Aim: This study aimed to follow the impact of human papillomavirus (HPV) catch-up and vaccination on the very high cervical HPV-prevalence in women at a youth clinic in central Stockholm during the period 2008–2018.Background: 2008–2010, cervical HPV-prevalence (69.5%) and HPV16 prevalence (34.7%) were high in non-vaccinated women at a youth clinic in Stockholm. 2013–2015, after the introduction of the quadrivalent-Gardasil® HPV-vaccine, HPV16 and HPV6 prevalence had decreased. Here, cervical HPV-prevalence was investigated 10 years after primary sampling.Material and Methods: 2017–2018, 178 cervical swabs, from women aged 15–23 years old, were tested for 27 HPV types by a bead-based multiplex method. HPV-prevalence data were then related to vaccination status and age and compared to HPV-prevalence in 615 samples from 2008 to 2010 and 338 samples from 2013 to 2015 from the same clinic, and to HPV types in 143 cervical cancer cases during 2003–2008 in Stockholm.Results: The proportion of vaccinated women increased from 10.7% (2008–2010) to 82.1% (2017–2018). The prevalence of all 27 HPVs, all high-risk HPVs (HR-HPVs) and the combined presence of the quadrivalent-Gardasil® types HPV16, 18, 6, and 11, was lower in vaccinated compared to unvaccinated women . Furthermore, HPV16 prevalence in non-vaccinated women 2017–2018 was lower than that in 2008–2010  and similar trends were observed for HPV18 and 11. In both vaccinated and non-vaccinated women, the most common non-quadrivalent-Gardasil® vaccine HR-HPV types were HPV39, 51, 52, 56, and 59. Together they accounted for around 9.8% of cervical cancer cases in Stockholm during 2003–2008, and their prevalence tended to have increased during 2017–2018 compared to 2008–2010.Conclusion: Quadrivalent-Gardasil® vaccination has decreased HPV-vaccine type prevalence significantly. However, non-vaccine HR-HPV types remain high in potentially high-risk women at a youth clinic in Stockholm. Human papillomavirus (HPV) infections represent the most common sexually transmitted diseases, affecting millions of people worldwide. About 90% of HPV infections are cleared within 2 years without any need for medical intervention  has approved three HPV-vaccines: quadrivalent-Gardasil®, Cervarix®, and Gardasil®9, consisting of type-specific HPV L1 virus-like particles (VLPs) that induce type-restricted protection , we reported a cervical HPV-prevalence of 69.5%  in HPV non-vaccinated individuals at a youth clinic in Stockholm, Sweden  and 2013–2015  and to HPV types occurring 2003–2008 in 143 cervical cancer cases (111 squamous carcinomas and 32 adenocarcinomas), in Stockholm . For HPV16 and HPV33 primers and probes targeting the E6-1F region were also included as described previously  together or alone, were compared between vaccinated and unvaccinated groups using Chi-square analysis. Differences of HPV types collected from this study were also compared with former studies using Chi-square analysis.In total, 172/178 samples had sufficient material for HPV analysis. Total cervical HPV-prevalence, irrespective of HPV-vaccination status, was 72.1% (124/172) and HR-HPV prevalence was 65.1% (112/172) (data not shown). p = 0.0031 and 60.1 vs. 86.7%, p = 0.0057, respectively). The four specific HPV-vaccine types combined were also less common in vaccinated than in unvaccinated women , while for the 13 non-vaccine HR-HPV types the same trend was not statistically significant 60.1 vs. 76.7%, p = 0.099).Vaccination status was available for 168/172 women above. Of these 138/168 (82.1%), had received at least one HPV-vaccination. p = 0.058 and 0 vs. 3.3%, p = 0.179 respectively), but did not reach statistical significance (p = 0.0052), while HPV11 was not detected at all (neither in vaccinated or non-vaccinated women) in this study  in vaccinated as compared to non-vaccinated women, while this was not the case for the remaining HR-HPV types  or 15 HR-HPV types per sample tended to be lower in vaccinated than in unvaccinated women . However, when only HPV infected women are considered, the average number of any HPV or HR-HPV type per sample was similar in vaccinated and non-vaccinated women . The maximum HPV types per sample was 11, (9/11 HR-HPVs), and was detected in a sample of a non-vaccinated woman.HPV-vaccination coverage increased from 10.7% (2008–2010) to 71.0% (2013–2015) and 82.1% (2017–2018). Initially most women were HPV catch-up vaccinated, while in 2017–2018, most women aged 16–18 years were vaccinated, likely through the school-based vaccination program. HPV-prevalence was generally high irrespective of time period. More specifically, when comparing vaccinated with non-vaccinated women, it was 53.9 (earlier unpublished data) vs. 69.5% in 2008–2010, 64.6 vs. 74.5% in 2013–2015, and most recently in 2017–2018, it was 67.4 vs. 93.3%  , while in unvaccinated women, the corresponding rise was significant for HPV51, 56 and 59  (When comparing (irrespective of vaccination status) HPV-prevalence 2017–2018 of the five most common HR-HPVs  with their corresponding prevalence in 2008–2010, we observed significant increases for all of them (ctively) . More spctively) . Notablyctively) .HPV vaccination, with high coverage has been shown to have an impact on HPV related diseases, reducing the burden of HPV infection, genital warts and cervical disease (Schmitt et al., These data emphasize the importance of HPV-vaccination and show similar to others studies that high vaccine coverage prevents HPV infection, especially of the four quadrivalent-Gardasil HPV types, and potentially prevents a considerable proportion of HPV related diseases e.g., cervical cancer (Cutts et al., The fact that some HR-HPV types seem to have increased could be due to various reasons. One unconfirmed explanation would be an increased sexual activity in the past decades. Alternatively, one could argue that potential cross-immunization induced by naturally occurring HPV-vaccine types e.g., HPV16, 18, was better against these non-HR HPV types than that induced by the vaccine. This argument was however not supported by the work of Saccucci et al. where e.g., cross-immunization against types genetically related to HPV16 was observed in vaccinated, but not in non-vaccinated women (Saccucci et al., Both this study, and our study from the period 2008–2010 (Ramqvist et al., Earlier, cross-protections induced by the HPV-vaccines were reported against HPV31 and 45, types closely related to HPV16 and 18, respectively (Saccucci et al., Gardasil®9 is the latest HPV-vaccine and covers HPV6, 11, 16, 18, 31, 33, 45, 52, and 58 (Schiller and Lowy, Finally, this study has some bias and limitations that need to be taken into consideration. The young women subjected for this study visit the healthcare center for birth control advice and for the treatment of sexually transmitted diseases (Ramqvist et al., To conclude, quadrivalent-Gardasil® vaccination has significantly decreased the vaccine specific HPV-types HPV16, 18, 6, and 11, but five non-vaccine specific HR-HPV types HPV39, 51, 52, 56, and 59 still remain high in potentially high-risk women at a youth clinic in Stockholm. Of these five HR-HPV types, only HPV52 is included in Gardasil®9. It is therefore important to follow up HPV infections in the future and possibly consider the most prevalent HPV types in this study for the next generation of HPV-vaccines.All datasets generated for this study are included in the manuscript and/or the supplementary files.LE, TD, and JD: conception and design; AÄ-R, TR, LE, TD, and JD: development of methodology; AÄ-R, NG, RU, LH, YH, MS, and AP: acquisition of data; AÄ-R, LC, TR, TD, and JD: analysis and interpretation of data; LC, TD, and JD together with all authors: writing, review, and/or revision of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


This population-based study aimed to fill the knowledge gap on Human Papillomavirus (HPV) prevalence and associated sociodemographic risk factors of the general population in the North Tongu District, Ghana. These results are needed to guide cervical cancer prevention efforts, as the leading type of female cancers.A cross-sectional study including 2002 women in the North Tongu District, Ghana investigated HPV prevalence and associated sociodemographic risk factors. Women were recruited by geographical distribution through the local community-based health system and samples collected using a self-sampling device. For HPV genotyping BSGP5+/6+-PCR with Luminex-MPG readout was used. Multivariate logistic regression analyzed sociodemographic risk factors for HPV positivity.Of 2002 self-collected samples, 1943 were eligible, contained sufficient DNA and provided valid HPV genotyping results. Prevalence of single high risk HPV types was 32.3% and of multiple high risk types 9.7%. The five most common detected HPV types were HPV16 , HPV52 , HPV35 , HPV59 , HPV56 . Highest prevalence was observed among women aged 18–24 years, while age 25–54 years was inversely associated with high risk HPV positivity in multivariate analysis. Sociodemographic risk factors identified were i) having any sexual partner, ii) more partners increased the odds for high risk HPV positivity, iii) independently from this marital status, in particular not being married.Most importantly, the high risk HPV prevalence detected from this study is higher than estimates reported for Western Africa. This needs be considered, when deciding on the cervical cancer screening algorithms introduced on a wider scale. Follow-up and triage, depending on the methods chosen, can easily overburden the health system. Self-sampling worked well and provided adequate samples for HPV-based screening. Women with increasing number of sexual partners and not being married were found to have higher odds of being high risk HPV positive, therefore could be a higher prioritized screening target group. Cervical cancer is the 4th most common cancer among women in the world leading to about 528.000 registered new cancer cases and 266.000 cervical cancer deaths annually . About 9Low-middle income countries (LMIC) carry the greatest global burden of cervical cancer with about 85% of incident cases and 87% of annual deaths occurring there . ReasonsIn Ghana cervical cancer is the 2nd most common female cancer among women at the age of 15 to 44 years and the 2nd leading cause of cancer deaths . With a Despite this high burden of disease little is known about the prevalence of HPV infection and its risk factors in the general population of Ghana. Studies investigating this are very rare and limited to small studies (n<230) or specialized populations . Prevalence rates stated are for example 10.7% among 75 women attending the gynecology outpatient clinic in Accra , or 42% Adequate Cervical cancer Capacity building, Education and Screening by new Scientific INstruments in Ghana” and a program funded by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) and the German Rotary Voluntary Doctors (GRVD). The program was conducted during a hospital partnership in collaboration between the Catholic Hospital Battor in the Volta Region, Ghana, and the Charité—Universitätsmedizin Berlin, Clinic for Gynecology, Germany. The aims of this program were to assess the HPV and STI prevalence with a cross-sectional study design in the general population, to evaluate a potential screening algorithm for cervical cancer screening on its feasibility, and to build the capacity to independently and autonomously introduce cervical cancer screening. The program was conducted from October 2013 until February 2017 including two pilot studies with 250 and 150 women screened at the Catholic Hospital Battor, respectively, and a main study with 2002 women screened from the rural and urban communities in the North Tongu District.ACCESSING is an acronym for “This manuscript presents the results from the ACCESSING main study investigating HPV prevalence, genotype distribution, and the sociodemographic risk factors associated with high risk HPV positivity. This shall help decision makers to identify adequate cervical cancer screening methods and potentially prioritized risk groups for screening.This evaluation of the ACCESSING program is a cross-sectional study conducted in the North Tongu District, Ghana in a collaboration of the Catholic Hospital Battor, Ghana and the Charité—Universitätsmedizin Berlin, Germany. Women in the age of 18 to 65 years without a history of cervical cancer and who were not pregnant were recruited.Sample size calculation was based on a HPV prevalence estimate of 21.3% and the objective to identify a clinically relevant difference of 2.5% to this suggested prevalence . AdjustiEthical clearance for this study was given by the Ghana Health Service Ethical Review Committee (Ref. No. GHD-ERC: 05/05/13) in October 2013. Signed/thumb-printed written/translated informed consent was obtained from all women participating in the screening.The number of women included in each village within the North Tongu District was defined based on the population size reported during the latest Population Census from 2010 and adjusted to a sample size of 2000 study participants . RecruitThe samples were collected using an approved (Ghana FDA) self-sampling device, namely the Evalyn brush . Evalyn Brush samples were self-collected or collected with assistance from a CHW according to manufacturer’s instructions and stored dry and at ambient temperature for a maximum time period of 7 days until arrival in the laboratory of the Catholic Hospital Battor, Ghana. Every woman screened filled out a questionnaire asking for general demographic data  as well as specific risk factors such as age at first intercourse, number of sexual partners, etc.  was used according to manufacturer’s instructions. DNA was eluted into 60 μl of elution buffer and stored at -20°C until further used.Genotyping of mucosal HPV was done by BSGP5+/6+ PCR followed by Luminex-MPG read-out according to Schmitt et al. 2008  detectinAccording to WHO monograph classification HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59 were considered as high risk HPV genotypes. HPV66 and 68a and 68b were defined as probable, HPV26, 53, 73, and 82 as potential high risk and the HPV types 6, 11, 42, 43, 54, 57, 70, 72, 90 as low risk types .Women who tested positive for high risk HPV were recalled to the clinic for cytology and upon abnormal cytology result called again for colposcopy. Based on the diagnosis by the treating gynecologist treatment, such as loop electrosurgical excision procedure (LEEP) or hysterectomy, was provided. Cytological examination was done at the Department of Pathology, University of Cape Coast, Ghana. HPV testing as well as any clinical follow-up required were provided free of charge for the study participants.Statistical analysis of categorical data was done using high risk HPV positivity as the dependent variable. Univariate and multivariate logistical regression analysis was used to identify potential sociodemographic risk factors for high risk HPV positivity. Variables for multivariate logistic regression were chosen based on their association resulting from univariate analysis as well as from sociodemographic risk factors reported in the literature. The multivariate model was built using forward stepwise selection and the likelihood ratio test to compare the fit of the models. The unadjusted odds ratio (OR), adjusted odds ratio (AOR), 95% confidence intervals (95%CI) and p-values from univariate and multivariate logistic regression were reported as a measure of association. All reported p-values were 2-sided with a significance level of 0.05. For statistical analysis STATA version 15  was used.From a total of 2002 women samples with a self-sampling brush were collected through the CHW system in the North Tongu District within 5 weeks. Two samples did not reach the laboratory, 18 were excluded from this analysis because they were not within the age range of 18–65 years and an additional 39 samples were excluded due to insufficient DNA present in the sample for HPV testing. Hence a total of 1943 samples were included in the HPV and risk factor analysis . Among tThe distribution of sociodemographic characteristics is summarized in Among the 1943 samples left for analysis, high risk HPV was detected in 32.3% (95%CI: 30.2–34.5) and 9.7% (95%CI: 8.4–11.1) were positive for multiple high risk HPV types. On average women with multiple high risk types had 1.4 high risk types detected (range: 1–7 high risk types). 18.4% (95%CI: 17.7–20.2) were positive for low risk HPV as single or multiple infection and 53.5% (95%CI: 51.3–55.8) HPV negative. Among women aged 30–49 years, the WHO recommended screening age, high risk HPV prevalence was 27.3% (95%CI: 24.3–30.5). Women high risk HPV positive were invited for clinical follow up free of charge. This was structured in cytology and based on indication colposcopy, LEEP and potentially hysterectomy. Results of clinical follow up are presented in the supporting information The five most prevalent high risk HPV types were HPV16 , HPV52 , HPV35 , HPV59 (4.7% 95% CI: 3.8–5.8) and HPV56  . HPV66, The age-specific HPV prevalence is presented in Univariate analysis suggests high evidence for decreasing odds ratio (OR) of high risk HPV positivity for women with the following sociodemographic factors . Women aAfter multivariate logistical regression only the factors age, marital status and number of sexual partners appeared to have a high association for infection . Here, aSample collection via self-sampling worked exceptionally well in this study. The integration of recruitment and sampling in the responsibilities of CHW system allowed simultaneous screening across the District within only 5 weeks. With 98% of the samples providing valid HPV genotyping results, this sampling method should be considered for large-scale screening programs, especially for widespread communities.The results of this cross-sectional HPV prevalence study show an exceptionally high prevalence of the high risk HPV genotypes of 32.3%. This is a 52% increase compared to the initially expected prevalence of 21.3%, which had been used as an estimate for Western Africa in the sample size calculation . Even amLooking at some of the other scarce studies conducted among the general population in Ghana, a prevalence of 10.7% was found among 75 women (mean age: 33.3 years) attending the gynecology outpatient clinic in Accra , or of 4Nevertheless, the majority of women (65.4%) recruited for this study was at the age of 18–34 years with a prevalence of 35.0% for this age group. Looking at the age distribution of the population living in North Tongu district from the 2010 Population and Housing Census, the age group 20–34 years comprises about 51.0% among the 20–64 years old women (similar to the age range meeting the study inclusion criteria) of the North Tongu population and is hence overrepresented among the women recruited for this study. On the other hand the older age group  comprises 48.9% among 20–64 years old in North Tongu women’s population and is therefore underrepresented here. Since the peak of HPV infection is expected among women aged ≤25 years , this coAdditionally, it has been described that although the accuracy of HPV testing from self-collected samples compared to physician-obtained samples is similar, there is a tendency of more HPV types being detected in self-collected samples from the cervicovaginal compartment as compared to physician-collected cervical-targeted sampling –30. ThisThe five most prevalent high risk HPV types found in this study are 16, 52, 35, 59 and 56, in descending order, known to contribute to a total of 59.4% of cervical cancer cases in the African Region, as defined by WHO . The typ9.7% of the women in this investigated population had multiple high risk HPV infections. Multiple high risk HPV infections are often reported among HIV positive persons –34. HoweBased on the self-reported answers provided to the questionnaires several risk factors have been investigated and shown to be associated with high risk HPV infection. Knowledge of these risk factors is of great importance to target women at highest risk of infection with screening programs, especially in countries with limited resources for screening. Three risk factors remained associated with high risk HPV infection after multivariable regression analysis: Age, relationship status, and number of sexual partners.Transmission of genital HPV and hence infection occurs with the onset of sexual activity and HPV infection has been described to peak among younger women aged ≤25 years . This isBeing single or divorced was highly associated with infection compared to being married. Surprisingly, having a steady partner and living with someone but not being married was also associated with infection, even after adjusting for age and the number of sexual partners. This might be due to ambivalent interpretation of these two categories by the study participants. The questionnaires were filled out under supervision of the CHW and that might have influenced the answers given. Possibly different interpretation of relationship length influenced the category of “having a steady partner”. Other studies reported that being in a relationship for 12 months or longer is protective for infection, indicating that the duration of a relationship seems to be an important factor . In the Other studies found lower levels of formal education to be associated with infection . In our While this cross-sectional study is sufficiently powered to detect a difference in HPV prevalence compared to the estimate stated for Western Africa, it was not meant to be powered to assess risk factors. The sociodemographic and behavioral characteristics are based on self-reported questionnaires and may therefore be subject to biased answers. The associations we found have to be investigated in larger studies and a similar context.Additionally, problems with sample genotyping resulted in longer waiting times than expected for the women participating. Since women may travel across the country with the harvest season and also the CHWs responsible for the respective area change locations for training, to mention only a few potential factors, only about half of the positively tested women travelled to the clinic for follow-up. The unexpectedly high prevalence made it difficult for all women to receive colposcopy and therefore the additional cytology triage step was introduced. Therefore, we cannot make any conclusions on the clinical status of all women tested positive and hence excluded the clinical outcome from any further analysis.The main finding of this study is a higher prevalence of high risk HPV than expected until now. Secondly, we found that three HPV types, namely HPV35, 56 and 59, are among the top 5 types found but not covered by any HPV vaccine even though they are found in 16.4% of cervical cancers in Western Africa . ThirdlyDespite the high HPV prevalence found in the investigated population there is currently no national screening program for cervical cancer screening in Ghana. Although the recent national control program for non-communicable diseases (NCDs) states an instituted cervical cancer screening system as a national policy priority, little of the suggested means have been implemented until today  and the Self-sampling worked well and provided adequate samples for HPV-based screening. However, the high HPV prevalence found would require further triage and follow-up for a large number of women, which can easily overburden the health system. This is a major aspect when deciding on the feasible cervical cancer screening algorithm introduced on a wider scale.S1 File(PDF)Click here for additional data file.S1 Fig(TIF)Click here for additional data file.


Few studies focused on longitudinal modifications over time of high-risk HPV (HR-HPV) at anal and oral sites in HIV+ men who have sex with men (MSM).We described patterns and longitudinal changes of HR-HPV detection and the prevalence of HR-HPV covered by the nonavalent HPV vaccine (vax-HPV) at oral and anal sites in 165 HIV+ MSM followed in an Italian hospital. The samples were collected at baseline and after 24 months (follow-up). The presence of HPV was investigated with Inno-LiPA HPV Genotyping Extra II.3 (IQR 187–450). A total of 120 subjects (72.7%) were receiving successful antiretroviral therapy (ART). At baseline and follow-up, the frequency of HR-HPV was significantly higher in the anal site . Only 2.9% of subjects were persistently HR-HPV negative at both sites. All oral HR-HPV were single at baseline vs 54.6% at baseline at the anal site (p = 0.005), and all oral HR-HPV were single at follow-up vs 54.4% at anal site at follow-up (p = 0.002). The lowest rate of concordance between the oral and anal results was found for HR-HPV detection; almost all HR-HPV positive results at both anal and oral sites had different HR-HPV.The most frequent HR-HPV in anal swabs at baseline and follow-up were HPV-16 and HPV-52.At follow-up at anal site, 37.5% of patients had different HR-HPV genotypes respect to baseline, 28.8% of subjects with 1 HR-HPV at baseline had an increased number of HR-HPV, and patients on ART showed a lower frequency of confirmed anal HR-HPV detection than untreated patients (p = 0.03) over time. Additionally,54.6 and 50.5% of patients had only HR-vax-HPV at anal site at baseline and follow-up, respectively; 15.2% had only HR-vax-HPV at baseline and follow-up.Median age was 44 years (IQR 36–53), median CD4+ cell count at nadir was 312 cells/mmWe believe that it is important testing multiple sites over time in HIV-positive MSM. ART seems to protect men from anal HR-HPV confirmed detection. Vaccination programmes could reduce the number of HR-HPV genotypes at anal site and the risk of the first HR-HPV acquisition at the oral site.The online version of this article (10.1186/s12889-019-7004-x) contains supplementary material, which is available to authorized users. Patients with HIV infection are more likely to experience coinfection with human papillomavirus (HPV) compared to HIV negative subjects. Within the HIV positive population, over 80% of men who have sex with men (MSM) were HPV-positive in the anal canal, being higher than 80% and with a high frequency (ranging from 70 to 90%) of high risk HPV (HR-HPV) in most studies , 2. The 3. Limited evidence-based data on the independent role of long-term HPV DNA positivity on the incidence of head and neck squamous cell carcinoma in HIV+ MSM are available [The persistence of anal HPV DNA infection plays a central role in carcinogenesis. Marra et al.  reportedvailable .However, negative HPV detection does not imply definite clearance of the infection because the patient’s immune system may be able to control the infection below the detection limit of available HPV assays . FurtherThe aim of this work was to analyze the numerosity and the confirmed detection of oral and anal HPV infection over a 24-month period in a cohort of HIV-positive MSM; we focused on pattern and longitudinal changes in HR-HPV detection and the prevalence of HPV genotypes covered by the nonavalent HPV vaccine.HIV-positive MSM treated as outpatients at the Infectious Disease Unit of Padova University Hospital  from January 2013 to December 2013 were consecutively invited to take part to this study.The following inclusion criteria were applied: 1) aged > 18 years; 2) no cutaneous and/or mucosal lesion due to HPV infection at study entry and in the past; 3) no previous HPV vaccination; and 4) able to make the decision to sign the informed consent. Anal HPV testing was included in their clinical workflow: they were asked to give the consent for testing also oral mucosa and for the use of their blinded data. No payment was provided to the subjects.HPV was tested in oral and anal swabs. All enrolled patients were evaluated by a physician and the samples were collected on two different visits separated by a 24-month interval (the maximum spread was 2 weeks before or after the deadline). The study time corresponding to the first sampling was defined as baseline and the time corresponding to the second sampling was defined as follow-up.The treating physician decided to start antiviral therapy or to left the patients untreated as prescribed by international guidelines that were current when the study started . The subThe variables studied at baseline were age in years at baseline, the achievement of plasma HIV RNA suppression throughout the study duration and CD4 lymphocyte count at nadir (cells/μl).The Ethics Committee of Padova University Hospital (prot. 2606-12P) approved this study, which was made according to the Declaration of Helsinki and local legislation. The patients included in the study gave written informed consent to all procedures and they agreed with the anonymous use of their data for scientific aims and publication.At baseline and at follow-up, anal Dacron swab PBS -moistened was inserted for 3 cm length into the anal canal, then the scraping of anal walls was made, rotating clockwise and anticlockwise three times each way. Oropharyngeal mucosa was scraped with strength to obtain oral samples by rotating twice clockwise and twice anticlockwise with another swab. After, the samples were agitated in 1.5 mL of 1 × PBS. The samples were stored at 4 °C and analyzed after no more than 4 h. The QIAamp DNA Mini Kit  was used for total DNA extraction: after, primers PC04 and GH20 (which target a 268-bp fragment of beta-globin) were first used. The samples were always processed and stored separately.No further analysis was performed on samples negative for beta-globin. ExoSAP-IT  was used to purify the DNA and Inno-LiPA HPV Genotyping Extra II   was the The statistical analysis was performed on all subjects whose valid results were available and on the subgroup of subjects who had HPV infection due to genotypes covered by the nonavalent vaccine  . The HPVContinuous variables were expressed as the median and interquartile range whereas categorical variables were indicated as the absolute number and frequency (%). The Mann-Whitney U test, the chi-squared test and Fisher’s exact test were employed as appropriate.The significance of the prevalence change from baseline to follow-up was estimated by Pearson’s chi-square test or by Fisher’s exact test, as appropriate.P values < 0.05 were considered to be significant.3 (IQR 187–450 cells/mm3). Further, 120 subjects (72.7%) were receiving successful ART, and most patients were treated with a protease inhibitor as the third drug .A total of 171 HIV+ MSM responded to the inclusion criteria: 4 subjects had not CD4+ cell count available and 2 subjects refused to provide informed consent, so 165 HIV+ MSM were included in the study. The median age was 44 years (IQR 36–53 years), and the median CD4+ cell count at nadir was 312 cells/mmp < 0.0001) HPV detection was confirmed in 12/103 (11.6%) oral samples and in 135/165 anal samples (81.8%).Valid anal samples were obtained from all patients at baseline and follow-up, whereas valid oral samples were obtained from 106 (64.2%) patients at baseline and from 162 (98.2%) patients at follow-up. Invalid oral samples were not analyzed if they were found negative for beta globin, possibly because of low cellularity. The overall prevalence of HPV (both HR-HPV and non-HR-HPV) in the anal specimens was 89.1% (147/165 patients) at baseline and 89.7% (148/165 patients) at follow-up, and it was significantly lower in the oral specimens  whereas, the percentage of HR-HPV detected at anal and oral sites at baseline and at follow-up was comparable . The relative frequency of patients with HR-HPV compared to all HPV-positive subjects was significantly higher in anal samples than in oral samples at both baseline  and follow-up . A description of the oral and anal swabs results according to HPV detection is reported in Fig. At baseline and follow-up, the absolute HR-HPV positivity was significantly higher in anal samples than in oral samples p < 0.000 whereas,Overall, 179 anal HR-HPV strains were identified at baseline  and 194 strains were identified at follow-up . The most frequent types of HR-HPV detected in the anal swabs at baseline and follow-up were HPV-16  and HPV-52 .p = 0.005) and follow-up . Among these HR-HPV positive anal samples, multiple HR-HPV patterns were found in 49 of 108 subjects (45.4%) at baseline and in 47 of 103 subjects (45.6%) at follow-up (p = 0.0331 with respect to the frequency at baseline) Of note, a different genotype combination was identified in all these patients at baseline and in 90.3% of these patients at follow-up.All HR positive oral samples at baseline and follow-up had a single HR-HPV detection; the prevalence of this pattern was significantly higher compared to the prevalence in the anal site at baseline  at baseline and in 34 patients (21%) at follow-up.p = 0.0002 and 7.9%, 8/101 patients at follow-up, p < 0.0001 with respect to the percentage of concordant negative results at the same study time).The highest rate of concordance between the oral and anal figure was found for negative results  and the lowest for HR-HPV detection  were always positive for HR-HPV at both the anal and oral sites and 3 patients (2.9%) were persistently negative.p < 0.0001) and of HR-HPV . The HR genotypes of the 4 patients with confirmed HR-HPV at the oral sites were the same at baseline and follow-up .A total of 104 patients had HPV tested in oral samples at both baseline and at follow-up. The percentage of patients with the same pattern at both study times was significantly higher in patients with negative results  with respect to the detection of non-HR-HPV . Patients receiving ART showed a significantly lower frequency of confirmed HR detection compared to untreated patients . At follow-up, 30 out of 80 patients (37.5%) had HR-HPV at follow-up with a different genotype than that at baseline, 37 patients (46.3%) had one HR-HPV strain with the same genotype at both baseline and follow-up, 11 (13.7%) had 2 HR-HPV and 2 (2.5%) had 3 HR-HPV with the same genotypes at baseline and follow-up.The number of patients with anal HR-HPV was comparable at baseline and follow-up (108 and 103 respectively), and most  of the subjects with HR-HPV at baseline were also positive for HR-HPV at follow-up (Most patients who become HR-HPV-positive at follow-up reported a single HR positivity: 83.3% (5/6 patients) in case of negative result at baseline and 82.3% (14/17 patients) in the case of non-HR-HPV identification at baseline. A detailed description of the oral and anal HR-HPV patterns modifications from baseline to follow-up is reported in Fig. Fifty-nine subjects had a single type of HR-HPV found at baseline; at follow-up, 6 subjects 10.2%) became negative, 12 patients (20.3%) had non-HR-HPV and 41 (69.5%) had confirmed HR-HPV positivity. Twenty-four of the 41 patients had 1 HR-HPV strain at follow-up (16 subjects with a different genotype from baseline), and 17 (28.8%) subjects had an increased number of HR-HPV strains detected at follow-up. The percentage of MSM with confirmed HR-HPV detection at follow-up was 80% in the case of 2 HR found at baseline, 75% in the case of 3 HR-HPV found at baseline and 100% when 4 HR-HPV were found at baseline (only 3 patients were included in the subgroup with 4 HR genotypes); no patients with ≥3 types of HR-HPV at baseline had a negative result at follow-up (Table % became p < 0.001), HPV-18 (p < 0.001), HPV-31 (p = 0.000), HPV-35 (p = 0.05), HPV-45 (p = 0.000), HPV-51 (p = 0.000), HPV-58 (p = 0.004) and HPV-59 (p = 0.043).HPV 16 was the most frequently detected genotype at both baseline and follow-up: no significant difference in the prevalence of the specific HR-HPV genotype at baseline and follow-up was found, and the percentages ranged from 3.03 to 16.97% at baseline and from 3.64 to 17.58% at follow-up. A concordant positivity of the same genotype at both time points was reported for HPV-16 . Furthermore, single HR-HPV detection was the more frequent result (16 patients at baseline and 17 patients at follow-up). A detailed description of the HR-HPV genotypes identified at baseline and follow-up is reported in Fig. Nearly half of the patients with HR-HPV positivity at the anal site  had only HR-HPV genotypes covered by the vaccine, and 25 (15.2%) of the 165 subjects had this result at both study time points. The median age of the 25 patients was 44 years (range 39–55 years), and the nadir median value was 350 CD4+ cells/mmThis study focused on the characteristics of persistence and pattern evolution of HR-HPV infection in oral and anal areas over time in a cohort of HIV-positive MSM tested over a 24-month interval. We selected this study duration because the spontaneous clearance of nearly all HR-HPV strains occurs within this interval ; thus, wIn our opinion, HPV vaccination should be recommended for all HIV-positive MSM, regardless of age and of HPV detection at any site, even if published data are scarce, because of the high incidence of anal cancer in these subjects . SubjectThe first result of our study was a significantly higher frequency of all HPV genotypes and of confirmed HR-HPV detection at the anal site at follow-up compared to the oral site . Beachler et al.  reportedIn our study, the anal HR-HPV pattern was more complex than the oral pattern, both at baseline and at follow-up. The influence of the anatomic site of infection on the natural history of HPV is multifaceted and can include a faster clearance from oral epithelia and the continuous flow of saliva and associated immunoglobulins in the oral region , 33. PapAlmost all patients with HR-HPV positivity at both the anal and oral sites had different HR-HPV genotypes, as previously described , 38. TheDuring all DNA preparation, extraction and purification steps, precautions were taken to reduce the risk of false positive results or cross-contamination. However we cannot exclude a contamination. Besides this one, other limitations of this study must be recognized. First, we only sampled patients at 2 time points; thus, the evidence of persistent HR-HPV infection may instead be the clearance and subsequent transient exposure to the same genotype prior to the second sampling. Our HR-HPV detection was according to the type level; therefore, we could not exclude the possibility that someone could become infected with another variant of the same HR-HPV type; however, the young age of the subjects does not seem to indicate a modification in the exposure to risk. Second, only a small group of patients had all 4 samples available for testing, and positive HR detection was low at the oral site. These limitations restricted the power of the statistical analysis to detect correlations. Third, a more complete analysis on other sites of infection, such as the penis, and information about partners would make the analysis more informative. Fourth, we did not collect data on the patients’ sexual behaviour. Instead, our study focused on modifications of HR-HPV patterns after a 48-month study interval in adult patients rather than the reasons behind the modifications. Fifth, many oral samples were not evaluated because they were negative for beta globin, which indicates low cellularity; a different sampling method   could haIn conclusion, HR-HPV detection is a clinical problem for almost all HIV positive MSM and requires careful surveillance. The anal HR-HPV pattern was more complex than the oral pattern at both baseline and follow-up. Effective ART seems to have a positive impact on HR-HPV confirmed detection at the anal level and should be associated with an extended vaccine campaign in light of ongoing new HIV diagnoses mostly in young patients , 44.Additional file 1:Description of HR-HPV genotypes in oral and anal samples at baseline and at follow-up (24 months after baseline). Data are reported according to the number of HR-HPV genotypes detected and to the relative frequency of each specific combination within the group. (PDF 162 kb)


The human papillomavirus (HPV) vaccine is an underutilized cancer control practice in the United States. Although individual contextual factors are known to impact HPV vaccine coverage rates, the impact of macro-level elements are still unclear. The aim of this analysis was to use HPV vaccination rates to explore the underuse of an evidence-based cancer control intervention and explore broader-level correlates influencing completion rates.A comprehensive database was developed using individual-level date from the National Immunization Survey (NIS)-Teen (2016) and state-level data collected from publically available sources to analyze HPV vaccine completion. Multi-level logistic models were fit to identify significant correlates. Level-1  and level-2 (state) correlates were fitted to a random intercept model. Deviance and AIC assessed model fit and sampling weights were applied.The analysis included 20,495 adolescents from 50 U.S. states and the District of Columbia. Teen age, gender, race/ethnicity, and maternal education were significant individual predictors of HPV completion rates. Significant state-level predictors included sex education policy, religiosity, and HPV vaccine mandate. States with the lowest HPV coverage rates were found to be conservative and highly religious. Little variation in vaccine exemptions and enacted sex and abstinence education polices were observed between states with high and low HPV vaccine coverage suggesting various contextual and situational factors impact HPV vaccine completion rates.Given that gender, religiosity, political ideology, and education policies are predictors of HPV vaccine completion, the interaction and underlying mechanism of these factors can be used to address the underutilization of the HPV vaccine. In the United States, human papillomavirus (HPV) is the most common sexually transmitted infection causing genital warts and HPV-related cancers . HPV traEfficacy studies have indicated HPV vaccines are a highly effective prevention tool prior to HPV exposure , 6. As aAttitudes and beliefs that HPV is a low health priority and vaccination is an elective health measure have resulted in low adherence to HPV vaccine guidelines . ConsideIn order to explore opportunities to enhance HPV vaccine uptake, the aim of this paper is to study the combination of individual  and macro-level factors  potential influences on HPV vaccine completion rates as limited evidence is available. Further understanding these relationships, will not only broaden the evidence in the literature to consider influences beyond the individual, but provide guidance and support to leaderships and facilitators whom have decision-making power in HPV vaccine-related activities. These findings can potentially translate into successful implementation of HPV vaccine interventions and identify potential influences hindering their utilization. We hypothesize that broader-level factors, in addition to individual-level influences, highlights potential modifiable and non-modifiable HPV vaccine barriers influencing suboptimal HPV vaccine adherence nationally. More specifically, we seek to (1) explore possible factors of high and low HPV vaccine coverage rates, and (2) illustrate the current HPV vaccine coverage rates across the United States.For our analyses, a comprehensive database was created using individual and state-level variables from publicly available sources.The National Immunization Survey (NIS)-Teen (2016) is a cross-sectional survey which estimates vaccine coverage rates among 13–17 year old teens in the United States using random digit dialing conducted by the National Center for Immunization and Respiratory Diseases and the National Center for Health Statistics within the Centers for Disease Control and Prevention (CDC) , 22. TelFunding appropriated for HPV vaccination promotion efforts in 2017 and state and local public health governance (2015) was taken from the Centers for Disease Control and Prevention (CDC) websites , 24. TheVaccine coverage, or completion data, was based on medical records from providers and vaccines administered after the NIS-Teen interview were excluded . HPV vacCovariates at the teen and family-level were chosen from the NIS-Teen dataset based on previous literature and included teen age, gender, race/ethnicity; maternal education; family poverty status; and whether a provider had recommended an HPV vaccine series for the child. Indicator variables were used to examine race and ethnicity of the teen as Non-Hispanic White, Non-Hispanic Black, Hispanic, and Non-Hispanic other or mixed race. Poverty status of the family was categorized as above or below the federal poverty line, and maternal education was dichotomized as up to a college graduate and college graduate or higher., central, mixed, or shared [State public health departments were categorized according to their jurisdiction type as decentralr shared . FundingThe presence of an HPV vaccine and sex education mandate in state legislation, along with the type of abstinence-only policy  were also examined as potential state correlates. States that have “stressed abstinence” policies strongly emphasizes abstinence as a standard teaching . AlternaMulti-level models were fit to identify important correlates of HPV vaccine completion and quantify relationships with odds ratios and 95% confidence intervals (CI). First an unconditional logistic model was fit without any independent variables to calculate the intra-class correlation for states. Random intercept models were then fit with individual (level-1) and subsequently state (level-2) correlates. Model fit was assessed using deviance and Akaike information criterion (AIC). Sampling weights calculated for the provider-confirmed data were taken from the NIS-Teen data, which account for selection and non-response probability and were rescaled to account for the multi-level nature of the data according to best practice recommendations . Models Additionally, an analysis of education policy and broader-level factors on HPV vaccine completion rates was done. Sex and abstinence education policies were coded into four groups based on comprehensiveness of policy: (1) having both a sex and abstinence education policy (SA-YY), (2) having a sex education only policy and not an abstinence education policy (SA-YN), 3) not having a sex education policy and having an abstinence only education (SA-NY), and (4) not having either a sex and abstinence education policy (SS-NN)  and the District of Columbia (62.0%) had the highest HPV vaccine coverage rates in the United States. Those with the lowest HPV vaccine coverage rates in 2016 were Wyoming, Mississippi, South Carolina, Utah, and Texas. These states were found to be more conservative and highly religious than states with the highest coverage rates. Little variation among these states regarding education polices and vaccine exemptions was observed. . Gender, political ideology, religiosity, and sex education policy were not found to have similar impacts on Tdap and MMR vaccination rates as the HPV vaccine. See Table This multi-level analysis using state and national data found the significant predictors of HPV vaccine completion were the presence of an HPV vaccine mandate, religiosity, being female, and Hispanic or Black race/ethnicity. Although we expect race, gender, living below the poverty line, and maternal college education to be indicative of higher HPV vaccine completion rates, the effects of additional macro-level factors are important to consider in improving suboptimal HPV vaccine adherence. This suggests that a state’s sex and abstinence education policy, religiosity, and political ideology may be important correlates of HPV vaccine completion.Our analysis suggests an 11-fold decrease in HPV vaccine completion rates among states with a higher percentage of religious adults. Religion has been found to influence immunization decisions as several states have religious exemptions for school mandated vaccines. If parents are religiously opposed to immunizing their children against infectious disease such as tetanus or measles, the likelihood of vaccinating these teens for a sexually transmitted disease like HPV poses a challenge to vaccine completion rates. Although there is limited evidence, the role of religion has been found to guide decisions around certain health behaviors therefore influencing HPV vaccine acceptance and uptake , 34. As A study in Utah found that non-religious females were more likely to complete the HPV vaccine series (received 3 doses) than religious females . A similLittle is known about how strongly and consistently state-level polices impact HPV health outcomes, but these results indicate certain policies may impact HPV vaccine coverage rates. There is significant political opposition and criticism to enact legislation mandating HPV vaccination for adolescents , 37. As Despite strong support for abstinence-only education policies among some stakeholders,  it has bFurthermore, as shown in other studies, –45 our rThere are many factors that affect HPV vaccine completion rates as is not reliant on a single policy or individual-level characteristics. Gender, religiosity, political ideology, and education polices are independent predictors of HPV vaccine completion rates as they were not found to be present in Tdap and MMR vaccine completion models. Thus, further research should consider the complexity of the political and religious environment as well as other state-level policies must be considered when trying to the address the underutilization of this cancer prevention vaccine. Roberts et al. identified a combination of state-level policies associated with higher vaccine uptake, including Medicaid expansion, HPV vaccine school mandates, HPV vaccination through pharmacies, and sex education policies . This suThis analysis can also serve as an example showing how mis-implementation of an evidence-based cancer intervention is occurring. According to Padek et al., mis-implementation is the continuation of ineffective programs and policies or the discontinuation of effective ones . The impNext steps should explore current HPV vaccine-related policies and initiatives in states not having neither education policy to gain insight into other activities contributing to HPV vaccine completion rates. As states that enacted sex education policies were found to have the highest coverage rates among any policy combination, more study of the effects of comprehensive sex education to increase HPV vaccine coverage rates is supported.Although the governance of state health departments were not significant predictors of HPV vaccine completion rates, research to understand the role of state health departments on current efforts, barriers, and allocation of resources regarding cancer control programs is essential to identify the mis-implementation at a state-level. Considering and understanding the role of factors leading to mis-implementation of cancer control programs and policies regarding HPV vaccine can prevent missed opportunities to appropriately implement these efforts.Lastly, learning and further exploring elements that contribute to low and high vaccine coverage rates among states can inform the development of comprehensive HPV vaccine interventions and policies to increase the utilization of the HPV vaccine in the United States.We acknowledge that there are several limitations to this analysis. The cross-sectional nature of our study limits our ability to draw any firm conclusions on the macro-level contributing factors to low-HPV vaccine uptake. Evidence shows that provider-level recommendations has a significant influence on patient uptake of the vaccine –52.HowevDespite the study’s limitations, this analysis highlights the potential impacts of broader contextual factors effects on HPV vaccine coverage rates in the United States. found that in addition to individual-level correlates , policy, political ideology, and religiosity state-level factors are significant correlates of HPV vaccine completion rates. However, there is limited evidence on how these factors interact with each other within a state to promote HPV vaccine efforts. Further studies need to continue to identify state and local-level factors that contribute to HPV vaccine uptake and adherence as well as understand the underlying mechanisms of these factors within states of high and low HPV vaccine coverage rates. An in-depth case analysis of these states may provide insight on effective strategies, initiatives, and policies along with overcome challenges and barriers to serve as a guidance for other states and better inform HPV vaccine interventions.


TRIM37 mutations. TRIM37 is characterized by the presence of a RING domain, B-box motifs, and a coiled-coil region, and its C-terminal part includes the MATH domain specific to TRIM37. MULIBREY nanism is a rare autosomal recessive caused by TRIM37 mutations and characterized by severe pre- and postnatal growth failure. Constrictive pericarditis is the most serious anomaly of the disease and is present in about 20% of patients. The patients have a deregulation of glucose and lipid metabolism, including type 2 diabetes, fatty liver, and hypertension. Puzzlingly, MULIBREY patients, deficient for TRIM37, are plagued with numerous tumors. Among non-MULIBREY patients affected by cancer, a wide variety of cancers are associated with an overexpression of TRIM37. This suggests that normal cells need an optimal equilibrium in TRIM37 expression. Finding a way to keep that balance could lead to potential innovative drugs for MULIBREY nanism, including heart condition and carcinogenesis treatment.TRIpartite motif (TRIM) proteins are part of the largest subfamilies of E3 ligases that mediate the transfer of ubiquitin to substrate target proteins. In this review, we focus on TRIM37 in the normal cell and in pathological conditions, with an emphasis on the MULIBREY (MUscle-LIver-BRain-EYe) genetic disorder caused by  TRIM genes arose from a common ancestor and can be found in most eukaryotes. The tripartite motif is restricted to metazoans, and there is a wide variation between species in the number of TRIM proteins, which range from 78 in humans to much less in worms (20) and flies (10). This suggests an extensive adaption over time of the TRIM family in vertebrates and invertebrates, with an important maintenance throughout evolution together with an expansion of novel TRIM genes engaged in a wider diversity of functions.In 2001, Reymond et al. used functional genomic techniques to show that the TRIpartite motif (TRIM), with the presence of a RING domain, B-box motifs, and a coiled-coil region, defines a family of 37 proteins with common cellular functions and compartmentalization. These proteins were regrouped in the TRIM superfamily (TRIpartite motif) . The. The2]. TRIM37 mutations.TRIM proteins are implicated in many biological processes, including post-translational modifications, signal transduction, DNA repair, immunological signaling, autophagy, and oncogenesis, with the RING motif as an ubiquitin E3 ligase signature ,5. E3 ubTRIM37 gene is located in chromosome 17q22-23 and contains 25 exons, with one copy per haploid genome. The full genomic size is approximately 125 kb. The promoter region is G+C rich and TATA box less . The phenotype of MULIBREY nanism is variable and overlaps with others, such as the Silver–Russell syndrome or the 3M syndrome. Up to now, 135 cases of MULIBREY nanism have been reported in the literature. TRIM 37 is also known as the MULIBREY protein. MULIBREY nanism (muscle–liver–brain–eye) (MIM 253250) is a rare autosomal recessive disorder that affects several tissues of mesodermal origin, presenting with severe pre- and postnatal growth failure, characteristic dysmorphic features, but normal neurological development . MULIBREHeart manifestations, including constrictive pericarditis, myocardial fibrosis, and myocardial hypertrophy, constitute the main common heart diseases of MULIBREY syndrome. Lipsanen-Nyman et al. studied a cohort of 49 male patients and followed them for up to 25 years. Half of them had congestive heart failure, more than a third had pericardiectomy for constrictive pericarditis, and 20% had died of cardiac causes. Of the patients, 19 were pericardiectomized and 12 among them benefited from lasting clinical benefit. Congestive heart failure recurred in approximately one third of patients. Autopsies showed a fibrotic thickening of pericardial leaves with myocardial hypertrophy and myocardial fibrosis . RecentlMetabolic alterations are also associated with the disease. When subjected to a 3-h oral glucose tolerance test, the MULIBREY patients had a regulation of glucose and lipid metabolism that varied wildly with age. The youngest patients had low fasting glucose and low insulin levels, while a vast majority of the adults patients (aged >20 years) had high fasting and postload insulin values. Among adult patients, 92% presented either with type 2 diabetes (50%) or with impaired glucose tolerance (42%). Metabolic syndrome was found in 70% of the adult patients . There iTRIM37 knock-out mouse was described that recapitulates several features of the human disease. Mice were viable with normal weight until 12 months of age after which they experienced increasing weight loss, smaller skull size, with no difference in length of long bones. They presented with low fasting serum insulin level, elevated fasting blood glucose, enlarged and fatty liver, and cardiomyopathy.A Both sexes were infertile, with germ cell aplasia. Similar to MULIBREY patients, mice experienced a wide range of tumors . Mutations leading to changes in the ubiquitination activity are related to genetic diseases, immune response, cellular transformation, and inflammatory responses. One of the main roles of post-translational modifications performed by ubiquitination is to select the fate of various proteins. Proteins are either targeted to proteasome for degradation or to participate in cell signaling pathways. Inflammatory pathways are tightly regulated by ubiquitination, and the human ubiquitin-mediated inflammatory signaling system ensures regulation of inflammatory responses . DeregulTRIM37 mutations in MULIBREY patients could induce various immunity problems. The immune system must operate in an effective, precise, and safe manner to defend against diverse pathogens while avoiding attacking the body itself and commensal bacteria. Given the implication of TRIM37 in innate immunity described above, one could suspect that A MULIBREY female patient with humoral immunodeficiency displayed subnormal concentration of serum IgG2 and IgG4 and low concentration of serum IgM. In contrast, IgA and IgD were elevated . In young patients from North of France, we also found that IgM levels were decreased. Moreover, while the patients were vaccinated against tetanos, no vaccinal-specific Ig could be detected .TRIM37 KO mice are infertile [MULIBREY patients are plagued with numerous infertility problems. Girls experience a transient minipuberty during childhood with a high follicle-stimulating hormone (FSH) surge that is normally found during mid-menstrual cycle in adult women where it will be responsible for ovulation. More than half never menstruate and only 8% of adult women menstruate regularly. In addition, ovaries are hypoplastic . Concernnfertile . Infertinfertile  and femanfertile , is partRNA quality-control mechanism, named nonsense-mediated decay (NMD), recognizes and degrades mRNAs with premature translation termination codons . NMD preTRIM37 mutations are associated with a more frequent cancer diagnosis  is amplified in more than one third of breast cancers, and TRIM37 expression is increased in breast tumor. In contrast, the authors state that the major H2A ubiquitin ligase RNF2  is downregulated. TRIM37 is associated with polycomb repressive complex 2, while RNF2 is associated with polycomb repressive complex 1 (PRC1), Both cases result in the silencing of specific target genes. The decrease in TRIM37 results in loss of ubiquitinated H2A and therefore a decrease in tumor growth, while overexpression of TRIM37 induces tumorigenesis [The genomic region hosting the igenesis .Array comparative genomic hybridization in the 17q region identified highly frequent gain and loss of genetic material affecting more than 40% of ovarian cancers, suggesting that the MULIBREY gene is associated with ovarian tumorigenesis . TRIM37 TRIM37 was found to be one of the 44 genes indispensable for another part of cell division, the centriole formation [ormation . Centrioormation . Modificormation . The ubiormation . TRIM37 localizes to peroxisomes and nucleus with an E3 ubiquitin ligase activity as a main function . PeroxisTRIM37 overexpression and cancer. However, how patients with TRIM37 mutations have a high risk of developing tumors still remains a challenging problem. Protein quality control and protein degradation are regulated by the ubiquitination proteasome, the NF-κB system, and autophagy. Further characterization of the signaling pathways that modulate TRIM37 expression and activity should help to understand the large repertoire of human pathologies in which TRIM37 is involved. Finding a way to keep equilibrium in the cellular expression of TRIM37 could lead to potential therapeutic treatments and future drug discoveries for developmental anomalies and cancer.Dysregulation of TRIM proteins causes several types of diseases in humans. Inactivation of TRIM37 results in MULIBREY nanism and predisposes to both benign and malignant tumors, with several reports revealing a positive correlation between


CTTN, CCND1 and ANO1 genes mapping at the 11q13 amplicon in relation to the HPV status in HNSCC patients. CTTN, CCND1 and ANO1 protein expression and gene amplification were respectively analyzed by immunohistochemistry and real-time PCR in a homogeneous cohort of 392 surgically treated HNSCC patients. The results were further confirmed using an independent cohort of 279 HNSCC patients from The Cancer Genome Atlas (TCGA). The impact on patient survival was also evaluated. CTTN, CCND1 and ANO1 gene amplification and protein expression were frequent in HPV-negative tumors, while absent or rare in HPV-positive tumors. Using an independent validation cohort of 279 HNSCC patients, we consistently found that these three genes were frequently co-amplified (28%) and overexpressed (39–46%) in HPV-negative tumors, whereas almost absent in HPV-positive tumors. Remarkably, these alterations (in particular CTTN and ANO1 overexpression) were associated with poor prognosis. Taken together, the distinctive expression and amplification of these genes could cooperatively contribute to the differences in prognosis and clinical outcome between HPV-positive and HPV-negative tumors. These findings could serve as the basis to design more personalized therapeutic strategies for HNSCC patients.Clear differences have been established between head and neck squamous cell carcinomas (HNSCC) depending on human papillomavirus (HPV) infection status. This study specifically investigated the status of the  Head and neck cancer represents a heterogeneous group of tumors that accounts for about 5% of the total annual worldwide cases of cancer, usually associated with poor prognosis ,2; howevThe proportion of HPV-related oropharyngeal tumors can vary considerably among regions; the observed prevalence in Europe varies from an estimated 17% in southern countries to as high as 93% in northern countries like Sweden . More thRecent studies have consistently showed that HPV-related (HPV+) and unrelated (HPV−) tumors represent two different entities in terms of clinical, biological, and molecular characteristics. Thus, HPV-positive tumors generally arise in the oropharynx, have a more favorable prognosis, a better response to chemotherapy and radiotherapy, and less genetic alterations when compared to HPV-negative tumors ,4,5,6.CTTN (Cortactin), CCND1 (Cyclin D1), and the more recently discovered ANO1 (Anoctamin-1). CTTN and CCND1 are well-established oncogenes, associated with advanced disease stage and poor prognosis [ANO1 encodes a calcium-activated transmembrane chloride channel whose overexpression and amplification have been correlated with increased cell migration and propensity to develop metastases [ANO1 in HNSCC have only recently emerged and, hence, are still limited.One of the most frequent genetic alterations found in HNSCCs is the amplification of the chromosomal region 11q13, which has been associated with tumor aggressive behavior, increased lymph node metastases, and poor outcome . Moreoverognosis ,9. On thtastases ,11. HoweANO1, we believe it is crucial to study in depth the molecular alterations involved in HNSCC and their relationship with HPV infection, in order to have a better understanding of the pathogenesis of the disease with the ultimate goal of establishing the path for the development of new and more effective treatment strategies. This consideration prompted us to study the status of various genes  mapping at the 11q13 amplicon in relation to HPV infection in two large independent cohorts of HNSCC patients.Recent studies have evidenced important differences in the molecular alterations and the impact of the 11q13 chromosomal region in HNSCC, depending on the anatomic site of the tumor and the HPV infection status. These studies suggest that the amplification of 11q13 in HNSCCs is more frequent in HPV-negative than in HPV-positive tumors , and thiSurgical tissue specimens from 392 patients with HNSCC who underwent resection of their tumors at the Hospital Universitario Central de Asturias and Hospital Sant Pau between 1990 and 2010 were retrospectively collected, in accordance to approved institutional review board guidelines. All experimental protocols were conducted in accordance to the Declaration of Helsinki and approved by the Institutional Ethics Committees of the Hospital Universitario Central de Asturias and Hospital Sant Pau and by the Regional CEIC from Principado de Asturias . Informed consent was obtained from all patients. Representative tissue sections were obtained from archival, paraffin-embedded blocks, and the histological diagnoses were confirmed by an experienced pathologist (Aurora Astudillo). Clinical, sociodemographic, follow-up, and risk factors information was collected from the medical records. The stage of the tumors was determined according to the TNM system of the International Union Against Cancer (7th Edition). The original archived hematoxylin- and eosin-stained slides were reviewed by an experienced pathologist (Aurora Astudillo) to confirm the histological diagnoses. Five morphologically representative areas were selected from each individual tumor paraffin block: two for DNA isolation and three for the construction of a TMA. To avoid cross-contamination, two punches of 2 mm diameter were taken first, using a new, sterile punch  for every tissue block, and stored in eppendorf tubes  at room temperature. Subsequently, three representative tissue cores (1 mm diameter punches) were selected from each tumor block and transferred to a recipient ‘Master’ block in a grid-like manner using a manual tissue microarray instrument to construct TMA blocks, as described previously ,14. In aThe protocol for DNA extraction from paraffin-embedded tissue sections has been described elsewhere . BrieflyThe algorithm used to detect the presence of HPV in these patients has been previously described in detail ,15. BrieCCND1 gene, Fw, 5′-GGAAGATCGTCGCCACCTG-3′ and Rv, 5′- GAAACGTGGGTCTGGGCAAC-3′; for ANO1 gene, Fw, 5′-CAAAGGCAGGTGCTTTGCA-3′ and Rv, 5′-TCTACGGGCCTCTGCTCACT-3′; for CTTN gene, Fw, 5′-GATCTCATTTGACCCTGATGACATC-3′ and Rv, 5′-CGTACCGGCCCTTGCA-3′; and for the reference gene TH , Fw, 5′-TGAGATTCGGGCCTTCGA-3′ and Rv, 5′-GACACGAAGTAGACTGACTGGTACGT-3′. Dissociation curve analysis of all PCR products showed a single sharp peak, and the correct size of each amplified product was confirmed by agarose gel electrophoresis. The relative gene copy number was calculated using the 2CT-ΔΔ method, as we previously described [CT represents the difference between the paired tissue samples , with ΔCT being the average CT for each target gene minus the average CT for the reference gene (TH). Relative copy numbers ≥2-fold were considered gene gain, and relative copy numbers ≥4-fold were considered positive for gene amplification.Gene amplification was evaluated by real-time PCR (Q-PCR) in an ABI PRISM 7500 Sequence detector  using Power SYBR Green PCR Master Mix and oligonucleotides designed according to Primer Express software v2.0  with the following sequences: for escribed ,17. The The formalin-fixed, paraffin-embedded tissues were cut into 3-µm sections and dried on Flex IHC microscope slides . The sections were deparaffinized with standard xylene and hydrated through graded alcohols into water. Antigen retrieval was performed using Envision Flex Target Retrieval solution, high pH . Staining was done at room temperature on an automatic staining workstation (Dako Autostainer Plus) with mouse anti-Cyclin D1 monoclonal antibody DCS-6  at 1:100 dilution, rabbit polyclonal Anti-TMEM16A antibody (Abcam # ab53212) at 1:500 dilution, or mouse anti-cortactin monoclonal antibody Clone 30  at 1:200 dilution, using the Dako EnVision Flex + Visualization System (Dako Autostainer). Counterstaining with hematoxylin was the final step. The slides were viewed randomly without clinical data by two of the authors, according to the scoring systems previously described ,18 with p values ≤0.05 were considered to be statistically significant. Fisher’s exact test was used for comparison between categorical variables, and t Student test for parametric continuous variables. Correlations between protein expression, gene amplification, and HPV status were estimated by Kendall‘s tau correlation test. All tests were two-sided; A large cohort of 392 homogeneous surgically treated HNSCC patients was selected for study. A flow diagram of the experimental setup is shown in We found that 67 cases (17%) showed nuclear and cytoplasmic p16 expression, a surrogate marker for HPV infection (2) . HPV DNACCND1, ANO1, and CTTN gene gain and amplification was assessed by real-time PCR in 88 cases selected from the same HNSCC tissue blocks, including 26 HPV-positive cases. We found gene gains and amplifications of CCND1 in 32 (36%) tumors, ANO1 in 42 (48%) tumors, and CTTN in 26 (30%) tumors , while absent in HPV-positive tumors.) tumors , with re) tumors . When anV status . Thus, ahttp://cbioportal.org/) [CTTN, CCND1 and ANO1 depending on HPV infection status. Thus, increased mRNA expression levels of these genes were frequently and significantly observed in HPV-negative tumors   . The clie tumors A–D, while tumors . Similare tumors A,E. Furtn = 530) .The incidence of HPV-related HNSCC is currently increasing and gaining importance, while tumors associated to tobacco and alcohol consumption are declining ,5. RecenCTTN, CCND1, and ANO1 genes mapping within this locus. Immunohistochemical analysis of CCND1, CTTN, and ANO1 revealed that the expression of these three proteins was strongly and inversely correlated with HPV infection. Noteworthy, all the HPV-positive cases showed negative ANO1 expression, and 28 out of 30 HPV-positive cases had also negative CTTN expression. Likewise, the analysis of gene copy amplification by real-time PCR consistently showed that amplifications of CTTN, CCND1 and ANO1 were frequently detected in HPV-negative tumors (ranging from 42 to 61%), while absent or rare in HPV-positive tumors (0–15%). Mechanistically, we found that the contribution of gene amplification to protein expression varied widely depending on each gene. Even though tumors harboring amplification also concomitantly expressed high protein levels, positive CCND1 and CTTN expression occurred at a higher frequency than gene amplification, while ANO1 protein expression was less frequent than ANO1 gene amplification. Additional regulatory mechanisms  should contribute to protein expression, as previously reported [Given the importance of the 11q13 locus in HNSCC and to contribute to the molecular characterization of these tumors, we conducted a study on a large unbiased cohort of 392 homogeneous surgically treated HNSCC patients to investigate the role of 11q13 amplification in relation to HPV status. This was accomplished by assessing the specific relationship of the protein expression and amplification of the reported . A limitet al. [CCND1, CTTN and ANO1 genes between HPV-related and unrelated tumors. It is worth mentioning that the two HNSCC cohorts selected for study are representative, sharing multiple of the unique characteristics reported for HPV-positive tumors [et al. [These results were further and significantly validated using an independent cohort of 279 TCGA HNSCC patients, thus confirming that the mRNA expression levels of CCND1, CTTN, and ANO1 were significantly increased in a high proportion of HPV-negative tumors, whereas most HPV-positive patients exhibited normal mRNA levels of all these genes. Similar observations were obtained by analyzing the frequencies of copy number alterations. These findings are also consistent with some studies that reported that 11q13 amplifications and gains were less frequent in HPV-related tumors . This iset al.  that, in [et al.  providedCCND1, CTTN and ANO1 genes within the 11q13 amplicon could play a significant role in HPV-negative tumors but not in HPV-positive tumors. Given that 11q13 amplification has been associated with poor prognosis in HNSCC patients, and, in particular, these three genes have been involved in tumor progression and resistance to radio-, chemotherapy [ORAOV1, CPT1A, SHANK2 and PPFIA1) as important drivers of 11q13 amplification that showed an impact on prognosis [Together, these findings suggest that the otherapy ,24,25,26otherapy , the herrognosis . TherefoCTTN, CCND1 and ANO1 amplification and overexpression were frequent in HPV-negative tumors and correlated with reduced patient survival, while absent or very rare in HPV-positive tumors. Therefore, these molecular alterations could contribute to the distinct clinical outcomes of these two HNSCC entities and serve as the basis to design more personalized therapeutic strategies for HNSCC patients.


Despite the high prevalences of Human Papilloma Virus (HPV) infections and cervical cancer in Nigeria, utilization of the HPV vaccine as a highly effective preventive measure remains low. The aim of this study was to find out the awareness and attitudes of caregivers to HPV infections and the factors that determine acceptance of an HPV vaccine for their pre-adolescent girls.This was a cross-sectional descriptive study of 508 caregivers of female children in Enugu Nigeria. A semi-structured questionnaire was used to collect information on knowledge of HPV, cervical cancer as well HPV vaccine and its acceptance for pre-adolescent female children. The data was analysed using descriptive statistics.Five hundred and eight (508) caregivers of female children were interviewed. Less than half, 221,(43.5%) of them knew about HPV, among these, 163 knew how HPV is transmitted. Only 12 (2.4%) of the caregivers know that an HPV infection is a major risk factor for cervical cancer. Among the 221 participants who knew the meaning of HPV, 132 (59.7%) were aware of an HPV vaccine. Only 26 (19.7%) of those aware of a vaccine agreed it can effectively prevent cervical cancer. Lack of awareness about the vaccine and accessibility were the major reasons given by parents on why the vaccine has not been received by their female children.Despite high levels of education, awareness of HPV, HPV vaccine and the risks for cervical cancer remains low among caregivers in Enugu, south-east, Nigeria. Awareness and accessibility were the major determinants of HPV vaccine uptake among the caregivers. There is a need for massive and sustained awareness creation to increase HPV vaccination uptake in Nigeria. Human Papilloma Virus (HPV) is the most common sexually transmitted virus and it is estimated that about 75% of sexually active women and men will acquire a genital HPV infection at some time . HPV is There has been an increasing interest in HPV because of their relationship with tumours particularly cervical. Epidemiological, molecular and clinical evidence has shown that cervical cancer is caused by HPV. About 13genotypes are closely linked with cervical cancer especially genotypes 16 and 18 . High riGlobally, cervical cancer is a major public health problem. Over 560,000 new cases and about 275,000 deaths are recorded each year, with more than 80% occurring in developing countries , 14. It Cervical cancer is the second most common cancer in Nigeria and second to breast cancer among its female population –21. In 2A large number of European countries as well as United States, Australia and New Zealand have recommended including an HPV vaccine in the school vaccination program for young adolescent girls, often coupled with a catch-up program for older teenage girls , 26. TheThe knowledge of HPV infections and HPV vaccines, among the Nigeria population, are inadequate, and the cost of HPV vaccination per person is beyond what the average Nigerian can afford –36.Awareness and knowledge of the infections and the vaccines would stimulate demand and uptake of the vaccines. Increasing demand may drive the introduction of the vaccine into the national immunization schedule thereby making the vaccine more affordable and accessible.The aim of this study was to find out the knowledge and attitudes of parents to and the factors that determine the demand of HPV vaccine for their adolescent girls. This study was focused on the usefulness of HPV Vaccine as a preventive measure for the reduction of the incidence of cervical cancer hence the focus only on adolescent girls.This was a cross-sectional descriptive study of 508 parents/caregivers of young children from primary schools in the three Local government councils of Enugu metropolis- Enugu-South, Enugu- North and Enugu-East. Fifteen primary schools were  were randomly selected for the study. The researchers attended the Parents- Teachers forum of these schools. During the meeting, the researchers introduced themselves and the purpose of their research. They were then granted permission to administer the questionnaire to consenting parents of female children. Every eligible caregiver of a female child less than 18 years was recruited into the study. The data was collected consecutively from school to school. Data was collected between the months of January and July 2017. Data collection tool was semi-structured questionnaire reviewed by a panel of experts for validity. The questionnaire was either self-administered or interviewer-administered for study participants who were not literate. Items on the questionnaire include; socio-demographic variables; knowledge of cervical cancer; knowledge of HPV infections and HPV vaccines, their attitudes towards the effectiveness of the vaccines and reason (s) for uptake or otherwise of these vaccines for their adolescent girls. The data was analysed using descriptive statistics.A total of 508 caregivers were interviewed out of which 476 (93.7%) were below the age of 50 years. 385 (75.8%) were females and 123 (24.2%) males. Out of the 508 caregivers, 218 (42.9%) had more than one female child. The mean age of the children of the respondents was 7.3 years (SD + − 5.3) Three hundred and forty-seven (68.3%) had tertiary level of education while only 30 (5.9%) had no formal education. Three hundred and thirty (65%) caregivers were married  parents knew what HPV meant, among these, 163(74%) knew how it is transmitted  of the parents who were aware of HPV knew the risk factors for genital HPV infections while a total of 66 30%) of these knew that the risk of developing invasive cervical cancer is the major “sequale” following HPV infection (Tables 0% of theAlthough 361(71%) of the respondents have heard about cancer of the cervix, 65% of them did not know what it means. Only 12 out of the 221(5.4%) participants that know about HPV are aware that it is risk factor for developing cervical cancer. These 12 were part of the 66 who identified that risk of developing cervical cancer as a sequale of genital HPV infections  were aware of HPV vaccine. Furthermore, of the 132 participants who are aware of the HPV vaccine; only 26 (19.7%) agree that HPV vaccine can effectively prevent cervical cancer; 59(44.7%) didn’t think so while 47(35.6%) had no idea.Among those aware of the vaccine, 72 (54.5%) do not know what ages the HPV vaccine should be administered and only 6(2.75%) of the parents had given HPV vaccine to their eligible female children.The major reasons given by parents/caregivers for not giving HPV vaccine to their eligible children were that they were not aware of the vaccine (74.1%) and inability to access the vaccine among those aware of it. (72.5%) Table .Table 6RIt was observed that many the study participants had formal education. The finding that 68.3% of the respondents had tertiary level of education signifies a high literacy level. However, despite this, awareness of cancer of cervix amongst them was low. This finding is similar to other studies in Nigeria, among women with similar social characteristics  where only a small proportion of respondents knew about the disease despite high levels of literacy , 36. HowAwareness about HPV infection was also low in this study; very few caregivers knew the risk factors for HPV infection as well as the relationship between HPV infection and cervical cancer. This may be because it is not part of routine health talks at ante-natal or immunization sessions. These are the major places where most mothers get health information in this environment with limited access to internet and electricity. Similar finding of low awareness about HPV were also found in Lagos and Malaysia where only less than half of the mothers with similar educational attainment were aware of HPV disease . HoweverPrimary prevention of cervical cancer can be achieved through prevention and control of genital infection with oncogenic HPV types . OncogenThis study is similar to a number of other studies which have shown that awareness of the vaccine is also very low , 34, 35.As much as 45% of those aware of the vaccine do not agree that HPV vaccine can effectively prevent cervical cancer. Cost of the vaccine, concerns about the effectiveness and safety of the vaccine were reasonsgiven by the caregivers for poor uptake of HPV vaccines. Previous studies –36 have Awareness campaigns in places like ante-natal clinics, parents-teachers forums of schools etc., particularly amongst caregivers of young female children is pivotal to improving uptake of HPV vaccination and reducing incidence of cervical cancer in Nigeria. Governments should subsidize and include the HPV vaccine in National immunization schedules to encourage uptake and subsequently reduce the incidence of cervical cancer.Despite high levels of education, the following, awareness of HPV infections and cervical cancer, and their related risk factors and HPV vaccines were low among caregivers of female children in Enugu, south-East, Nigeria.Similarly history of HPV vaccination among the children of the respondents was low, accessibility and affordability was the most common challenge among those aware of the vaccine. There is a need for massive and sustained awareness creation to step up HPV vaccination in Nigeria.


Sexually transmitted Human Papilloma Virus (HPV) infection is a known risk factor for cancer of the anal canal in both men and women.We describe a report of synchronous carcinoma of the anal canal in a heterosexual couple. High risk type 16 HPV DNA was detected in both tumors.Longstanding sexual partners may share risk of HPV-associated anal canal cancer. Over 8,000 new cases of cancer of the anal canal are expected in the United States in 2017, with 2/3 of them in women –6. Men wA 60-year-old woman sought medical attention after a 2-month history of minor rectal bleeding and an anal nodule. On physical examination, a 3-cm mobile anterior ulcerative mass in the anal canal was palpable, beginning at 1 cm from the anal verge with no extension to the anorectal junction. No nodes were appreciated in the inguinal regions. A biopsy revealed an invasive squamous cell carcinoma, well-differentiated Fig. . StagingThe patient had a past medical history remarkable for an in-situ cervical carcinoma treated with laser therapy over 20 years ago with no subsequent recurrence. She also underwent a right salpingo-oophorectomy for an endometriotic cyst of the right ovary 8 years prior to her anal canal cancer diagnosis. She is a life-time non-smoker and social alcohol drinker. There was no past history of any autoimmune disorders.2 on day 1) and infusional 5-fluorouracil (1000 mg/m2/day for 4 days), given concurrently on week 1 and week 5 of radiation. The patient developed RTOG grade 3 skin and perineal reactions. She had an episode of fever without neutropenia managed by oral antibiotics.For her T2N0M0 anal cancer, the patient underwent a course of chemo-radiotherapy as per institutional protocol. The total dose was 54 Gy in 30 daily fractions to the primary and elective nodal irradiation consisted of 36 Gy in 20 fractions to the inguinal/femoral, mesorectal, presacral and external/internal iliac nodal regions. The radiation treatment was delivered using volumetric modulated arch therapy (VMAT) technique. The chemotherapy regimen consisted of mitomycin C (10 mg/mWhile the female was undergoing chemoradiation, her husband, with whom she has been married for over 30 years, requested a screening colonoscopy during his regular urological follow-up. The investigation revealed an anal mass that was biopsied and demonstrated a poorly-differentiated squamous cell carcinoma with prominent lymphoid infiltration Fig. . This 63This patient was treated with the same institutional protocol of chemoradiation for his T2 N2 anal cancer with a total dose of 54 Gy to the primary and the involved nodes plus concurrent chemotherapy with 5-fluorouracil and mitomycin C. The elective nodal irradiation dose was 36 Gy. The patient developed neutropenia and thrombocytopenia, diarrhea, oral mucositis and the usual perianal/perineal skin reaction.The immunohistochemical profiles of both the wife’s and husband’s lesions were similar. Both tumours demonstrated diffuse and strong immunoreactivity for p16 Fig. -d suggesTwo-thirds of anal canal cancer cases are seen in females and the incidence among men is about 20 times higher in men who have sex with men . TherefoThis report brings to light two interesting points. First, the route of HPV transmission to the anal canal in men who do not have receptive anal sex is not yet fully understood. One possible route of transmission is self-contamination from genital or perianal sites that may occur with either sexual or non-sexual behavior. An association between genital and anal canal HPV co-infection has been described . In factThe second learning point illustrated by this report of the 2 cases relates to the theoretical higher risk of development of HPV-related cancers in partners of patients with cancers associated with this virus. Recently, a systematic review suggested a 2–3 fold increase risk of HPV-related cancer in spouses of patients with previous HPV-related malignancies . SimilarAnal canal cancer is an uncommon entity that most frequently affects women or men who have sex with men. This report suggests that men who have sex with women may be at risk of cancer of the anal region. In conclusion, both male and female partners of patients with HPV-related cancers are at increased risk of malignancies associated with this virus, including carcinoma of the anal canal.