle on the first day to make the birds adapt to the environment, and it was reduced by 1 hour every day until it reached 16∶8 light/dark cycle, which was maintained for the remaining days. This study was carried out in strict accordance with the recommendations in the Guide for the Care and Use of Animals of the Zhejiang University. The protocol was approved by the Committee on the Ethics of Animal Experiments of Zhejiang University.Upon arrival, all chicks were assigned to one of the following five light spectral groups, including two monochromatic light spectral groups, i.e., the monochromatic green light spectral group (Green group) and monochromatic blue light spectral group (Blue group), and three polychromatic light spectral groups, i.e., the green-blue dual light with depleted blue component (Blue-Depleted group), with medium blue component (Blue-Medium group) and with enriched blue component (Blue-Enriched group). All illumination was provided by light-emitting diode (LED) arrays, purchased from Langtuo Biological Technology Co. Ltd. . The spectral distributions of the LED arrays are presented in Food intake and body mass were recorded at 45, 60, 72 and 81 d of age, and the percent gain in body mass was calculated relative to the initial body mass. The growth condition of the seven lighting treatments was described using a nonlinear regression analysis with the mathematical model of body mass vs. age. At the end of the trial (81 days of age), after being fasted for 12 h, 30 birds were randomly selected from each group as 3 birds from each replicate to balance the contribution of the replicates. The birds were then killed by cervical dislocation to collect blood samples and were eviscerated to weigh abdominal adipose. Blood samples were centrifuged at 4°C for 30 min at 3,000×g to remove clots. Blood serum was aspirated and stored in sealable polypropylene micro-centrifuge tubes at −70°C for subsequent determination. Metabolic indicators including total cholesterol (TC), total triglyceride (TG), high-density lipoprotein cholesterol (HDL-CH), low-density lipoprotein cholesterol (LDL-CH) and glucose (GLU) were determined using an Automatic Biochemistry Analyzer .P<0.05.Data were subjected to statistical analyses using SPSS Statistical software (V. 20.). Statistical analysis of data was factorial by rooms and by light. Rooms were found not to be significant for all treated variables, and the results were retested by a one-way ANOVA to analyze the effects of the light spectral composition on birds. Homogeneity of variance was checked for each set of data, and no transformations were applied. When appropriate, post hoc comparisons were made using least significant differences. Data are presented as the mean ± SEM. In every case, a difference between the group means and the correlation coefficient was considered statistically significant if the value of P = 0.028; P = 0.265). Moreover, at these ages, no significant difference was found among the Green, Blue, Blue-Medium and Blue-Enriched groups (P = 0.153). A similar effect of spectral composition was observed for percent body mass gain, as shown in The effects of monochromatic light (Green and Blue group) and polychromatic light  on the body mass of chicks are given in Polychromatic light composition had two-side effects on chick body mass compared with monochromatic light spectra, according to variations in the spectral composition. Thus, relatively lower body masses were obtained in the Blue-Depleted and Blue-Medium groups, while relatively higher body mass values were obtained in the Blue-Enriched group than in the Green and Blue groups. Moreover, we found that polychromatic light with a higher blue component resulted in higher body mass in birds (Blue-Enriched>Blue-Medium>Blue- Depleted groups), as shown in P = 0.086). Regardless of age, chicks in the Blue-Depleted group consumed the lowest amount of food compared with the other lighting groups. At 45 days of age, Blue-Medium group chicks ate more food than did the other lighting-treated chicks. This tread continued to 60 days of age. However, at 72 days of age, Blue-Enriched group chicks exhibited the highest food intake of the groups, even higher than that of Blue-Medium group chicks. Moreover, at 81 days of age, chicks exposed to polychromatic light with a higher blue component ate more food than did chicks exposed to a lower blue component, which was consistent with the relationship between the blue component and body mass in chicks (Blue-Depleted<Blue-Medium<Blue-Enriched groups). Correlation analysis confirmed that food intake was positively correlated with final body mass in chicks , a positive relationship was observed between blue component and food conversion values (Blue-Depleted<Blue-Medium<Blue-Enriched groups).Food conversion can be calculated using the formula /period food intake. Food conversion was calculated to directly evaluate the food efficiency of birds in each group. At early growth stages (45 and 60 days of age), a significant lower food conversion in chicks from Blue-Depleted group was found compared with that in Blue-Medium group (−1), and ln(b)/k represents the inflection point or maximum growth age To compare the growth condition of chicks in various lighting groups, their growth curves (body mass vs. age) were adjusted to a nonlinear mathematical model (Gompertz). The Gompertz equation was used in the following form with 3 parameters: W = a×exp(-b×exp(-k×t)), where W is BM (g) at age t (d), a is asymptotic BM reached as t →∞, k is the maturing rate . However, the estimates of the mature weight (a) and the maximum growth (ln(b)/k) ranged broadly between 1971.3–2658.1 (g) and 55–64 among groups, respectively. Thus, birds from Green group would grow to 2658.1 (g), while birds from Blue group would only grow to 1971.3 (g) as t →∞. Birds exposed to polychromatic light with a higher blue component would result in heavier body mass as t →∞ (Blue-Enriched>Blue-Medium>Blue-Depleted groups). Birds from the Blue-Medium and Blue-Enriched groups would attain maximum growth at 55 days of age, while the Blue-Depleted and Blue groups would attain maximum growth at 56 and 57 days of age, respectively, suggesting that the blue component had a minimal effect on the maximum growth of chicks.The Gompertz model was quite suitable to describe the growth of birds in all lighting groups (P = 0.003). Additionally, chicks in the Blue-Depleted group attained significantly higher body temperatures compared with the Blue-Medium, Blue-Enriched and Blue groups (P = 0.015). Moreover, chicks treated with a higher blue component had lower body temperatures (Blue-Depleted>Blue-Medium>Blue-Enriched>Blue groups), suggesting that the body temperature of chicks was negatively correlated with the blue component level.The body temperature measurements showed that spectral composition had a significant difference on the body temperature of chicks . Chicks P = 0.021). The Blue-Medium group obtained the highest abdominal adipose weight. In contrast to the Blue group, chicks in the Blue-Medium group had significantly higher abdominal adipose weights. However, no significant difference was found in abdominal adipose weight in chicks treated in the Green, Blue-Depleted, Blue-Medium and Blue-Enriched groups (P = 0.605).As shown in P = 0.047; P = 0.281; P = 0.437; P = 0.107; P = 0.057; 2R = 0.6406, P = 0.0001; 2R = 0.784, P = 0.0001; The effects of spectral composition on serum metabolic indicators including low density lipoprotein cholesterol (LDL-CH), high density lipoprotein cholesterol (HDL-CH), total cholesterol (TC), total triglyceride (TG) and glucose (GLU) are presented in It has been reported that rates of body weight gain in birds in the tropics are 23% lower than the rates in similarly sized birds inhabiting temperate areas 2R = 0.5058, P = 0.006). Therefore, the study suggests that low levels of light at night (5 lux) disrupt the timing of food intake, leading to excess weight gain. The conclusions are relevant to the coincidence between artificial light compositions, especially blue component and body mass increase in birds. As described above, blue component correlated positively with final body mass in chicks. Moreover, chicks exposed to polychromatic light with a higher blue component ate more food than did chicks exposed to a lower blue component. Correlation analysis confirmed that food intake was positively correlated with final body mass in chicks . In addition, we also found that light component had a significant influence on abdominal adipose deposition in present study; thus, the Blue-Medium group had the highest abdominal adipose weight among the Blue-treated birds. The chicken is typical of most diurnal birds in that it possesses seven photoreceptor cell types, including one rod and six cones. There are four different types of single cone, which are maximally responsive to violet, blue, green and red light Polychromatic light composition has two-side effects on chick body mass compared with monochromatic light spectra, according to variations in spectral composition. On the one hand, relatively lower body mass values were obtained in the Blue-Depleted and Blue-Medium groups; on the other hand, relatively higher body mass values were obtained in the Blue-enriched group compared with the Green and Blue groups, which indicated that blue-depleted and blue-medium spectra decrease growth and that blue-enriched spectrum promotes growth in chickens. Moreover, progressive changes in the green and blue components could give rise to consistent progressive changes in body mass, as suggested by polychromatic light with higher blue component resulting in a higher body mass in birds (Blue-Enriched>Blue-Medium>Blue-Depleted groups). A previous study reported that artificial light at night (16∶8 light/dim light cycle) can affect body mass Food conversion was calculated to directly evaluate the food efficiency of birds in each group. The results of the study indicated that polychromatic light composition with various blue components had a significant influence on feed efficiency, particularly at early ages (45 and 60 days of age). At later growth stages, higher food conversion was found in birds exposed to higher blue component groups, indicating that increasing the blue component could increase the food conversion value (Blue-Depleted<Blue-Medium<Blue-Enriched groups). It was reported that blue light could affect behavior to calm chickens As multiple studies recommended that the Gompertz model be included in growth analyses The circadian rhythm of body temperature is generated by an endogenous component that is controlled by a circadian clock and an exogenous component that is primarily caused by motor activity variations 2R = 0.6406, P = 0.0001; 2R = 0.784, P = 0.0001; It has been reported that exposing chickens to suboptimal environmental factors, including temperature and light, during the course of growth has an impact on blood physiological variables such as blood acid-base balance and metabolites The mechanisms through which polychromatic light component may affect the growth and metabolism of birds are unclear. However, polychromatic light component may not just have a direct effect through eyes


More information is needed about time between sexual initiation and human papillomavirus (HPV) infection and development of cervical precancer.The objectives were to investigate the time between first sexual activity and detection of first cervical HPV infection or development of first cervical intraepithelial neoplasia (CIN), and associated factors in women from the double-blind, multinational, 4-year PATRICIA trial. PATRICIA enroled women aged 15-25 years with no more than 6 lifetime sexual partners. Women were randomized 1:1 to the HPV-16/18 AS04-adjuvanted vaccine or to control, but only women from the control arm who began sexual intercourse during the study or within 6 months before enrolment, and had no HPV infection detected before the recorded date of their first sexual intercourse, were included in the present analysis. The time between onset of sexual activity and detection of the first cervical HPV infection or development of the first CIN lesion was analyzed using Kaplan-Meier and univariate and multivariable Cox proportional-hazards models.Chlamydia trachomatis history, and duration of hormone use. CIN1+ and CIN2+ lesions were most commonly associated with HPV-16, with an overall incidence rate of 1.87 and 1.07 per 100 person-years, respectively. Previous cervical HPV infection was most strongly associated with CIN development.A total of 9337 women were enroled in the control arm of PATRICIA of whom 982 fulfilled the required inclusion criteria for analysis. A cumulative total of 28%, 44%, and 62% of the subjects had HPV infection within 12, 24, and 48 months, respectively. The overall incidence rate was 27.08 per 100 person-years. The most common oncogenic types associated with 6-month persistent infection were HPV-16 (incidence rate: 2.74 per 100 person-years), HPV-51 (2.70), HPV-52 (1.66), HPV-66 (1.14), and HPV-18 (1.09). Increased infection risk was associated with more lifetime sexual partners, being single, More than 25% of women were infected with HPV within 1 year of beginning sexual activity. Without underestimating the value of vaccination at older ages, our findings emphasize its importance before sexual initiation.NCT00122681.clinicaltrials.gov: The online version of this article (doi:10.1186/s12879-014-0551-y) contains supplementary material, which is available to authorized users. Human papillomavirus (HPV), the causal agent of cervical cancer, is believed to be the most common sexually transmitted infection worldwide, with up to 75% of sexually active people being infected during their life . A persiHPV vaccination programs have been introduced in many countries worldwide and are primarily targeted at adolescent girls. Vaccination before first sexual intercourse is important because HPV infection is frequently detected in sexually active adolescent girls and young women ,13]. HP. HP13]. To add to the body of knowledge concerning the natural history of HPV, more data are needed about the time between onset of sexual activity and first acquisition of HPV infection and first development of detectable lesions under surveillance using defined referral algorithms. However, few prospective data are available ,15],,. Wr. Wr19]. PATRICIA enrolled women with no more than 6 lifetime sexual partners. The exclusion criterion of no more than six lifetime sexual partners was not applied in Finland, in accordance with local regulatory and ethical requirements, so women with more than six lifetime sexual partners enrolled in Finland were included in the trial . The anaA self-administered behavioral questionnaire collecting data on smoking, sexual activity, and contraception was completed 1 month after first vaccination and yearly thereafter during the follow-up period . ParticiThe first HPV infection detected or first CIN detected was used in the analysis. HPV infections were classified as an infection of any duration (HPVI) and as a 6-month persistent infection (6MPI). A 6MPI was defined as detection of the same HPV genotype in cervical samples at two consecutive evaluations over approximately a 6-month period i.e. a sequence of positive samples with the same HPV type not interrupted by negative samples over a total range of >5 months (>150 days). The start of the 6MPI was defined as the date of the first positive sample in the sequence. Histopathologically confirmed CIN was detected in biopsy samples after colposcopy or excision samples after treatment. Endpoints were defined as CIN grade 1 or greater (CIN1+) and CIN grade 2 or greater (CIN2+). Only HPV-positive lesions were included in the analysis.Incidence rates for HPVI, 6MPI and CIN were calculated per 100 person-years (PY) according to individual HPV type, with 95% confidence intervals (CI). The time to detection of the first cervical HPV infection or development of the first CIN lesion was measured from the date of first sexual intercourse reported by the woman. Thus, although visits were scheduled for every 6 months, it was possible to establish a duration of infection of less than 6 months. The time between onset of sexual activity and detection of the first infection or CIN lesion was analysed using the Kaplan-Meier method as well as univariate and multivariable Cox proportional-hazards models. The statistical unit was the subject.Chlamydia trachomatis during the past 12 months, marital/partner status, use of hormones for contraception or other indication, and duration of use of hormones for contraception or other indication. The number of lifetime sexual partners was determined from the behavioral questionnaire. All behavioural covariates were considered as time dependent and therefore no proportional hazard checks were required. Region and age were considered as time-fixed covariates and the hazard assumptions were assessed directly from the Kaplan-Meier curves. In addition, for the time to detection of a 6MPI, CIN1+ and CIN2+, the models also included previous cervical HPV infection as a time-varying covariate. Previous cervical HPV infection was defined as an HPV infection preceding the onset of the referent 6MPI or preceding the onset of the referent infection associated with a CIN1+ or CIN2 +.Nine potential factors (covariates) associated with acquisition of HPV infection were included in the models: region, tobacco exposure measured as number of pack-years , age at first sexual intercourse (15-17 years and ≥18 years), number of sexual partners during the past 12 months, number of lifetime sexual partners, history of Data were censored for women who completed the study at 54 months after first sexual intercourse . For women who did not complete the study, data were censored at their last recorded visit. Covariates with a p-value <0.2 in the univariate model were included in the multivariable models, with the exception of region which was always included regardless of the p-value obtained. All analyses were performed using SAS version 9.2.A total of 982 women who experienced first sexual intercourse during the study and had no HPV infection detected before the recorded date of their first experience of sexual intercourse, and women who experienced first sexual intercourse less than 6 months before inclusion, were included in the analysis Figure . Among tAn HPVI was detected in 496 women  , HPV-16 (4.91 per 100 PY), HPV-52 (3.33 per 100 PY), HPV-18 (2.73 per 100 PY), and HPV-66 (2.51 per 100 PY) (Table Chlamydia trachomatis (HR: 3.00 [2.07-4.36]) and cumulative duration of hormone use . Being a single woman was significantly associated with an increased risk of acquiring an HPVI (HR: 1.45 [1.04-2.04]) compared with living with a partner currently or in the past. Tobacco exposure did not increase the risk in the multivariable analysis, although it was significant in the univariate analysis .In the multivariable analysis, the main covariate associated with increased risk of acquiring an HPVI was a higher number of lifetime sexual partners. The hazard ratio [HR] was 4.76 (95% CI: 3.82-5.95) and 19.22 (14.02-26.34) for 2-3 partners and ≥4 partners, respectively   , and having ≥4 lifetime sexual partners was also associated with higher risk (HR: 4.02 [1.24-13.05]) . Likewise, a sensitivity analysis of all lesions (including both HPV-positive and HPV-negative cases) revealed similar results except for CIN2+ where the cumulative duration of hormone use had a univariate p-value <0.2 and was thus included in the multivariable analysis . However, it was not significant in the multivariable analysis.The analysis confirmed that HPV infection may be acquired relatively quickly following first sexual intercourse. The first cases of HPV infections were detected within 2-3 months following sexual initiation, and two thirds of women had acquired an infection within the 48 month follow-up period. Persistent infections were less common, detected in approximately one-quarter of women. The first cases of CIN1+ lesions were detected approximately 6 months following sexual initiation, and the first CIN2+ lesions approximately 12-18 months, but both were experienced by very few women.Other studies of virginal women experiencing sexual intercourse for the first time have shown broadly similar rates of oncogenic HPV acquisition, although it is difficult to compare estimates directly because of differences across studies in outcomes and follow-up times. At 2 years after sexual initiation, we found an incidence of HPV infection of 44%. Two previous studies have found slightly lower incidences at this time point. A population-based cohort study conducted in Denmark found an incidence of 35% among 70 women recruited as virgins and experiencing first sexual intercourse within the follow-up period , whilst In our analysis, the most common oncogenic HPV types in HPVI and 6MPI were HPV-16 and HPV-51, followed by HPV-52, and then by HPV-18 and HPV-66. HPV-6 was the most common non-oncogenic type; however, its incidence may be underestimated because the study did not systematically evaluate the external genital tract. In the overall PATRICIA cohort, the most common prevalent HPV types at study entry were HPV-16, followed by HPV-51, HPV-18, and HPV-31 . This isFew women experienced CIN1+ and even fewer experienced CIN2+, so estimates of time to lesion development and the most common HPV type associated with CIN lesions have somewhat low precision. However, it was clear that HPV-16 was by far the most frequent type found in CIN1+ and CIN2+, as seen in other studies ,25]..25].Chlamydia trachomatis infection and longer cumulative duration of hormone use also significantly increased the risk of acquisition. Although the univariate analysis indicated an increased risk for HPVI with tobacco exposure, the multivariable analysis showed no significant association. For the overall PATRICIA cohort, infection with HPV at entry was significantly associated with not being married or living with a partner, tobacco exposure, age <15 years at first sexual intercourse, higher number of sexual partners during the past 12 months, longer duration of hormone use, and history of a sexually transmitted infection [In our analysis, higher number of lifetime sexual partners was most strongly associated with a higher risk of an HPVI or 6MPI. History of nfection . The PATnfection .Previous cervical HPV infection was associated with lower risk of a 6MPI with any HPV type, perhaps indicating a protective effect of naturally acquired antibodies to the prior infection. In contrast, previous cervical HPV infection was strongly associated with increased risk of developing CIN1+ and CIN2+. In another analysis of the whole PATRICIA control group, previous infection with an oncogenic HPV type was also significantly associated with increased risk of developing CIN1+ and CIN2+ . AccumulFour or more lifetime sexual partners was also associated with increased risk of CIN1+ and CIN2+. An association between cervical cancer and higher number of sexual partners has been seen in previous studies . YoungerA strength of our analysis is that participants of the PATRICIA study were well-characterized, with high follow-up rates over 4 years and standardized virologic and histologic sampling methods. Although the population of the present analysis was a relatively small subset of the entire PATRICIA population, more women were included in this analysis than in any other study of virginal women. Study limitations included the fact that women from Finland made up approximately two thirds of the population who had not had experience of sexual intercourse before enrolment, a consequence of the school-based trial recruitment strategy in Finland. In addition, PATRICIA included only women aged 15-25 years with no history of immunosuppressive disease, limiting its generalizability. The smaller population in the present analysis meant that the 4-year follow-up period was long enough to detect only a small number of CIN cases, limiting the conclusions that can be drawn about the time between first sexual intercourse and development of pre-cancerous lesions.Infection with HPV can occur within 2-3 months following first sexual intercourse, and the first CIN1+ lesions within approximately 6 months. The role of previous cervical HPV infection in increasing the risk of developing a pre-cancerous lesion is confirmed, as is the role of the number of lifetime sexual partners in acquisition of an HPV infection. Our estimates of time to infection and time to CIN after sexual initiation are important as they will inform modeling exercises on the natural history of cervical carcinogenesis and the impact of HPV vaccination programs. Furthermore, without underestimating the value of vaccination at older ages, our findings emphasize the importance of vaccinating at a young age, well before girls begin sexual activity, most likely achieved via school-based vaccination programs.Additional file 1: List of Independent Ethics Committees/ Institutional Review Boards. (DOC 572 KB)Authors’ original file for figure 1Authors’ original file for figure 2Authors’ original file for figure 3Authors’ original file for figure 4Authors’ original file for figure 5Below are the links to the authors’ original submitted files for images.


High risk oncologic Human Papilloma Virus (HPV) is one of the leading causes of cervical cancer worldwide. We investigated HPV genotypes among women living or not with Human Immuno-deficiency Virus (HIV) in two major hospitals in the south of the republic of BENIN in the city of Cotonou. Our objective is to investigate the association of high risk-HPV to cervical dysplasia among women under stringent anti-retroviral (ARV) treatment and in controls without HIV.n = 86); and one control group without HIV infection and attending the hospital Mènontin for routine gynecologic checkup and designated as ME group (n = 86). Cells derived from cervical uterine smears (CUS) were used for this investigation. The samples in ME group were selected to have similar lamin A/C profile with CH group. HPV genotypes were assessed by polymerase chain reaction (PCR) while lamin A/C expression profile was assessed by western blotting to corroborate the risk of cervical dysplasia.The investigation was carried out within 1 year period in two groups of adult women: one group with HIV1 infection and under ARV therapy in the National University Hospital (CNHU-HKM) designated as CH group  of women in CH group and in 1 % (1/86) of women in ME group at the time of CUS collection. The adjustment of the risk to develop cervical cancer in the future related to HPV infection and the total loss of lamin A/C is not significantly different in both groups.Women living with HIV are more sensitive to multiple HPV infection but not all HPV infections generated cervical dysplasia. The effectiveness of antiretroviral therapy in CH group may reduce significantly the frequency of cervical dysplasia. Human Papilloma Viruses (HPV) viruses come in diverse genotypes. High risk HPVs (HR-HPV) are some of the leading causes of cervical cancer worldwide –6. Over n = 86); and one control group without HIV infection and attending the hospital Mènontin for gynecologic routine checkup and designated as ME group (n = 86). Women in group CH with HIV1 infection are under stringent anti-retroviral treatment at CNHU-HKM while women in group ME without HIV infection are not receiving any treatment. The CH group is under free stringent ARV treatment program offered by the Ministry of Health in BENIN.The investigation was carried out within 1 year period in two groups of adult women: one group with HIV1 infection and under ARV therapy in the National University Hospital (CNHU-HKM), designated as CH group ((R), Abbott Diagnostics) or Genie2(R)  test as previously reported  and kept on ice for 30 min with vigorous agitation every 5 min as previously described . Samplesp <0.05.This study is a transversal case control study between HIV infected group (CH) and non HIV group (ME). The Fisher test (F-test) was used on Excel software to compare the prevalence of HPV infection between groups CH and ME. The CUS with HPV are given the value of 0 if there are not infected with HR-HPV, the value of 1 if they are infected with one type of oncogenic HPV, the value of 2 if they are co-infected with two types of HR-HPV, the value of 3 if they are co-infected with three types of HR-HPV, the value of 4 when are co-infected with 4 types of HR-HPV and the value of 5 when they are co-infected with five types of HR- HPV; the difference between group CH and ME is considered significant when p <0.05.The non-parametric Mann-Whitney test was used to compare lamin A/C profile between both groups. Lamin A/C profiles were given the value of 3 when normal expression was observed, the value of 2 for weak expression of lamin A/C and the value of 0 for total absence of lamin A/C. The difference between group CH and ME groups is considered significant when Women uterine cervix was examined with a video Colposcopy (SONY) by a gynecologist. Staining with dilute acetic acid followed by Lugol’s iodine solution was done to reveal the cervical lesions if present. The lesions of the cervix appeared white when stained with acetic acid  and yellow when stained with Lugol’s iodine solution  as previously reported , 12.The protocol of this study including objectives, participants, sample collection, analysis, and reporting of data was approved by the Ethics Committee of the Institute of Biomedical Sciences and Applications (CER-ISBA) and by the Ministry of Health in Republic of BENIN. The objectives of the study were explained to all participants before inclusion. Signed informed consent was freely obtained from all participants before sample collections for the study .Dual, quadruple and quintuple HR-HPV type co-infections were observed in 7/86 (8 %) women in CH group, {; ; ; ; ; ; }. The HPV56 9/86 = 10 %) is more frequent than HPV58 (6/86 = 7 %) and HPV42 (6/86 = 7 %) followed by HPV 52 (4/86 = 5 %), HPV43(4/86 = 5 %) and HPV 39 (3/86 = 3 %), HPV 45 (2/86 = 2 %), HPV 66 (2/86 = 2 %), HPV35 (1/86 = 1 %), HPV 33(1/86 = 1 %) and HPV 31(1/86 = 1 %) as shown in Fig. 0 % is moDual and triple HR-HPV co-infections were observed in 5/86 (5 %) of women in group ME: ; ; ; HPV42, 59, 68]; . In group ME, HPV 66 (4/86 = 5 %) is more frequent than HPV58 (3/86 = 3 %), HPV56 (3/86 = 3 %), HPV33 (3/86 = 3 %) followed by HPV59 (2/86 = 2 %), HPV18 (2/86 = 2 %) and HPV45 (1/86 = 1 %), HPV16 (1/86 = 1 %) as shown in Fig. , 59, 68;p < 0.001, as shows in Fig. n = 43) compared to ME group without HIV (n = 27), p < 0.001. The length of ARV treatment in CH group varies between 1 to 15 years (Table More women in CH group have significantly higher HR-HPV infections 27/86 = 31 %) than women in ME group (20/86 = 23 %); 1 % than The prevalence of cervical dysplasia in both groups is significantly lower than the prevalence of HR-HPV infections and it is opportune in this instance to evaluate the risk to develop cervical dysplasia with the deficiency in lamin A/C. An example of western blot performed with cell lysates derived from CUS samples in CH group is shown in Fig. In CH group cervical dysplasia was observed in 4/86 5 %) of women living with HIV. We observed low grade cervical intraepithelial lesions (CIN-1) in one woman (52 years old) with co-infections HIV/HPV58 and HPV43; high grade lesions (CIN-2) in one woman (49 years old) with co-infections HIV/HPV52, HPV43, HPV 66 and HPV39; condylomatous epithelial lesions in one woman (26 years old) with co-infections HIV/HPV56, HPV33, HPV42, HPV39 and HPV68; condylomatous epithelial lesions in one woman (28 years old) with co-infections HIV/HPV HPV35 and HPV42. One woman with co-infections HIV/HPV52, HPV42, HPV66 and HPV39 has not developed cervical lesions at the time of CUS collection as shown in Fig.  % of womIn ME group without HIV infection, one woman with HPV18 has developed cervical dysplasia (CIN I) at the time of sample collection 1/86 or 1 %) associated to the loss of lamin A/C. All other women with HPV infection have not developed cervical lesions at the time of sample collection but the silencing of lamin A/C is observed in 34 % of them and this put them at risk to develop cervical dysplasia in the future  the most common HR-HPV types among HIV-positive women were HPV68, HPV35, HPV52 and HPV16. Among women with negative/unknown HIV status, the most common HR-HPV types were HPV52, HPV35 and HPV18 as reported . In ThaiAlthough HR-HPV infections are more frequent in CH group with HIV Fig. , not allAside of viral integration into the genome, nuclear protein anomalies and chromosomal instabilities occur to initiate tumor formation and progression –17. The Although the prevalence of HPV infection is significantly higher in the CH group, the frequency of HR-HPV infection adjusted to the deficiency of lamin A/C is not significantly different in both groups investigated making this assessment more predictable of the risk to develop cervical cancer in the future. Due to the diversity of virus types involved in cervical cancer development and progression, we recommend to investigate further more molecular biomarkers in living individual for the screening and prevention of cervical cancer rather than taking solely into consideration HR-HPV infection rate especially in African countries.Women living with HIV are more sensitive to multiple HR-HPV infections but not all HR-HPV infections generate cervical dysplasia. The effectiveness of antiretroviral therapy in CH group may reduce significantly the frequency of cervical dysplasia although it has no influence on the prevalence of HR-HPV/HIV co-infection. Lamin A/C should always be used as biomarker for cervical cancer screening associated to HR-HPV genotypes in African countries to not skip women who develop cervical dysplasia independently of HR-HPV infections.3, Sodium azide; PBS, phosphate Buffered Saline; PMSF, Phenyl-Methyl-Sulfonyl Fluoride; SDS, sodium dodecyl sulfate; TBS, Tris Buffer Saline; TBST, Tris Buffer Saline plus Tween-20; Tris-HCl, Tris-HydrochlorideARV, Anti-retroviral; CUS, cervical uterine smears; EDTA, Ethylenediaminetetraacetic acid (EDTA); HIV, Human immunodeficiency Virus; HPV, Human Papilloma Virus; HR-HPV, high risk Human Papilloma Virus; HRP, Horseradish Peroxidase; KCl, potassium chloride; NaCl, Sodium chloride; NaF, sodium fluoride; NaN


The licensed human papillomavirus (HPV) vaccines elicit type-restricted immunity but do not target cutaneous HPV types of the beta genus that are associated with non-melanoma skin cancer in immune-compromised patients, and it is unclear if these diverse types share a common mechanism of infection. Residues 11-88 of minor capsid protein L2 contain cross-protective epitopes, and vaccination with concatamers of this region derived from as many as eight alpha HPV (L2 α11-88x8) is being developed as an alternative prophylactic vaccine with potentially broader efficacy. There is also interest in developing broadly protective topical microbicides, such as carrageenan or heparin that block HPV receptor interactions, or small molecule inhibitors of infection. Here we have examined several inhibitors of HPV infection and antisera to L2 α11-88x8 for their breadth of activity against infection by 34 HPV types from within both the alpha and beta families using pseudovirions (PsV) carrying a luciferase reporter as surrogates for native virus. We observed that both heparin and carrageenan prevented infection by mucosatropic HPV types, but surprisingly PsV of several epidermotropic alpha4 and beta HPV types exhibited increased infectivity especially at low inhibitor concentrations. Furin and γ-secretase inhibitors and L2 α11-88x8 antiserum blocked infection by all HPV PsV types tested. These findings suggest that the distinct tropism of mucosal and cutaneous HPV may reflect distinct cell surface receptor interactions, but a common uptake mechanism dependent upon furin and γ-secretase proteolytic activities. Carrageenan, which is being tested as a vaginal microbicide, broadly inhibited infection by the high-risk mucosatropic HPV PsV, but not most skin tropic alpha and beta HPV. Vaccination with an L2 multimer derived exclusively from alpha papillomavirus sequences induced antibodies that broadly neutralized PsV of all 34 HPVs from within both the alpha and beta families, suggesting each displays conserved L2 neutralizing epitopes. Human papillomaviruses (HPV) comprise a family of at least 120 non-enveloped epitheliotropic viruses which contain a double-stranded circular DNA genome and are phylogenetically classified into five genera; alpha, beta, gamma, mu and nu d iscosahedral symmetry Papillomavirus virions have a non-enveloped 60 nm diameter capsid with T = 7Recombinant expression of L1 is sufficient to form virus-like particles (VLP) that mimic native virus morphologically and immunologically. Similar to infectious virions, VLP can bind to heparan sulfate proteoglycans (HSPG) on the cell surface, and HSPG mimetics such as soluble heparan sulphate or carrageenan compete this interaction http://clinicaltrials.gov/show/NCT00543543). Another approach is vaccination with the amino terminus of L2 including residues 11-88 The licensed HPV vaccines, Cervarix and Gardasil, were both developed to prevent HPV16- and HPV18-associated persistent anogenital infection and disease, in particular epithelial dysplasias and cancers, and Gardasil to also prevent benign genital warts associated with HPV6 and HPV11 in vitro, PsV are used as surrogates for biologic studies of native virions, particularly given their capacity to deliver a reporter construct upon its encapsidation by over-expression of L1 and L2 Our mechanistic understanding of papillomavirus infectious process(es) is based on studies generally performed with only a few HPV types. Here we examine if medically significant HPV types of different genera, carcinogenic potential and tropism share a common infection mechanism. As the known inhibitors and vaccines have also been tested predominantly against a limited number of HPV types, their breadth of activity cannot be fully appreciated. Further, several studies indicate differences in receptor usage and uptake pathways by different HPV types http://home.ccr.cancer.gov/Lco/pseudovirusproduction.htm. Briefly, plasmids containing L1 and L2 late genes of different HPV types were transfected with plasmid expressing luciferase reporter gene into 293TT cells utilizing TransIT-2020 transfection reagent. Cells were incubated for 48 h at 37°C, harvested, washed with DPBS-Mg (DPBS supplemented with 9.5 mM MgCl2), and lysed with equal volume of lysis buffer (DPBS supplemented with 0.5% w/v Brij58 and 0.2% v/v benzonase). For PsV maturation, cell lysates were incubated for 24 h at 37°C and adjusted to 850 mM NaCl. For extraction lysates were centrifuged at 10,000×g for 10 min, and clarified supernatants loaded onto a 12 mL step gradient of Optiprep , and spun at 40,000 rpm in a SW40 rotor for 15 h at 16°C. After centrifugation, 1 mL fractions were collected from the top layer and the fraction demonstrating the highest infectivity was selected for further experiments.L1/L2 expression plasmids were provided by Martin Müller and Lutz Gissmann , Christopher Buck and John Schiller , and Helena Faust  and Joakim Dillner . Additional constructs were synthesized by Biobasic . Briefly4 293TT, HeLaT or HaCaT cells in 100 µL DMEM-10 or KH-SV cells in 100 µL KSFM were infected with 250, 500, 1000, or 2000 million particles of each HPV types in 100 µL medium in triplicate and incubated for 72 h at 37°C. Luciferase activity was measured as described in inhibition assays. All experiments were performed in triplicate.1.5×104 cells in 100 µL 10% FBS DMEM (DMEM-10) per well in 96-well plates and allowed to attach overnight. For heparin and carrageenan inhibition studies, heparin (Sigma H-4784) and carrageenan (Sigma C1138) were serially diluted in DMEM-10 and incubated with 250 million PsV particles of different HPV types in 100 µL DMEM-10 for 1 h at 37°C. Mixtures were added to 293TT cells and incubated at concentrations of 64, 128, 256, 512 µg/mL of heparin or carrageenan for 72 h at 37°C. For furin inhibition studies, furin inhibitor 1 (Decanoyl-RVKR-CMK) was mixed with 250 million particles of each HPV type in 100 µL DMEM-10 and the mixtures were immediately transferred to 293TT cells and incubated at 20 µM concentration of furin inhibitor 1 for 72 h at 37°C. For γ-secretase inhibition studies, XXI was mixed with 250 million particles of each HPV type in 100 µL DMEM-10 and the mixtures were immediately transferred to 293TT cells and incubated at a final concentration of 500 nM XXI for 72 h at 37°C. As a positive control, 4 µL of L1 antiserum from mice vaccinated i.m. with L1 DNA utilizing electroporation in 50 µL of culture medium was mixed with 250 million particles of each HPV type in 50 µL. Mixtures were transferred to 293TT cells and incubated for 72 h at 37°C. Following infection cells were washed with 1× PBS, and lysed with 30 µL of Cell Culture Lysis Reagent on rocking shaker for 15 min at room temperature. Lysates were transferred to 96-well black plate and luciferase activity was measured by GloMax-Multi Detection System after adding 50 µL of luciferin substrate to each well. All experiments were performed in triplicate.293TT cells were seeded at 1.5×104 cells per well in 96-well plate and incubated 24 h at 37°C. 4 µL of rabbit L2 α11-88x8 antiserum 293TT cells were pre-plated at 1.5×10Each HPV PsV preparation was normalized by the amount of L1 protein. Samples were boiled for 5 min with reducing gel sample buffer, subjected to SDS-PAGE analysis using 4-20% Tris-HCl gels, and proteins were transferred to PVDF membrane. The membrane was blocked with 5% non-fat milk in PBST (PBS containing 0.1% Tween-20) at room temperature for 1 hour, incubated with a rabbit L2 α11-88x8 antiserum at room temperature for 1 hour and binding detected with HRP-conjugated goat anti-rabbit IgG secondary antiserum.TTG ACC GCC TGA AGT CTC TGA and ACA CCT GCG TCG AAG ATG TTG), 250 nM of TaqMan probe (6FAM-CCG CTG AAT TGG AAT CCA TCT TGC TC-TAMRA), and 5 µL of extracted reporter plasmid in 50 µL final volume using an I-Cycler IQ (Bio-Rad). Each sample was conducted in duplicate.Reporter plasmid was extracted from 20 µL of each HPV PsV preparation using PureLink Viral RNA/DNA extraction kits. The real time PCR was performed with 25 µL of universal PCR Master Mix, 900 nM of forward and reverse primers , the non-linear model Y = Bottom + (Top-Bottom) /(1+10∧((LogEC50-X)*HillSlope)) was fitted to the logwww.addgene.com)). HPV PsV were prepared by co-transfection of 293TT cells with pY-luc and the L1/L2 expression vectors per standard methodology PsV are useful surrogates for biologic studies of native virions, particularly given their capacity to recapitulate early events of papillomavirus infection and neutralization, deliver a reporter gene of choice and their relative ease of production We first tested infectivity of each HPV PsV type normalized to 250 million particles (as estimated based on L1 concentration) by measuring luciferase activity  72 h post-infection in 293TT cells. The HPV PsV infected cells showed dramatic differences in reporter expression . OverallIt is possible that the weak infectivity of the PsV derived from cutaneous HPV types reflects use of 293TT cells a target cell line, rather than one derived from skin cells. Therefore we also tested infectivity of diverse alpha and beta HPV PsV in HeLaT clone 4 cells, a human cervical cancer line transduced with SV40 large T antigen L2 is known to play several important functions during virion assembly and infection, and therefore differences in the incorporation of L2 may account for the wide range of PsV infectivity by HPV type. Thus, the level of L2 incorporation into the gradient-purified preparations of HPV PsV was analyzed by Western blot  using a Differences in the infectivity of each type of HPV PsV might also reflect variable efficiency in reporter plasmid encapsidation. Therefore the number of copies of benzonase-resistant, and therefore presumably encapsidated, reporter plasmid DNA present within 315 ng of each gradient purified HPV PsV preparation was measured by quantitative real time PCR. The lowest levels of reporter DNA encapsidation were observed for PsV of HPV27, 57, and 34 . Since LCHO cells deficient in heparan sulfate proteoglycan (HSPG) production are no longer infected by HPV PsV Carrageenan is also a potent inhibitor of HPV infection via a mechanism resembling that of heparan sulfate After binding to HSPG on extracellular matrix, HPV16 undergoes a conformational change and exposes the previously buried amino terminus of L2 on the capsid surface prior to cell entry The γ-secretase inhibitor XXI potently blocks HPV16 infection, and homozygous deletion of γ-secretase component subunits nicastrin or presenilin-1 also prevents HPV16 infection The amino terminus of L2 contains a protective epitope and it is also evolutionarily highly conserved between types and even different species. We previously described that rabbit antiserum targeting the L2 antigen α11-88x8 can neutralize a broad spectrum of mucosal HPV types, notably those associated with cervical cancer and benign genital warts, and that passive transfer of this antiserum protects mice from genital HPV PsV challenge The two licensed vaccines safely provide robust protection for men and women against acquiring infections by the two most potent oncogenic types, HPV16 and HPV18, and Gardasil also protects against the two most common types associated with genital warts, HPV6 and HPV11. In spite of their effectiveness, there is still a demand for new approaches for the prevention of HPV infection due to the high cost and type-restricted protection afforded by the licensed vaccines and also the need for immunization More than 120 HPV genotypes has been completely characterized so far, but studies of the mechanisms of infection have been focused only on a very limited number of HPV types of the greatest medical significance, mainly due to restricted availability of PsV of a few HPV types. Therefore to assist in understanding the biology of HPV as well as assessing the breadth of protection provided by new vaccine and microbicide candidates, we generated and tested a diverse set of 34 PsV including 29 alpha types and 5 beta types . The mecThe initial studies focused on HSPG because it is the most studied cell surface receptor for HPV, and there is evidence of differential utilization by different genotypes When the concentration of heparin or carrageenan was reduced to 10 µg/mL, PsV of some cutaneous HPV types demonstrated enhanced infectivity . This reDespite efficiently blocking infection by the mucosatropic alpha types, neither heparin nor carrageenan were consistent inhibitors of the cutaneous types, and indeed frequently promoted infection. This failure of heparin to inhibit infection by one beta type was also observed previously for HPV5 We expected to observe broad spectrum blockade of HPV infection by furin inhibitor because the furin cleavage consensus sequence RX(R/K)R in L2 was conserved for all HPV types examined herein. This sequence and the requirement for furin cleavage is also conserved in bovine (BPV) and other animal papillomaviruses The γ-secretase inhibitor XXI also effectively inhibited PsV infection for all HPV types tested . Beta tyAlthough the amino terminus of L2 is a weaker immunogen compared to L1 VLP, it is considered to provide broader protection In conclusion, we have considered agents that block infection via inhibiting receptor interaction, furin cleavage or γ-secretase function as alternative approaches to vaccination to broadly prevent both mucosal and cutaneous HPV infections. At present, carrageenan shows promise as a vaginal microbicide to broadly prevent infection by mucosatropic high-risk papillomaviruses Figure S1Neutralization of PsV by L1 VLP antiserum. PsVs of each indicated HPV type, each carrying a luciferase reporter gene, were mixed with mouse or rabbit L1 VLP antiserum or their respective pre-immune serum (each at 1∶50 dilution) for two hours at 37°C, then the mixtures were transferred to 293TT cells and cultured for 72 hours (n = 3). Cells were then lysed and luciferase activity was measured. Percent neutralization by L1 VLP antiserum was plotted. Pre-immune serum was non-neutralizing in all cases. Red and blue bars represent mucosal and cutaneous HPV types, respectively.(TIF)Click here for additional data file.Figure S2Infectivity of diverse HPV on mucosal and skin cell lines. HeLaT (A), HaCaT (B), KH-SV (C) cells were treated with titrations of diverse HPV PsV from alpha and beta subfamilies and incubated at 37°C for 72 hours. Cells were lysed after incubation and luciferase activity was measured. Red and blue bars represent mucosal and cutaneous HPV types, respectively.(TIF)Click here for additional data file.Table S1Sequences of codon modified L1 and L2 genes utilized in expression constructs used to generate new HPV PsV types.(XLSX)Click here for additional data file.


HIV infection leads to a decreasing immune response, thereby facilitating the appearance of other infections, one of the most important ones being HPV. However, studies are needed for determining associations between immunodeficiency caused by HIV and/or the presence of HPV during the course of cervical lesions and their degree of malignancy. This study describes the cytological findings revealed by the Papanicolaou test, laboratory characteristics and HPV molecular profile in women with and without HIV infection.A total of 216 HIV-positive and 1,159 HIV-negative women were invited to participate in the study; PCR was used for the molecular detection of HPV in cervical samples. Statistical analysis  determined human papillomavirus (HPV) infection frequency (single and multiple) and the distribution of six types of high-risk-HPV in women with and without HIV infection. Likewise, a logistic regression model was run to evaluate the relationship between HIV-HPV infection and different risk factors.3 CD4-count (p = 0.004) and higher HIV-viral-load (p = 0.001). HPV-DNA detection, <200 cell/mm3 CD4-count (p = 0.001), and higher HIV-viral-load (p = 0.001) were associated with abnormal cytological findings.An association was found between the frequency of HPV infection and infection involving 2 or more HPV types  in HIV-positive women ; such frequency was greater than that found in HIV-negative women . Statistically significant differences were observed between both groups (p = 0.001) regarding HPV presence (both in infection and multiple HPV infection). HPV-16 was the most prevalent type in the population being studied (p = 0.001); other viral types had variable distribution in both groups (HIV-positive and HIV-negative). HPV detection was associated with <500 cell/mmThe HIV-1 positive population in this study had high multiple HPV infection prevalence. The results for this population group also suggested a greater association between HPV-DNA presence and cytological findings. HPV detection, together with low CD4 count, could represent useful tools for identifying HIV-positive women at risk of developing cervical lesions. Epidemiological and molecular studies have led to a causal relationship being established between infection involving certain types of human papillomavirus (HPV), known as high risk (HR-HPV), and the development of cervical cancer (CC) . FifteenThis type of cancer accounts for the second cause of death by malignant neoplasia in women, primarily those of childbearing age and living in developing countries. A CC mortality rate of 18.2 for every 100,000 women per year was reported in Colombia in 2010 [HPV infection  is necessary but not the sole factor for CC to develop; several risk factors can trigger the development of this cancer, immunosuppression being one of the most significant ones -5.One of the most studied types of immunosuppression is that due to human immunodeficiency virus (HIV) infection . Such inHigher HPV infection prevalence has been documented in HIV-infected women; the foregoing, taken together with a deficient immune system, thus contributes towards new infections involving other HPV types being acquired (multiple infection or the coexistence of 2 or more HPV types) which, as the virus cannot be eliminated, increases HPV infection persistence in the body ,8.The clinical significance of HPV persistence concerns this virus’ long-term existence. This allows for the efficient replication and integration of viral oncoproteins (E6 and E7) in the host genome, mutations to become accumulated, genomic instability and chromosomal aberrations; this causes rapid morphological changes to cells, thereby contributing towards CC development ,10.Mild dysplasia prevalence in immunocompetent women does not exceed 27%, whereas this can rise to 80% in HIV-positive women; immunosuppression in the latter group implies the development of more aggressive lesions and a lower response to treatment , as well3 have greater HPV infection prevalence and increased cervical intraepithelial lesion incidence rates; the foregoing, together with a high HIV viral load, significantly increases the risk of developing this type of lesion [It has been described that HIV-positive women having a CD4 count of less than 200 cells/mmf lesion .It has been stated that the relationship between HIV-HPV might become a worldwide public health problem ; howeverNo studies have been carried out to date in Colombia to determine HIV-HPV infection-related epidemiological profiles, so this study was aimed at describing the prevalence of multiple HPV infection, involving the type-specific distribution of six HR-HPV types amongst women with and without HIV infection involved in sexual and reproductive health programmes at four hospitals in Bogota. The resulting information has contributed towards knowledge regarding HIV-HPV-related sexually-transmitted infections.This was a cross-sectional study; the patients participated between February 2007 and November 2012. All hospitals included in this study are located in the country’s capital city, Bogotá. The group of HIV-positive women (classified as having human immunodeficiency virus type 1) were attending a programme being run by Asistencia Científica de Alta Complejidad S.A.S (n = 216). The HIV-negative women were participating in sexual and reproductive health programmes being provided by state-run healthcare institutes; this group of women was recruited at the Hospital de Bosa (n = 232), Hospital de Fontibón (n = 290) and the Hospital de Engativá (n = 637), all located in Bogotá. The participating institutions reported the HIV status for all the women included in the study.All the women were told about the study’s purpose. Those who volunteered to participate signed an informed consent form and completed a questionnaire aimed at collecting data concerning socio-demographic characteristics and risk factors before being given a gynaecological exam. An informed consent form, signed and approved in the presence of a parent or guardian, was required for women younger than 18 years old. This study was approved and supervised by all health care participating institutions’ Ethics Committees as follows: the Bioethics Committee of ‘Asistencia Científica de Alta Complejidad’, the Ethics Committee of the ‘Hospital de Bosa E.S.E.’, the Ethics Committee of the ‘Hospital de Fontibón E.S.E.’, and the Hospitalary Ethics Committee of the ‘Hospital de Engativá Nivel II’.β-globin gene segment could not be amplified.The inclusion criteria took into account the HIV status reported by the participating institutions, the women’s voluntary participation in this study by signing the consent form and filling in a questionnaire which considered socio-demographic characteristics and risk factors. Exclusion criteria considered women where a Papanicolaou test (Pap test) samples were collected following Colombian Ministry of Health guidelines for the early detection of CC ; the PapCervical samples for detecting HPV-DNA were obtained during cytological exam; cells were collected from the cervix using a cytobrush which was stored in a tube containing 95% ethanol as a means of preservation and transport .β-globin gene segment). Independent PCRs were then used for the generic detection of HPV, using three sets of primers directed towards detecting segments encoding viral proteins L1 and E6-E7. Independent PCRs were also used on samples where generic detection had revealed the virus; type-specific identification involved using primers directed towards genes encoding early proteins E5, E6 and E7 [The methodological design for detecting HPV involved using PCR, firstly, directed towards determining DNA quality and integrity , following the manufacturer’s instructions.β-globin gene segment in independent PCR reactions to confirm the presence of human DNA in all the samples [PCR analysis involved GH20/PC04 and PC03/PC04 specific primers for detecting a  samples .Established PCR techniques were used for HPV-DNA detection ,18. ViraSamples having a positive result for HPV-DNA by PCR (samples proving positive for one or more of the three generic primer sets) were used for type-specific identification using primers targeting regions encoding viral oncogenic proteins E5, E6 or E7 from six high-risk HPV types , these being the most prevalent in the Colombian population and accounting for 90% of CC cases .All PCRs were run simultaneously in separate reactions and in previously described conditions ,18.Sample size was determined as being 179 in the HIV-positive group and 716 for the HIV-negative group to ensure 80% power for detecting a 1.60 odds ratio (OR). The proportion in group one (HIV-positive women) was assumed to be 0.45 by null hypothesis and 0.55 by alternative hypothesis.A descriptive analysis of the demographic characteristics and risk factors was made and they were treated as categorical variables , percentages); estimations were made, along with their respective 95% confidence intervals (95% CI). Chi-square and Fisher’s exact tests were used (when applicable) to evaluate differences in proportions. The coexistence of 2 or more HPV types was defined as multiple infection in this study. The strength of association was measured using ORs with 95% CI; logistic regression was used for ordinal data to estimate adjusted ORs. The cofactors included in regression analysis were age, marital status, age at first intercourse, number of pregnancies, having had other STDs, the number of lifetime sexual partners, contraceptive methods used and smoking status, along with laboratory characteristics . All hypothesis tests were set at 0.05 significance level. STATA11 was used for all statistical procedures.The study involved 1,375 women aged 14–76 years . The predominant ethnic group consisted of 1,337 mestizo women (97.2%: 96.2-98.1 95% CI), the remaining 38 (2.8%: 1.92-3.65 95% CI) being Afro-descendants and indigenous females.216 of the women were HIV-positive whose ages ranged from 20–73 years old  and a second group consisted of 1,159 HIV-negative women aged 14–76 . The estimator revealed statistically significant differences regarding some women’s socio-demographic characteristics and risk factors according to HIV status (such as ethnicity and age at first intercourse), whilst no statistically significant difference was recorded for pregnancies (p = 0.173) and/or infection with other sexually transmitted diseases (p = 0.071)  were used in the statistical analysis. The virus was detected in 48.1% of the samples (n = 662: 45.5-50.8 95% CI) and multiple infection (defined as coexistence of 2 or more HPV types) in 57.4% (n = 380: 53.5-61.7 95% CI) of HPV positive samples.All samples  which amplified for the HPV-DNA was detected in 44.3% of samples from HIV-negative women (n = 513: 41.4-47.2 95% CI) and multiple infection in 51.3% of them (n = 263: 46.8-55.7 95% CI). The presence of HPV was observed in 69.0% of HIV-positive women (n = 149: 62.3-75.0 95% CI) and multiple infection was found in 78.5% of the sample (n = 117: 71.0-84.8 95% CI). Statistically significant differences were observed between both groups of women (p = 0.001) regarding HPV presence (both in infection and multiple HPV infection).Cytological findings proved negative for intraepithelial lesions or malignancy in 68.5% of the HIV-positive women (n = 148: 61.9-74.7 95% CI) and abnormality occurred in 31.5% of them (n = 68: 25.3-38.1 95% CI), classified as follows: ASCUS occurred in 35.3% of cytological abnormalities (n = 24: 24.1-47.8 95% CI), LSIL in 57.3% (n = 39: 44.8-69.3 95% CI) and HSIL in 7.4% of them (n = 5: 2.4-16.3 95% CI).79.2% (n = 918: 76.7-81.5 95% CI) of HIV-negative women proved negative for lesions, whilst 20.8% of them (n = 241: 18.5-23.2 95% CI) had some degree of abnormality: 52.7% (n = 127: 46.2-59.1 95% CI) had ASCUS, 41.5% (n = 100: 35.2-47.9 95% CI) had LSIL and 5.8% (n = 14: 3.21-9.55 95% CI) HSIL. The difference between abnormality detected by Pap test for women having different HIV infection status was statistically significant (p = 0.003).2 (1) = 16.13 p = 0.001). Calculating regression analysis association between HIV status and Pap test result revealed a positive trend for HIV-positive and SIL  = 18.04 p = 0.001). All associations remained statistically significant after using logistical regression to adjust for cofactors  . A positive association was observed when comparing SIL cytological findings  = 23.03 p = 0.001), higher than 100,000 copies/mL HIV viral load  = 23.40 p = 0.001) and women with and without ART treatment  = 15.96 p = 0.001)  between abnormal cytological findings  and clinical and laboratory characteristics  showed a positive trend for CD4 cell count below 200 cell/mm3 CD4 cell count , higher than 100,000 copies/mL HIV viral load  and women with and without ART treatment . These associations remained significant in multivariate analysis . The results revealed statistically significant associations between HIV-positive women and an increased likelihood of HPV-DNA detection , multiple infection , clade 7  and clade 9 detection , lower than 500 cell/mmRegarding type-specific distribution in HIV-positive and negative groups, HPV-16 was the most prevalent infection for the entire study population (p = 0.001). Significant differences were observed regarding the percentages of HPV infection types for each population, HPV-31 was the second most prevalent in HIV-positive women (p = 0.001), HPV-18 the third (p = 0.001) Table  whilst H3 CD4 count; HPV-18 had the greatest prevalence (p = 0.041), followed by HPV-16 (p = 0.241) and HPV-31 (p = 0.008). Other differential distributions were observed for higher than 100,000 copies/mL HIV viral load; however, they were not statistically significant  may have been partly due to immune system deficiency, thereby contributing towards the inefficient removal of the virus or evasion by certain types of HPV. The latter benefits the colonisation and persistence of some viral types (mainly oncogenic HPV) ,8,30.3 CD4 count with abnormal cytological findings, compared to those having higher CD4 count, thereby agreeing with a previous report [3 count indicates a deficient immune system and, together with HPV detection, could be used as predictors of pre-neoplastic cervical lesions [A positive association was seen in the current study for women having lower than 200 cell/mms report . Lower t lesions .3 CD4 count was associated with HPV detection, thereby reflecting the inability of HIV-positive women’s immune systems to respond to opportunist infection. High HIV viral load and low CD4 cell counts could facilitate acquiring HPV infection [Our groups’ results showed that a lower than 500 cell/mmnfection ,33.The effect of antiretroviral drugs on the incidence of cervical lesions having a poor prognosis has not been clearly established; previous studies, such as the US WIHS (Women’s Interagency HIV Study) cohort, have indicated that ART treatment for HIV positive women has led to duration and progression becoming reduced . Our groMore lesions were detected in the HIV-positive group (mainly LSIL); studies have indicated that women having this type of immunosuppression have a higher incidence and prevalence of premalignant lesions caused by the immune system becoming unable to efficiently eliminate HPV infection. This also favours the virus’ persistence in the body, ultimately contributing towards the development of this type of dysplasia ,35.Association studies have shown that HIV infection increases the risk of CC development (up to 22-fold) compared to such risk in the general population . The natThis can be explained as immunosuppression leads to an alteration in local and systemic immune response, thereby preventing suitable clearance of HPV infection. This results in recurrent pre-neoplastic lesions and lower regression rates; however, it has not been clearly established whether this is the main mechanism ,13,21.Our results showed a significant association between infection involving clade 9 and HIV-positive women; this may have been partly due to HPV-16 in this clade being the most prevalent viral type in such population. This viral type has been shown to have an association with the risk of acquiring other HPV types; however, it has not been clearly established whether a higher risk of acquiring a phylogenetically-related type is associated with the risk of acquiring another type of HPV ,24.Interestingly, a positive trend was found between ASCUS cytology and HPV-DNA being detected. ASCUS cytology indicated that cytological-morphological changes were not benign; however, this did not meet the criteria for classification as squamous lesions, even though studies have shown that this type of cytological interpretation is highly related to characteristic subjective reading of Pap tests ,38.Studies have found that HPV detection in women having ASCUS has provided high sensitivity in detecting severe dysplasia and cancer . This isOne of this study’s limitations lay in the detection of 6 of the 15 HPV types described as being high risk. Even though the types identified in the present study are considered to be prevalent in the Colombian population, other types of high and low risk HPV should be included in future studies. This study’s cross-sectional design did not lead to determining a causal relationship between the immunodeficiency caused by HIV and/or the prevalence and persistence of HPV.There is limited information in Colombia regarding HPV infection in HIV-positive women. This is the first study in Colombia which has evaluated epidemiological profiles concerning HPV infection in both HIV-positive and HIV-negative women. The results further showed multiple HPV infection as an associated factor in HIV-positive women; however, further prospective studies are needed to determine the dynamics and follow-up patterns (i.e. 5-year follow-up) for these infections and their influence on the development of cervical dysplasia.HR-HPV distribution in women should be studied to facilitate developing prevention and management strategies in the general population, prioritising HIV-positive women as they represent a special group due to their type of immunosuppression altering the natural course of CC development. The resulting information has contributed towards knowledge regarding HIV-HPV-related sexually-transmitted infections.HPV: Human papillomavirus; HIV: Human immunodeficiency virus; ART: Antiretroviral therapy; HR-HPV: High risk human papillomavirus; LR-HPV: Low risk human papillomavirus; DNA: Deoxyribonucleic acid; CC: Cervical cancer; SIL: Squamous intraepithelial lesions; ASCUS: Atypical squamous cells of undetermined significance; LSIL: Low grade squamous intraepithelial lesion; HSIL: High grade squamous intraepithelial lesion; STD: Sexually-transmitted diseases; Pap test: Papanicolaou test; 95% CI: Confidence interval; OR: Odds ratio; SD: Standard deviation; PCR: Polymerase chain reaction.The authors declare that they have no competing interests.MC was involved in the design of the study, helped in the collection of clinical data, performed the molecular tests and analysis and drafted the manuscript. SCSL was involved in the design of the study, helped in the collection of clinical data, performed the molecular tests and analysis and drafted the manuscript. MM was involved in the design of the study, helped in the collection of clinical data, performed the molecular tests and analysis and drafted the manuscript. RS conducted statistical analyses and contributed to the manuscript. DPH was involved in the analysis and interpretation of data. ACPP collected the clinical data and made a critical review of the manuscript. OS collected the clinical data and made a critical review of the manuscript. CP collected the clinical data and made a critical review of the manuscript. APP was involved in the analysis and interpretation of data. MEP co-designed the study and MAP co-designed the study, led the research project and proofread the final document. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/14/451/prepub


Human papillomavirus (HPV) causes most oropharyngeal cancers in the United States. Oral HPV prevalence is associated with immunosuppression, and drug use can be immunosuppressive, but the epidemiology of oral HPV among people who use drugs is not well described.We enrolled men and women with a current or prior history of injection drug use in this cross-sectional sub-study within the AIDS Linked to the Intravenous Experience (ALIVE) cohort. We tested oral rinse samples for 37 types of HPV DNA and collected self-reported risk factor information. We compared oral HPV prevalence across categories using chi-squared statistics and multivariable logistic regression.Among 199 subjects, 32% were HIV-positive (median CD4 count 384 cells/μL), 90% were Black, 56% had less than a high school education, 17% had recently used injection drugs, and the median age was 54 years. Most had performed oral sex (82%) but had fewer than 5 lifetime partners (58%). The prevalence of any oral HPV was 29%, and of any oncogenic oral HPV was 13%. Oral HPV prevalence was high among both heterosexual men (30%) and women (20%). After adjustment, odds of oral HPV were increased among HIV-positive individuals with a low CD4 count , but not among HIV-positive individuals with a higher CD4 cell count. Odds were also elevated for those who had recently performed oral sex on a woman  and, even after this adjustment, among bisexual/lesbian females . Oral HPV prevalence was not associated with vaginal sex, performing oral sex on a man, or recent drug use.Recent drug use was not associated with oral HPV prevalence in our study. However, despite modest numbers of sexual partners, the prevalence of oral HPV among this largely Black population with lower socioeconomic status was high. There are more than 45,000 new cases of oropharyngeal squamous cell carcinoma (OPC) each year in the United States  and moreThe prevalence of oral HPV is approximately 7% in the general U.S. population , with moParticipants for this cross-sectional analysis were enrolled as a convenience sample of subjects from the AIDS Linked to the Intravenous Experience (ALIVE) cohort study in Baltimore, Maryland, which includes men and women with a current or prior history of injection drug use . All ALIIn univariate analyses, we explored differences in the prevalence of oral HPV  across demographic and risk factor categories. We tested for statistically significant differences across groups using chi-square statistics. For variables that were collinear, we selected only one variable to include in the final model based on univariate results and prior literature. This included selecting current CD4 cell count instead of nadir CD4 cell count, and number of recent oral sex partners instead of recent open-mouth kissing partners. The final multivariable logistic model included age, race/ethnicity, HIV/CD4 cell count, sex and sexual orientation, and the number of women on whom the participant had recently performed oral sex.Our study included 199 people with a past and/or current history of injection drug use, including 64 HIV-positive and 135 HIV-negative participants . There wThe overall prevalence of any oral HPV was 29% (57/199), and prevalence of any oncogenic oral HPV was 13% (26/199). The most common oral HPV types detected were HPV55 (4.5%), HPV45 (4.0%), and HPV59 (3.0%), with HPV16 and HPV18 detected among 2.5% and 0.50% of participants, respectively. None of the types of recent drug use examined was associated with oral HPV prevalence. This included null associations for any recent use of: marijuana ; cocaine whether smoked/snorted  or injected ; heroin whether smoked/snorted  or injected ; or recent injection of any drug .woman was associated with higher oral HPV prevalence , but recently performing oral sex on a man was not . Other risk factors included higher prevalence among bisexual/lesbian females (58%) than other groups (p = 0.06) and among non-Hispanic Blacks than those of any other race/ethnicity . Oral HPV was not associated with any of the types of drug use that we examined, namely, tobacco, alcohol, marijuana, crack/cocaine, heroin, and any injection drug use .Risk factors for oral HPV prevalence in univariate analyses included immunosuppression, sexual behavior, sexual orientation, and race/ethnicity . HIV-posMultivariable risk factors for prevalent oral HPV are described in In this cross-sectional study of 199 people who inject drugs, recent drug use was not associated with oral HPV prevalence. Despite modest numbers of sexual partners, the prevalence of oral HPV among this population of minority participants with lower socioeconomic status was high. Risk factors for oral HPV infection included HIV-related immunosuppression and recently performing oral sex on a woman.The overall prevalence of oral HPV (29%) found in our study is much higher than in the general population (7%) . This waWe found no evidence that illicit drug use itself is associated with oral HPV, consistent with another small study that considered the effects of marijuana, heroin, cocaine, crack, and speedball use on oral HPV . This diThe association of HIV-related immunosuppression (CD4<350 cells/μL) with oral HPV prevalence observed in this study is consistent with several other studies ,8,14,28.Our findings support the hypothesis that performing oral sex on a woman confers higher risk of acquiring oral HPV than performing oral sex on a man ,27,29. IStrengths of our study include a high participation rate, detailed risk factor information, and centralized laboratory testing of all samples. We were limited by our sample size, which may have prevented us from detecting small associations between oral HPV and drug use, if they exist. Our study population was also fairly homogenous with respect to race/ethnicity and age, so we were unable to adequately describe variation in oral HPV prevalence across these characteristics. Though we interpreted the detection of HPV DNA to indicate HPV infection, it is also possible that in some cases we detected HPV DNA in saliva samples that did not actually represent infection. Finally, because our study is cross-sectional, we have described patterns in prevalence of oral HPV but we cannot address HPV incidence or clearance.In conclusion, our results suggest that HIV-related immunosuppression and performing oral sex on a woman are strong risk factors for oral HPV, while drug use was not associated with oral HPV. Nevertheless, we observed high oral HPV prevalence among people who currently or formerly used injection drugs, implying that this population may have increased risk of HPV-related OPC. Additional research will be needed to determine how many of these infections persist long-term and may represent cancer risk, and whether this population could benefit from increased emphasis on HPV vaccination or perhaps oral cancer screening.S1 File(CSV)Click here for additional data file.