HPV account for most of the incidence of cervical cancer. Approximately 90% of anal cancers and a smaller subset (<50%) of other cancers  are also attributed to HPV. The L1 protein comprising HPV vaccine formulations elicits high-titre neutralizing antibodies and confers type restricted protection. The L2 protein is a promising candidate for a broadly protective HPV vaccine. In our previous study, we found the most prevalent high-risk HPV infectious serotypes were HPV-16 and HPV-58 among women of Southwest China. To explore gene polymorphisms and intratypic variations of HPV-16 and HPV-58 L1/L2 genes originating in Southwest China, HPV-16  and HPV-58  L1/L2 genes were sequenced and compared to others described and submitted to GenBank. Phylogenetic trees were then constructed by Neighbor-Joining and the Kimura 2-parameters methods (MEGA software), followed by an analysis of the diversity of secondary structure. Then selection pressures acting on the L1/L2 genes were estimated by PAML software. Twenty-nine single nucleotide changes were observed in HPV-16 L1 sequences with 16/29 non-synonymous mutations and 13/29 synonymous mutations . Seventeen single nucleotide changes were observed in HPV-16 L2 sequences with 8/17 non-synonymous mutations (one in beta turn) and 9/17 synonymous mutations. Twenty-four single nucleotide changes were observed in HPV-58 L1 sequences with 10/24 non-synonymous mutations and 14/24 synonymous mutations . Seven single nucleotide changes were observed in HPV-58 L2 sequences with 4/7 non-synonymous mutations and 3/7 synonymous mutations. The result of selective pressure analysis showed that most of these mutations were of positive selection. This study may help understand the intrinsic geographical relatedness and biological differences of HPV-16/HPV-58 and contributes further to research on their infectivity, pathogenicity, and vaccine strategy. Human Papillomavirus (HPV) virions are one of the most important pathogenic agents for cervical cancer, which accounts for a worldwide cancer burden in women second only to breast cancer The HPV genome is packaged within a non-enveloped, icosahedral capsid composed of 72 pentamers of the major capsid late protein (L1) and an unknown number of the minor capsid proteins L2 The inner conical hollow of L1 pentamers can be occluded with a monomer of L2 Due to the high prevalence of HPV not only among asymptomatic women but also in samples of different neoplasias worldwide, the association between intratypical variants of HPV-16 L1 has been described in several papers. Nevertheless, data concerning molecular variants of HPV-16 and HPV-58 L2 are still limited, necessitating further studies that would be essential to expand knowledge of the different variants. Furthermore, there is little data regarding the intratypical variants of HPV-16 L1 in Southwest China.The aim of this study is to detect the nucleotide variability, gene polymorphism and phylogeny in the L1 and L2 genes of the High-Risk HPV-16  and HPV-58  samples obtained from Southwest China. The most variable sequences were chosen for an analysis of the diversity of their secondary structure. Nucleotide and amino acid sequence alignments were used to evaluate variant clusters. Amino acid changes of L1 and L2 genes might affect immune responses to HPV-16 and HPV-58 capsid proteins and advance HPV vaccine strategies. The genomic characterization of HPV variants is pivotal for a deeper understanding of the intrinsic geographical relatedness and biological differences of these viruses and contributes further to research on their infectivity and pathogenicity.Written consent was obtained from each participant. The study protocol was approved by the institutional ethics committee  and was in accordance with the Declaration of Helsinki for Human Research of 1974 (last modified in 2000).Samples examined in this study were obtained from cervical scrapings of 3000 volunteer outpatients from women in Southwest China from 2009 to 2011. After routine cytology and HC2 testing, a cell suspension from each sample was placed in a 1.5 mL Eppendorf tube and transferred to a laboratory at the Institute of Medical Biology for HPV DNA amplification. HPV typing of these specimens was performed using a nested multiplex PCR assay as described previously Molecular characterization was performed by sequence analysis of L1 and L2 gene amplicons. The entire region of L1 and L2 genes of HPV-16 and HPV-58 were amplified using degenerate primer pairs. Two partially overlapping fragments for each virus were amplified. All Primers were designed and synthesized by Sangon Biotech (Shanghai). The GeneBank reference sequences used for primer design were HPV-16 NC001526  and HPV-http://www.ncbi.nim.nih.gov/GenBank/index.html): JX313693-JX313793. The reference viral sequences that were used to construct the distinct phylogenetic branches were collected from the GenBank sequence database under the following accession numbers: HPV-16: AY686580, FJ006723 , AY686581, EU118173, AF534061, U89348, AF536179, AF472508, AF536180, AF472509, and AY686579 All sequences from a given sample were combined and used to construct alignments. ClustalX (version 1.83) multiple sequence alignment analysis was carried out to calculate the percentage of sequence similarity between the L1/L2 amplicons and the representative sequences of the HPV-16 and HPV-58 variants. Phylogenetic trees of respective HPV-16 and HPV-58 L1 and L2 sequences were constructed by the Neighbor-Joining method L1 HPV-16 sequences were determined and analyzed by aligning L1 1596 nucleotide sequences from all viral strains . The neighbor joining phylogenetic tree can be seen in http://npsa-pbil.ibcp.fr/cgi-bin/npsa_automat.). 1 of 31 sequences did not belong to any standard type branch  were synonymous mutations and 16/29 (55.2%) were non-synonymous mutations. Of the 6 amino acid mutations observed in the sequences encoding the alpha helix, only one was a non-synonymous mutation. 2 non-synonymous mutations were observed in the sequences encoding the beta turn (glycine to arginine) . The neighbor joining phylogenetic tree can be seen in Seventeen single nucleotide changes were identified among the sequences studied. Specially, 9/17 (52.9%) were synonymous mutations and 8/17 (47.1%) were non-synonymous mutations. No amino acid changes were discovered at residues 65–71 and 112–120, which play a important role in inducing neutralizing antibodies Insertion and deletion events were not present and there was no evidence of premature stop codons or nucleotide deletions within the L2 HPV-16 analyzed sequences.L1 HPV-58 sequences were determined and analyzed by aligning L1 1575 nucleotide sequences from all viral strains . The neighbor joining phylogenetic tree can be seen in Twenty-four single nucleotide changes were identified among the sequences studied. Specifically, 14/24 (58.3%) were synonymous mutations and 10/24 (41.7%) were non synonymous mutations. 8 amino acid mutations (four non-synonymous) occurred in the sequences encoding the alpha helix, and 4 mutations were observed in the sequences encoding the beta turn with 2 being non-synonymous. 8 samples were found to have the same mutation from C to A at position 1124. The detected mutations are summarized in Compared to prototype HPV sequences, neither frame shifts, premature stop codons, insertions nor deletions were observed in the L1 HPV-58 analyzed sequences.L2 HPV-58 sequences were determined and analyzed by aligning L2 1419 nucleotide sequences from all viral strains . The neighbor joining phylogenetic tree can be seen in Seven single nucleotide changes were identified among the sequences studied. Specifically, 3/7 (42.9%) were synonymous mutations and 4/7 (57.1%) were non-synonymous mutations. No amino acid changes were observed at residues 65–71 and 112–120, which play an important role in inducing neutralizing antibodies. No amino acid mutations occurred in the sequences encoding the alpha helix and beta turn, but 6 mutations were found in the random coil, and one in the extended strand. The detected mutations are summarized in Insertion and deletion events were not identified and there was no evidence of premature stop codons or nucleotide deletions in the L2 HPV-58 sequences analyzed.We tested for variable dN/dS rate ratios among various lineages using the PAML4.0 Human papillomavirus (HPV) vaccines against L1 are now licensed in more than 100 countries. National and regional immunization programs aimed at young adolescent girls have been widely implemented, and include catch-up programs in some countries up to the age of 18 years or older. However these vaccines target only two of the 15 high-risk HPV types, responsible for 70–80% of cervical cancer cases. The prevention of 96% of cervical cancer would require immunity against at least 7 high risk HPV types  Among 3000 volunteer outpatients investigated in our early study between 2009 and 2011, 646 cases were HPV positive, for a rate of 21.5%. Among the 646 positive samples, 476 cases were of the high risk type , while 170 cases were of the low risk type . The most common HPV high risk subtypes in Southwest China among female reproductive tract infections were HPV-16, 58,18, 31, 33, and 35. The most common low risk subtypes were HPV-6, 11, and 81. Among 476 high risk type positive samples, HPV-16 and 58 were the main high risk subtypes. HPV-16 comprised 217 cases ; HPV-58 145 cases . HPV-16 and HPV-58 comprised 362 cases , while all the other high risk subtypes including HPV33,35,18,31,59,66 comprised only 114 cases  HPV-16 is the most prevalent high-risk types of HPV worldwide, and also the type that is most frequently associated with cancer Based on previous research of other research group and us, we chose HPV-16  and HPV-58  samples to explore the intratype variations, construct their phylogenetic trees and estimate selection pressures acting on the L1 and L2 genes in our current study.It is reported that specific intratype HPV genome variations may be related to virus infectivity, pathogenicity, progression to cervical cancer, viral particle assembly and host immune response The neighbor joining phylogenetic tree results showed that the L1 and L2 of HPV-16 and HPV-58 are distributed in two or three standard branches, not in one specific branch. Most HPV-58 L1 and L2 sequences fell into D90400 (Japan), EU918765, HQ537760 (isolate AS347), which belong to the Asian and the European branches. Some mutations occurred in the sequences encoding the alpha helix and beta turn, which influence protein secondary structure. The function of these mutations still needs further investigations. In this study, the most common mutation of HPV-16 L1 was A979C (T327P). This position located in a major common B cell epitope peptide in both mice and humans, which might affect the immunogenicity of HPV-16 L1 From the result of selective pressure analysis we conclude that most mutations of HPV-16 and HPV-58 L1 and L2 were of positive selection, which indicated that these amino acid changes were beneficial to accommodate the human papillomavirus to its environment.The L1 and L2 of HPV-16 and HPV-58 had a low rate of nucleotide changes, something that could be attributed to the fact that HPV uses the host cell's DNA replication machinery, which is characterized by proofreading capacity and post replication repair mechanisms Nucleotide substitutions in viral genomes may affect virus assembly, carcinogenic potential, and host immunologic responses


As fibrosis and melanosis are often seen in malignant melanoma, the presence of dermoscopic signs of regression may represent a clue for the diagnosis of malignancy. Our aim was to assess the frequency and extent of 11 dermoscopic features of regression evaluating dermoscopic images of 111 melanomas in situ (MIS). Regression structures  were present in 80.1% of the lesions. Approximately 80% of the lesions showed regression of dermoscopic structures and light brown areas. Most lesions showed the presence of grey-blue areas (74.7%), whereas peppering was observable in 30.6% of MIS. Areas of fibrosis were mainly observable as structureless areas with a pinkish hue (50.4%). Based on our data, the reticular pattern of blue regression and light brown areas can be considered a significant discriminator and a reliable predictor of MIS. White lesions , whereas lesions –8. Lesio lesions . The aimThe study population included 111 consecutive lesions, excised at the Department of Dermatology of the University of Modena in the years 2003–2009, where we assessed the presence or absence of 11 parameters of regression . The derDermoscopic descriptors. Regression was considered present when grey-blue areas, peppering, blue-whitish veil, and/or white areas were present. Grey-blue areas were further described as being globular, reticular, or structureless . “GlobulAbsolute and relative frequencies of the observations were obtained for each regression parameter. Absolute and relative frequencies of lesions showing only one or a combination of the evaluated dermoscopic features were calculated on the number of lesions presenting regression. The study included a total of 111 melanocytic lesions diagnosed as MIS according to conventional histopathological criteria. These were located on the trunk and limbs of 110 patients .When subdividing our cases according to the diameter of the lesion, we observed a higher percentage of lesions showing regression, in particular grey-grey-blue areas and white/pink structures, in MIS with a diameter >1 cm . Blue-white structures, corresponding to histological regression phenomena, are one of the most interesting dermoscopic features commonly seen in melanomas and represent a clue for the diagnosis , 11–16.  In our previously published paper, comparing the dermoscopic features of regression in equivocal lesions, MIS, and invasive MMs, we found that regression is not only more frequent and extensive in invasive MMs with respect to in situ lesions, but it also has a different morphological expression . In the present study, features of regression were re-evaluated on 111 lesions histologically diagnosed as MIS, assessing the extent, the morphology, and the correlation of regression features, also according to the diameter of the lesion. The results substantially confirm the data we obtained in the previous study: regression structures were present in 80% of cases and were mainly represented by grey-blue areas with a reticular pattern and structureless light brown pigmentation. Grey-blue areas can represent the only expression of regression features, or, less frequently, they can be associated to peppering. Unlike in our previous study, the presence of the blue-whitish veil was only considered when the lesion was clinically palpable; therefore, only few lesions with this feature were identified by our evaluation.We also observed that regression features, as expressed by the presence of grey-blue areas and white/pink structures are more frequently observable in large lesions indicating that the regression process evolves with the radial growth of the MM. In MIS, grey-grey-blue areas are presumably due to a deep melanophagic infiltration. Light brown areas may represent the start of the regression phenomenon, followed by a disarrangement later expressed by reticular blue structures. In lesion zones of MIS corresponding to light brown areas, the disappearance of the rete ridges and the scarcity of intraepidermal melanin may explain the lack of an evident pigment network and the light brown diffuse pigmentation . In conclusion, our study provides data about frequency, morphology, extent, and distribution of regression in a large population of MIS of different size. Confirming the findings of our previous paper, we can state that the identification of the reticular pattern of blue regression is a significant discriminator and a reliable predictor of MIS, extremely useful for the diagnosis of early melanoma.


Although cervical cytology screening has decreased the incidence of cervical cancer in industrialized countries, HPV-related cervical disease, including premalignant and malignant lesions, continues to represent a major burden on the health care system. Some of the problems include the potential for either under- or overtreatment of women due to decreased specificity of screening tests as well as significant interobserver variability in the diagnosis of cervical dysplastic lesions. Although not completely elucidated, the HPV-driven molecular mechanisms underlying the development of cervical lesions have provided a number of potential biomarkers for both diagnostic and prognostic use in the clinical management of these women. Cervical cancer remains a leading cause of morbidity and mortality worldwide, with an estimated incidence of 470,000 . Approxin = 1921), the prevalence of high risk HPVs was 15.2%. Furthermore, there was a marked peak in HR-HPV infection in women between the ages of 20 and 24, with a prevalence of 29% [The association between cervical premalignant and malignant epithelial lesions and human papillomaviruses (HPV) has been well established , 7. There of 29% . The vase of 29% , 12. If e of 29% . This unHistological examination of colposcopy-guided biopsies is still considered the “gold standard” in the assessment of cervical lesions; however, the histologic assessment of these lesions is limited to the interpretation of the morphology, with little to no information regarding the risk of persistence, progression, or regression. In addition, histologic assessment of cervical lesions is complicated by interobserver variability . The maiHuman papillomaviruses (HPVs) are a diverse group of viruses (numbering more than 100) that can infect numerous epithelial sites and cause a variety of epithelial lesions, including common warts, verrucas, laryngeal papillomas, and genital condylomata, depending on the type of HPV . The difINK4a  promoter, enabling high-level overexpression of p16INK4a  [The HPV genome consists of a double-stranded circular genome that includes early and late open reading frames (ORFs). The early ORFs E1 through E7 encode proteins that are involved in the regulation of DNA replication and cell proliferation, while the late ORFs L1 and L2 encode the two viral capsid proteins . CIN1 le16INK4a  . The ideDigene HPV test, which uses Hybrid Capture 2 (HC2) technology, and the Cervista HPV HR assay are the only methods that currently have FDA approval for diagnostic testing in the United States. The most widely used and extensively investigated biomarker in the management of cervical disease is HPV DNA testing. There are a wide range of HPV detection techniques, including in situ hybridization, and genotyping assays, including molecular amplification assays with or without genotyping . The DigDigene HPV Test  was the first HPV test that was licensed by the FDA (United States Food and Drug Administration). This test is a solution-phase hybridization assay that uses RNA probes complementary to HPV DNA, resulting in signal amplification. This test detects the presence of 13 HR-HPV types (16/18/31/33/35/39/45/51/52/56/58/59/68) or 5 low-risk types . The assay is usually performed using only the HR-HPV probe set, since LR-HPV is not clinically significant. In the ASCUS-LSIL Triage Study (ALTS), HC2 was shown to provide more effective triage of ASCUS cytology than a repeat cytology examination [The mination . Anothermination  and easemination . HPV genmination .The Cervista HPV HR test  detects the presence of 14 HPV types designated as high risk by the International Agency for Research on Cancer (IARC), consisting of 16/18/31/33/35/39/45/51/52/56/58/59/66/68. This assay utilizes Invader chemistry, a signal amplification method for the detection of specific nucleic acid sequences. This method comprises two isothermal reactions: a primary reaction on the targeted DNA sequence and a secondary reaction that produces a fluorescent signal. In a comparison between the Digene and Cervista assays, the Cervista assay demonstrated 100% sensitivity in the detection of CIN 3 or worse and 98% sensitivity for the detection of CIN 2 or worse . After aThe Cervista HPV 16/18 test  has been approved by the FDA for use in conjunction with the Cervista HPV HR test. This test utilizes the same Invader chemistry used by the HPV HR test in the analysis of cervical cytology specimens. Clinical validation and analytical performance studies report that the Cervista HPV 16/18 genotyping test demonstrated a high degree of analytical sensitivity, and specificity, and performed as expected in women with ASC-US cytology who were positive for HR HPV , 26. TheThe polymerase chain reaction (PCR) method of detecting HPV enables the sensitive amplification of even small amounts of HPV DNA, enabling the evaluation of extracts of formalin-fixed histologic sections which generally yield fragmented DNA . BrieflyOverall, HPV DNA testing has a sensitivity above 90% for the detection of underlying CIN2+ lesions but has generally poor specificity for underlying clinically significant lesions, because most positive cases represent only transient infections rather than providing evidence of cervical mucosal transformation . As a reViral load may be a useful marker in predicting the risk of progression. High viral load is often considered to be indicative of persistent infection and progression, while low viral load has been interpreted to reflect HPV viral clearance. A fundamental pitfall of this concept, however, is that CIN1 lesions reflect productive infections and may have thousands of viral copies/cell in upper layers of the cervical mucosa, but CIN2/3 and SCC lesions may have as low as a single copy of viral DNA/cell  . Thus, tAssays for the detection of E6/E7 mRNA have been developed based on the concept that E6/E7 expression results in a transforming event with unregulated cell-cycle progression due to degradation of p53 and Rb . The PreThe APTIMA HPV assay is another commercially available test for mRNA detection . The APTIMA HPV assay detects mRNA from 14 HR-HPV types  using liquid-based cervical cytology specimens. The assay involves target capture, target amplification, and the detection of the amplification products. This assay is currently in clinical trials, with a focus on the identification of women that are at high risk for persistent infection.The L1 capsid protein represents approximately 90% of the total protein on the virus surface and is generally detectable during the reproductive phase of HPV infection. The L1 protein is abundant in productive infections , 35; conINK4a  is a tumor-suppressor protein and cyclin-dependent kinase (cdk) inhibitor that blocks cdk4- and cdk6-mediated pRb phosphorylation to inhibit E2F-dependent transcription and cell-cycle progression [INK4a  and the accumulation of the protein in cells. p16INK4a  is thus a surrogate marker of HPV E7-mediated pRb catabolism, providing evidence of transformation of the cervical mucosa [INK4a  has been successfully deployed for the classification of HPV-related disease for several reasons [INK4a  is directly linked to the HPV oncogenic action, since continuous expression of E7 is necessary to maintain the malignant phenotype, (2) the expression of p16INK4a  is independent of the HPV type, and therefore, genotyping does not need to be performed, and (3) the expression of p16INK4a  by cycling cells is a specific marker of HPV-E7 overexpression or other events that inactivate Rb [INK4a  is present in almost all cases of CIN2, CIN3, and squamous cell carcinoma ; however, it is rarely detected in benign squamous mucosa or CIN1 lesions associated with LR-HPV [INK4a  as a marker of cervical neoplasia is that focal and occasionally diffuse expression can also be observed in benign endocervical intercalated columnar cells, in tuboendometrial metaplasia, and in cervical endometriosis [INK4a  in these cells, however, denotes no premalignant potential. Focal staining can also be detected in the lower third of some CIN1 lesions and in the upper third of the epithelium in a few cases of squamous metaplasia. The diffuse pattern of p16INK4a  expression within the lower third of the squamous mucosa, however, is highly specific for CIN1+ lesions, and diffuse expression in glandular epithelial cells usually reflects endocervical glandular neoplasia , AIS, or invasive adenocarcinoma.p16gression . In mostl mucosa , 41. p16 reasons : (1) theivate Rb . Immunohh LR-HPV , 41. Oneetriosis . The expINK4a  has been reported to reduce interobserver disagreement when compared with diagnosis of H&E stained sections [κ = 0.49) and substantial for cone biopsies (mean κ = 0.63) [INK4a -immunostained, consecutive slides read together with the H&E-stained slides significantly improved the interobserver agreement for the interpretation of both punch and cone biopsies. For the punch biopsies, the κ value increased from 0.49 (moderate agreement) to 0.64 , and the κ value for the cone biopsies increased from 0.64 to 0.70. A subsequent study by Bergeron et al. [INK4a  testing for both increasing interobserver agreement as well as increasing diagnostic accuracy. In this study, H&E-stained slides from 500 cases  were interpreted by twelve community pathologists. These interpretations were compared to the “gold standard” diagnoses established by three expert gynecologic pathologists. After a “washout” period of at least four weeks, the same H&E-stained slides were reassessed by the twelve pathologists, but this time in conjunction with p16INK4a -immunostained matched slides. The pathologists were blinded to their original diagnoses as well as the gold standard diagnoses. Overall, diagnostic accuracy for high-grade CIN was significantly improved with the addition of p16INK4a -immunostained slides. The mean sensitivity increased from 0.77 to 0.87 (an increase in sensitivity of 13%). The number of missed high-grade CIN cases was reduced by 45%. The number of cases with a gold standard diagnosis of CIN 3 that were missed by the community-based pathologists was decreased by 60%. Importantly, this gain in sensitivity was not associated with a relevant loss in specificity. Also, the interobserver agreement of the community-based pathologists for categorizing lesions as high-grade CIN versus CIN 1 or negative for dysplasia significantly improved with the addition of the p16INK4a -immunostained slides, with a κ coefficient of 0.749 . Also demonstrated in this study was the relative ease with which accurate, reproducible interpretation of p16INK4a -immunostained slides can be implemented into clinical practice [INK4a  immunohistochemistry may help in identifying CIN1 lesions that are associated with HR-HPV types; these lesions are at an increased risk for progression to high-grade dysplasia or carcinoma [For cervical tissue punch and cone biopsies, immunohistochemistry for p16sections –47. In o = 0.63) . The addn et al.  addressepractice . In addiINK4a  has also recently emerged as a sensitive and specific diagnostic adjunct for underlying CIN2+ lesions in cervical cytology specimens [INK4a  as an immunocytochemical diagnostic adjunct have relied on the use of scoring criteria that depend on both the morphologic interpretation of p16INK4a  positive cells and on the use of quantitative thresholds to establish positive test results [INK4a  test results that was associated with decreased sensitivity and negative predictive value but improved specificity and positive predictive value compared with most of the previous reports of p16INK4a  test performance. Denton et al. used a different scoring system in the evaluation of p16INK4a  test results and also demonstrated that the use of p16INK4a  immunostaining on cytology provides significantly better specificity than HR-HPV for the triage of ASC-US and LSIL cytology cases [INK4a  and other cervical cancer biomarkers is to improve test specificity rather than sensitivity relative to HPV testing.p16pecimens , 51. Mos results . SamarawINK4a  and Mib-1,  can be used to score cases positive on the basis of a single dual stained epithelial cell, independent of cell morphology, resulting in sensitivity that rivals HPV testing but with specificity that is greater than that provided by HR-HPV testing [Ki-67 is a proliferation marker that is confined to the parabasal cell layer of normal stratified squamous mucosa but shows expression in the stratified squamous epithelium in CIN lesions in correlation with the extent of disordered maturation. Although Ki-67 has been used as a diagnostic adjunct for the classification of cervical tissue specimens , 53, the testing –60.HPV infection may lead to DNA hypermethylation (discussed below), disruption of the normal cell cycle, and chromosomal aberrations, all of which may lead to changes in DNA content. Studies using DNA-cytometry of Feulgen-stained cytology material to assess ploidy have demonstrated significant differences in aneuploidy between HSILs and LSILs: 79% aneuploid versus 4%, respectively . Subsequα, in cervical cytology slides, as a marker of aberrant S-phase induction and underlying high-grade dysplasia. MCMs are members of the DNA licensing factor family that are required for the origination of DNA replication and are overexpressed in cervical high-grade dysplasia and carcinoma [The ProExC test  is a recently developed immunocytochemical assay for the detection of minichromosome maintenance proteins (MCMs) and in previous formulations, Topoisomerase 2arcinoma –68. Prelarcinoma , 70 but arcinoma , 72. FurINK4a  has been found to be inactivated in numerous cancers due to mutations and epigenetic alterations  [INK4a  exon1α has been associated with a variety of malignant tumors, such as nonsmall cell lung cancer, colorectal cancer or pancreatic cancer [α methylation, with frequencies ranging from 19% to 61% [INK4a  exon1α methylation, with comparison to p16INK4a  expression, using both cell lines and clinical samples [INK4a  exon1α without any influence on p16INK4a  expression and concluded that methylation in this region does not suppress p16INK4a  expression. Wentzensen et al. recently published a systematic literature review of studies analyzing the utility of methylation markers in cervical cancer [As part of the search for novel and relevant biomarkers in cervical disease, attention has been focused on methylated genes. Of particular interest is that p16equence) . Methylac cancer –76. Seve% to 61% –84; howe samples . They fol cancer . They idFluorescent in situ hybridization (FISH) technology has increasingly been recognized as a valuable tool to evaluate cervical dysplasia , 88. StuINK4a  immunohistochemistry to increase diagnostic accuracy of dysplastic lesions. Merely identifying the presence of HPV infection is not sufficient, as multiple studies have demonstrated. We expect that in the future, in addition to cervical cytology, more advanced techniques, including HPV genotyping, will be used to identify and triage those women most likely to harbor a clinically significant cervical lesion. Assays for HPV viral load and mRNA detection may be useful in both the triage of abnormal cervical cytology, and detecting persistent infection, which is associated with an increased risk for disease progression. We also reviewed new applications of technologies such as FISH and the detection of DNA methylation; although their clinical utility is still under investigation, they have the potential to provide valuable information in the identification of disease, risk of disease progression, and clinical management of patients. Although cervical cancer biomarkers will provide increasingly detailed and important information in countries that have organized screening programs, their utility will depend on the resolution of social and economic factors that have precluded the utilization of cervical cancer screening programs in developing nations. Despite the tremendous progress that has been achieved in the screening and management of women with HPV-related cervical disease, there is still a need for clinically robust biomarkers to further refine the screening, triage, and management of women. In this paper, we focused on those biomarkers that have the greatest utility in the clinical setting, such as those that will increase screening and diagnostic accuracy of cervical specimens and tissue biopsies, and we provide information regarding the risk for progression to a more severe lesion. Examples of these include HPV DNA testing for the effective triage of women with abnormal cervical cytology, and the use of p16


This study evaluates trends in antibody seroprevalences of seven high-risk human papillomavirus (hr-HPV) serotypes  between the 1995–96 and 2006–07 sero-surveys among the Dutch general population in the pre-vaccination era.Serum samples of men and women (0–79 years of age) from two cross-sectional population-based serosurveillance studies performed in 1995–96 (n = 3303) and 2006–07 (n = 6384) were tested for HPV-specific antibodies in a VLP-based multiplex immunoassay.HPV16-specific antibody seroprevalence increased during adolescence and shifted to younger ages in the 2006–07 survey compared to the 1995–96 survey. This step-up in HPV16 seroprevalence was most pronounced in women, while a more gradual increase was observed in men. Also in cohorts older than 49 years, HPV16 seroprevalence was higher in 2006–07 as compared to 1995–96 survey. A higher overall seroprevalence in individuals older than 15 years of age was found for HPV16, 18, 31 and 45 in 2006–07 as compared to 1995–96. For HPV33, 52 and 58 seroprevalences were comparable over this 11-year time period. Seropositivity for one or more HPV types was significantly higher in 2006–07 (23.1%) than in 1995–96 (20.0%) (p = 0.013). Multi-seropositivity increased from 7.1% in 1995–96 up to 10.2% in 2006–07 (p<0.0001). Differences in HPV seropositivity for at least one of the seven HPV types between both surveys could be explained in addition to demographic characteristics , also by changes in sexual behaviour .The observed increase in particular HPV16 seroprevalence could be due to changes in sexual behaviour over the years, and especially in age of sexual debut. Seroprevalence studies provide insight into the distribution of HPV types and infection dynamics in the general population over time, which is important to assess the impact of HPV-vaccination. Human papillomavirus (HPV) consists of a large family of more than 120 HPV genotypes of which 40 types are oncogenic HPV is a sexually transmitted virus and the highest HPV antibody seroprevalence is found among individuals 20–40 years of age with a decreasing seroprevalence in elderly Because HPV-specific antibodies are not often observed in transient infections, seroconversion is more strongly associated with persistent HPV infections Currently, comparisons between studies on trends in serological hr-HPV prevalence over time are limited because most studies are focused on DNA prevalence or incidence of cervical intraepithelial neoplasia (CIN) in women The study proposal was approved by the Medical Ethics Testing Committee of the foundation of therapeutic evaluation of medicines (METC-STEG) in Almere, The Netherlands . A written informed consent was obtained from all participants and for those below 18 years of age also from the parents, care takers or guardians.In The Netherlands, serum samples from two cross-sectional population-based serosurveillance studies performed from October 1995 to December 1996 and from February 2006 to June 2007 were available. Participants, women, men and children, of both studies were 0–79 years of age. The participation rates for the 1995–96 and 2006–07 surveys were 55% and 32%, respectively. Study designs have been described earlier Serum samples of both surveys were stored at −80°C until analysis. For the measurement of HPV-specific IgG serum antibodies against L1 virus-like-particles (VLP) of HPV16, 18, 31, 33, 45, 52, and 58, a VLP-based multiplex immunoassay (MIA) was used as previously described st 1996 and for the 2006–07 survey on January 1st 2007.Data analyses were conducted using SAS version 9.2 and Graphpad version 5.0. Age-specific seroprevalences were calculated and weighted. Weights  for the 1995–96 survey were determined proportional to the Dutch reference population on January 1To test whether any trends could be explained by differences in risk factors between the two serosurveys we performed a logistic regression analysis on a pooled dataset of both surveys for individuals older than 15 years of age. Only persons with information about all risk variables were included in the analyses (74%). We included the following variables: age, sex, urbanization degree, ethnicity, marital status and sexual behaviour. Besides odds ratios, we calculated unadjusted and adjusted probabilities and converted these to percentages Statistically significant differences (p<0.05) for HPV combinations or HPV seroprevalences were analyzed using a Chi-square test and differences between antibody concentrations of seropositive individuals were analyzed using a Mann-Whitney test.We tested 3303 serum samples from the 1995–96 survey (48% men and 52% women and 6386 samples from the 2006–07 survey (46% men and 54% women). In the 1995–96 survey the cohorts older than 15 years of age contained more individuals with the Dutch nationality, were married and less self-reported history of STI . The meaThe total age-specific antibody seroprevalence for any HPV type started to increase in the cohort of 15–19 years up to 30–39 years in 1995–96 and to 40–49 years in 2006–07 . In the Focusing on individuals older than 15 years of age, the most prevalent HPV-specific antibodies in 2006–07 were directed against HPV16 (11.5%) followed by HPV45 (7.2%), while in 1995–96 antibodies against HPV52 (6.9%) and HPV16 (6.6%) were most prevalent . In 2006Although a higher HPV16 seroprevalence was found in 2006–07 compared with 1995–96, the age-specific HPV16 geometric mean concentrations (GMCs) of seropositive individuals was comparable in all age cohorts between both studies . For HPVHPV seropositivity for at least one of the seven HPV types in individuals older than 15 years of age before adjustment of any variables was 20.7% in the 1995–96 study and 23.5% in the 2006–07 study . After pooling both surveys, adjustment of demographic characteristics  resulted in a smaller difference in HPV seroprevalence between the 1995–96 survey (21.0%) and 2006–07 (23.2%) survey . The difference between both surveys decreased even further with adjustments for demographic characteristics and sexual risk factors . The HPV seroprevalence of the 1995–96 survey (22.2%) and the 2006–07 survey (22.8%) only differed by 0.6% .HPV types 16, 18, 31, and 45 showed a significant difference between the 1995–96 and 2006–07 survey before adjustment of any variables. The risk factor analysis for seropositivity of each HPV type separately was comparable with the risk factor analysis of combined HPV seropositivity (seropositive for at least one of the seven HPV types), in which a decrease in ORs after adjusting for demographic characteristics and sexual risk factors was observed. However, even after adjustment of demographic characteristics and sexual risk factors the difference for HPV16  and HPV31  between the two surveys remained statistically significant.Several observations from this study indicate that the situation on HPV incidence has changed in The Netherlands. First, the overall antibody seroprevalence of seven hr-HPV types has increased, in the age cohorts older than 15 years of age, 3.1% in 2006–07 as compared to the serosurveillance study 11 years earlier due to a significant higher seroprevalence for HPV16, 18, 31 and 45. Secondly, the clear-cut rise in HPV16 seroprevalence in particular women has shifted to younger aged cohorts (from 25–29 to 20–24 years). Finally, seropositivity for HPV16/18 combinations, for one or more types, and for multiple HPV serotypes has also significantly increased during the 11-year time interval.Comparable HPV-specific antibody levels of seropositive individuals were observed between the 1995–96 and 2006–07 survey, suggesting that factors involved in the generation of HPV-specific antibodies have not changed over time. The increase in HPV seroprevalence, particularly for HPV16, between the two time periods could be due to an increase in HPV infection and/or HPV circulation Over the years, higher population mobility in recent years, including immigration of populations who are at higher risk for HPV seropositivity and also changes in sexual behaviour, for instance a younger age of sexual debut and more sexual partners, increased the risk of STI The observed HPV seroprevalence in children might be due to vertical or horizontal transmission of HPV, as HPV is also transmittable without having sexual contact In older adults (65–74 years of age) sexual activity declines with age although 53% is still sexually active The differences in the questionnaire used in both surveys were a limitation of our study. Because the questionnaire used in 1995–96 survey was extended for the 2006–07 survey, not all questions from the 2006–07 survey matched with those from the 1995–96 survey. Questions that were not included in both questionnaires, such as lifetime number of sexual partners, could have been a better predictor of HPV seropositivity as Vaccarella et al. observed that this variable was associated with HPV16 and 18 seropositivity To conclude, our data showed that HPV antibody seroprevalences in the general population have increased in The Netherlands over an 11-year period. HPV16 seroprevalences among young women shifted to younger ages over time, probably due to changes in sexual behaviour over the years, in particular the age of sexual debut. Interestingly, the increase in HPV seropositivity in older aged individuals might be caused by a higher percentage of the older aged individuals who are now still sexually active and these age groups are thus more at risk for STI. Serum antibody responses to HPV can persist over time, also after clearance of infection Figure S1HPV antibody concentrations. HPV16 (A) and HPV18 (B) antibody concentrations (LU/ml) of seropositive individuals in the 1995–96 (blue dots) and in 2006–07 (red dots) surveys. The dark grey lines indicate the geometric mean concentration. For HPV18 significant different antibody concentrations were found in the age cohorts 1–4 (p = 0.04), 50–59 (p = 0.04) and 60–69 (p = 0.02).(TIF)Click here for additional data file.


Quantitative real-time polymerase chain reaction was performed separately for epithelial and stromal tissue compartments. Differences in gene expression were analyzed by the Jonckheere-Terpstra trend test or the Student's t-test for pairwise comparison. Laser capture microdissection revealed an increase in TLR3 and a decrease in TLR1 mRNA levels in dysplastic and carcinoma epithelium, respectively. In the stroma, a trend of increasing TLR 1, 2, 5, 6, and 9 mRNA levels with disease severity was found. These findings implicate the involvement of TLR3 and TLR1 in early and late cervical carcinogenesis, respectively, suggesting that stromal upregulation of TLRs may play a role in cervical disease progression.The human papillomavirus (HPV) directly infects cervical keratinocytes and interferes with TLR signalling. To shed light on the effect of HPV on upstream receptors, we evaluated TLRs 1–9 gene expression in HPV-negative normal and HPV-positive pre-malignant and malignant  However, it is distinct from other type I IFNs as it signals in a discrete autocrine, rather than paracrine manner [The most important role of toll-like receptors (TLRs) in host defence is the regulation of innate and adaptive immune responses by epithelial cells, the first line of protection at, for example, the respiratory, gastrointestinal tract, skin and genitourinary mucosal sites. Present on a variety of cell types, TLRs play an essential role in innate immune system function by recognizing discrete exogenous pathogen-associated molecular patterns (PAMPs) and endogenous damage-associated molecular pattern (DAMP) ligands to induce an innate immune response . Ten funnd IFN-γ , 2. IFNsnd IFN-γ –5. The I and -τ  , and gen and -τ  , while Ie II IFN  and is ie II IFN . IFN-κ ie manner .TLRs 3, 7, 8, and 9 can be activated by viral products such as double stranded RNA , single The critical function of TLRs in innate immune functioning is well studied, but, in recent years, their role in tumour genesis and cancer progression has become an active field of research. Because of their innate immunity signalling, TLRs play an important gate keeper role in controlling the production of proinflammatory cytokines and chemokines as well as IFNs. It has recently been speculated that aberrant TLR expression and signalling in cancer cells and the resulting downstream cascades can directly promote tumour progression . Indeed,ex vivo cervical tissue by laser capture microscopy and quantitative real-time polymerase chain reaction [Cervical cancer is the second most common malignancy in women worldwide with human papillomavirus (HPV) recognized as its causative agent . HPV is reaction . Compareμm-thick tissue sections were cut, adhered to uncharged slides, and kept in −20°C prior to LCM preparation. All tweezers, brushes, and surfaces were cleaned with DEPC-treated 70% (v/v) ethanol between specimens to reduce RNAse activity and RNA cross-contamination. Cervical biopsies were obtained with written consent from women attending the Colposcopy Clinic at the Thunder Bay Regional Health Sciences Centre (TBRHSC) between November 2005 and November 2006. The study has been approved by the local Research Ethics Team at the TBRHSC (no. 21.05). Biopsies were snap frozen in liquid nitrogen and immediately transferred to −80°C. Tissue was sectioned on a cryostat , maintaining tissue temperature at −20°C using Tissue Tek embedding medium  and sectioned. For laser capture microdissection (LCM) analysis, 8 All samples collected in this study were thoroughly tested for RNA integrity, as previously described , 27. Of n = 11), HPV-positive and morphologically dysplastic  and HPV-positive and morphologically malignant .Ten tissue sections were cut and then taken immediately for LCM analysis, and placed into 1.5 mL microcentrifuge tubes for DNA extraction. DNA extraction was performed using the Qiagen QIAamp DNA micro kit  following the manufacturer's protocol for tissue samples. Samples were HPV genotyped using Luminex hybridization at the National Microbiology Laboratory , as previously described . In addiμm thick tissue sections of microdissected cervical cells or keratinocytes as previously described [RNA was extracted from 10 × 10 escribed . The quaescribed .μm in diameter whereas the laser power and duration ranged from 80 to 95 mW and 0.65 to 0.8 millisecond duration between specimens. Images of the excision process have been previously reported [Tissue specimens were prepared for laser capture microdissection (LCM) using the Arcturus Histogene Frozen Section Staining Kit, as previously described . Up to freported .μL (ranging from 0.6–2.8 ng/μL), depending on acquired LCM sample RNA concentration. Complementary DNA (cDNA) was amplified using the TaqMan PreAmp Master Mix Kit (Applied Biosystems). Gene amplification uniformity was assessed as previously described [μL volume were added to a 96-optical well plate (Applied Biosystems) and incubated at standard qRT-PCR conditions (50°C for 5 minutes 95°C for 10 minutes and then cycled at 95°C for 15 seconds and 60°C for 1 minute for 40 cycles (detection limit)). qRT-PCR was repeated for 10% of ex vivo human samples to ensure result reliability. Target genes were normalized to the housekeeping gene hypoxanthine phosphoribosyltransferase1 (HPRT1), as previous results indicate its expression is unaffected by HPV infection [RNA isolated from samples was reverse transcribed to complementary DNA (cDNA) using the High Capacity cDNA Archive Kit (Applied Biosystems) according to manufacturer's directions with random hexamer primers. RNA isolated from microdissected samples was reverse transcribed at a minimum of 0.6 ng/escribed . Reactionfection . TaqMan −ΔCT [t-test for pairwise comparison when comparing diseased versus normal tissue. P-values for all statistical comparisons are reported with at most two significant digits. Statistical significance is stated when P ≤ 0.05. All tests are two sided if not otherwise indicated and based on the “exact” version. Calculations were performed using Microsoft Excel version 12 (2008) and Cytel Studio StatXact7 version 7.0.0 (2005), Cytel Software Corporation (http://www.cytel.com/) and the SAS statistical analysis package  for statistical tests.The difference in cycle thresholds (ΔCT) between HPRT1 and the TLRs was calculated for each gene in each biological sample. These values were converted to relative expression values using 2−ΔCT . Statist−ΔCT  test forTo define baseline mRNA levels of TLRs in healthy cervical tissue, 11 cervical biopsies from histologically normal, HPV-negative women were analyzed, as shown in κ and IL-10 downregulation in dysplastic and carcinoma epithelium [P = 0.05, Student's t-test; P = 0.01, Student's t-test; κ levels previously reported in the same samples [To characterize TLR mRNA levels in dysplastic and carcinoma epithelium, 14 HPV-positive, diseased cervical epithelial samples were analyzed, as shown in ithelium . We ther samples .P = 0.05, 0.001, 0.02, 0.01, and 0.04 resp., Jonckheere-Terpstra test; P = 0.02, 0.001 and 0.05 resp., Student's t-test). Thus, the most striking results found in the stroma compartment were the increased mRNA levels for five TLRs, which coincides with our previous reported increase in downstream IL-10, IFN-κ, IFN-β, and IFN-γ in the stroma of the same samples [To characterize TLR mRNA levels in dysplastic and carcinoma stroma, 14 HPV-positive, diseased cervical stromal samples were analyzed, as shown in  samples .ex vivo analysis of gene expression in HPV-negative, healthy as well as HPV-positive premalignant and malignant cervical tissue, we report a transcriptome model with an emphasis on tissue compartmentalization for innate immune signalling pathways in cervical carcinogenesis. By conducting a systematic literature survey  downregulation of TLR9 by HPV16 E6, [κ promoter [κ by the HPV16 E6 oncoprotein [ Several mechanisms have been suggested for IFN-PV16 E6,  (ii) metpromoter  and (iiioprotein . The preoprotein . HPV-associated cancers are a worldwide health concern, and since the recently approved prophylactic vaccine against common high-srisk HPV types is not a treatment option, there is a great need for studies to characterize the effect of HPV on innate immune responses to advance treatment options. Because of their wide-ranging impact upon both innate and adaptive immunity in several disease settings, TLRs and their signalling pathways emerge as attractive therapeutic targets . Based oThe authors declare that they have no conflicts of interest.


Seventy percent of sexually active individuals will be infected with Human Papillomavirus (HPV) during their lifetime. These infections are incriminated for almost all cervical cancers. In France, 3,068 new cases of cervical cancer and 1,067 deaths from cervical cancer occurred in 2005. Two vaccines against HPV infections are currently available and vaccination policies aim to decrease the incidence of HPV infections and of cervical cancers. In France, vaccine coverage has been reported to be low.We developed a dynamic model for the heterosexual transmission of Human Papillomavirus types 16 and 18, which are covered by available vaccines. A deterministic model was used with stratification on gender, age and sexual behavior. Immunity obtained from vaccination was taken into account. The model was calibrated using French data of cervical cancer incidence.In view of current vaccine coverage and screening, we expected a 32% and 83% reduction in the incidence of cervical cancers due to HPV 16/18, after 20 years and 50 years of vaccine introduction respectively. Vaccine coverage and screening rates were assumed to be constant. However, increasing vaccine coverage in women or vaccinating girls before 14 showed a better impact on cervical cancer incidence. On the other hand, performing vaccination in men improves the effect on cervical cancer incidence only moderately, compared to strategies in females only.While current vaccination policies may significantly decrease cervical cancer incidence, other supplementary strategies in females could be considered in order to improve vaccination efficacy. Human Papillomavirus infection (HPV) is the most frequent sexually transmitted disease. At least 70 per cent of sexually active men and women are infected with HPV during their life span Epidemiological studies have established a causal relationship between HPV infections and occurrence of cervical cancer Invasive cervical cancer is the second most common cancer among women worldwide Vaccination against HPV infections represents an effective way to decrease cervical cancer incidence, particularly among young women. Two prophylactic vaccines against HPV infections are available in France and have been found to be highly effective in women who have never been infected with HPV The permanent Vaccines Advisory Committees (“Comité technique des vaccinations” and “Conseil supérieur d'hygiène publique de France”) recommend vaccinating 14 years old females. Moreover, a catch-up program has been offered to women aged from 15 to 23. Females eligible for the catch-up program either not have been sexually active yet or may report a first sexual relationship that occurred in the year prior to vaccination . A recent paper has estimated vaccine coverage in France to be low: about 30% of girls aged 14 had been vaccinated with three doses in 2007 and 2008 Since the recent introduction of vaccination policies in France, a reduction of cervical cancers and pre-cancerous lesions has been expected. As cervical cancers usually occur 15 years after HPV infections, mathematical models are useful to assess an expected reduction in cancer cases. In these models, vaccine coverage in young women is taken into account.Various dynamic models have been published to assess the potential impact of HPV vaccination in several countries. Some of them are cohort models In this paper, we present a deterministic model for the heterosexual transmission of HPV and its progression to cervical lesions and cervical cancer. We estimated the potential impact of vaccination on the reduction of cervical cancer incidence in French women. We first studied the current vaccine coverage to assess vaccine efficacy. Then, vaccine efficacy was assessed in different settings: adding vaccine coverage in boys and young men, achieving higher vaccine coverage in women and adding vaccine coverage in females under 14.http://www.scilab.org/fr) to design a deterministic model for heterosexual transmission of HPV types 16 and 18. We developed a system of 784 ordinary differential equations  or when they reached the age of 84. An additional death rate for women with cervical cancer was considered The heterosexually mixing population was divided into 14 age groups  based on age groups of published data on cervical cancer incidence in France l defining sexual-behavior to form a partnership with someone from group o is defined by:oN being the proportion of individuals in sexual-activity group o, oc representing the average number of annual partners in group o, the parameter ε described the degree of mixing between sexual activity groups which may vary from fully assortative  to fully random (ε = 1). Mixing between sexual activity groups was assumed to be preferentially assortative (ε = 0.4).Each age group was divided into 4 levels of sexual behavior. The level of sexual activity was defined by the number of sexual partners in last 12 months . Results from the French survey on sexual behavior fσ and mσ); number of sex partner in last 12 months ; proportion of infected individuals in the pool of sexual partner according to their age-group and level of sexual behavior. We developed a mixing matrix g,i,kρ appropriate for the sexually active population in France, which gives the proportion of individuals of gender g, in age-group i who have sexual partners in age-group k (see The force of infection by gender depends on: probabilities of transmission by partnership (not per sex act) from an infected individual to a susceptible  for both sexes and age-specific progression rates to different stage of cervical disease . A set of parameters which matched HPV 16/18 prevalence We divided the population into vaccinated and unvaccinated categories. Individuals entered the model at 14 years old (being vaccinated or not). Individuals in the youngest age groups  could beTo validate the model, we considered the epidemiological data before vaccination introduction and compared it with the steady-state estimates of the deterministic model for non-vaccinated individuals see . Probabiwww.invs.fr). Seventy percent of cervical cancers are due to HPV types 16/18. Age-specific incidence rates of cervical cancer predicted by the model were similar to the incidence rates of cervical cancers attributed to HPV 16/18 in France within a precision of 10%. Predicted HPV prevalence had a shape and a peak similar to that reported in literature data Among infected females, the rates of progression to various stages of cervical disease  were estimated for each age-group . We compε, which can vary between 0 (fully assortative) and 1 (fully random), was initially set to 0.4. We tested the effect of a value for ε closer to sexual mixing fully random (ε = 0.8) on the endemic prevalence of HPV infections in male and female. Although vaccine efficacy was initially set to 90%, in sensitivity analyses, we set vaccine efficacy to 60%. Thus, we studied the impact of vaccination on HPV prevalence and cervical cancer incidence using a low (60%) vaccine efficacy.Sensitivity analyses were conducted to assess the effect of parameter variations on model results. The degree of sexual mixing There was a modest effect on the prevalence of HPV infections when scenarios included vaccination coverage in men and women compared to those considering vaccination coverage only in females. For instance, in France, current vaccination coverage among females lead to a 52% reduction of HPV infection prevalence 20 years after the introduction of the vaccine, while adding vaccination with a similar coverage in boys and young men yielded a 59% reduction in HPV infection prevalence.Improving vaccine coverage (scenario 3 and 4) decreased HPV prevalence more importantly; in addition, the impact of the vaccines was observed earlier in time.Scenario 5, which considered an additional vaccination of girls before 14, yielded a better impact on HPV prevalence among females than scenario 2. This scenario considered vaccination with a similar coverage in males and females aged 14 to 24.The deterministic model that we developed takes into account the reduction of male HPV 16/18 prevalence due to female vaccination. All in all, scenarios that considered vaccination only in females had a lower impact on the reduction of HPV prevalence in males compared to females.Considering current vaccine coverage and screening in France (scenario 1), a 32% reduction of incidence of cervical cancers due to HPV 16/18 may be expected 20 years after the introduction of the vaccine see . A modesAdding vaccination among males (scenario 2) to current recommendations (considered in scenario 1) led to a similar reduction in cervical cancer.Considering a high coverage of vaccination (80% in scenario 3) for women, a halving of numbers of new cervical cancers would be expected 20 years after vaccine introduction. Adding vaccination in men would not lead to a much better reduction in cervical cancer cases (scenario 4).In scenario 5, females were vaccinated before 14 with a better coverage than females over 14 (50% versus 30%). This scheme led to better results than those from scenario 1 representing current vaccination policy in France. A 45% reduction in cervical cancer incidence could be expected 20 years after vaccine introduction in scenario 5 while scenario 1 yielded a 32% reduction in cervical cancer incidence.Beyond discrepancies in terms of vaccination impact due to vaccination policies, the scenarios we considered predicted a significant reduction in cervical cancers and infections due to HPV 16/18. A disappearance of cervical cancer due to HPV 16/18 could be expected in a time horizon of 100 years . The impε = 0.8) led to a 2% reduction of endemic prevalence of HPV infections in males and females compared to the initial value of ε (0.4).In sensitivity analysis, we tested the impact of an increase of the sexual mixing parameter that corresponded to an augmentation of random mixing. A high value of the sexual mixing parameter (A lower efficacy of vaccine (60%) reduced the impact on HPV prevalence and cervical cancer incidence. For instance, using scenario 1, model predictions yielded 50 years after introduction of vaccine a 25% higher HPV prevalence in females and a two-fold increase of cervical cancer incidence compared to scenario 1 with a 90% efficacy of vaccine.We developed a dynamical model for HPV transmission in a heterosexual population to assess the impact of vaccination against HPV infections on the incidence of cervical cancer in France. We considered current vaccination policies and compared several vaccination scenarios. We confirmed the effectiveness of vaccination against HPV to prevent infections and cervical cancers using deterministic modeling The use of a deterministic model in our study allowed us to take into account herd immunity, which corresponds to a decrease of HPV 16/18 infections and cervical cancers in non-vaccinated subpopulations of females due to vaccination coverage of other individuals.In the fitting procedure, probabilities of HPV 16/18 transmission for women and men were estimated to be of 0.25 and 0.20 respectively. The values that were yielded from our model are close to published estimates from fitted deterministic models for HPV Screening of precancerous lesions of the cervix and cervical cancer using cervical smear tests is recommended in France. Screening coverage has been estimated to be 58.7% in women of 25 to 65 years old in 2005; however, significant discrepancies were observed between age-groups www.has-sante.fr).The study could not take into consideration future changes in screening programs, using new screening policies or new screening technologies on the market. In France, in 2010 Public Health Agency (HAS) proposed to organize cervical cancer screening to improve screening coverage. Moreover, use of new screening tools may also modify current epidemiological data on HPV infections and related cervical cancers. In the USA, the ACOG guidelines (2009) and the American Cancer Society (2003) recommended HPV-plus-pap testing in women aged 30 and older Efficacy of vaccination was assumed to last lifelong. Consequently, we did not include the need for vaccine booster shots in our model. The protective effect of the vaccines is known to last at least several years The sophistication of deterministic models by adding strata corresponding to uncertain data may lead to computational difficulties and increase the uncertainty of outputs and parameters. Thus, screening and use of booster shots were not included in our model.ε), we observed a decrease of HPV 16/18 prevalence after using a high value of ε. This result is consistent with that reported in Garnett and Anderson paper ε is far from the assortative sexual mixing corresponding to ε = 0), the infection is less likely to persist endemically In sensitivity analyses that investigated the effect of an increase of the sexual mixing parameter . This scenario predicts a decrease in cervical cancer incidence due to HPV 16/18 by one third 20 years after introduction of vaccine and a halving of deaths by cervical cancer. In this scenario, we considered vaccine coverage to be constant in time. However, female vaccine coverage in France is decreasing. While 33.3% of girls aged 14 in 2007 were vaccinated with 3 doses of the vaccine, only 23.7% and 5.4% of girls aged 14 were vaccinated respectively in 2008 and 2009 In Scenario 3, we considered a high vaccine coverage for women and young girls (80%), which yielded a better impact of vaccination than scenario 1. In countries where school-based vaccination programs have been implemented , these vaccine coverage rates have been reached In scenario 5, young girls could be vaccinated before 14. In Europe, many countries recommend vaccination for females aged 12 In this paper, we did not assess the impact of vaccination on other cancers or diseases due to HPV 16/18 infections . Vaccination against HPV 16/18 infection is likely to reduce incidence of other cancers in the anogenital area in males and female. Reduction of HPV-16/18 prevalence in men due to female vaccination could reduce the incidence of some male cancers. These additional potential benefits of HPV 16/18 vaccination have to be investigated by developing specific dynamic models that consider the natural history of the diseases.Finally, some recent studies have shown the bivalent vaccine's protective effect against high-risk HPV types, which are not targeted by it (HPV types 31 and 45) In conclusion, we developed a deterministic model of HPV heterosexual transmission and progression to cervical cancer to assess the epidemiologic impact of HPV vaccination in France.While current vaccination policies may decrease cervical cancer incidence in France significantly, other complementary strategies could be employed for females to improve vaccination efficacy.Appendix S1Description of the mathematical model.(DOC)Click here for additional data file.Figure S1Distribution of women aged 14 to 84. Data observed in France on 01/01/2006 in blue (www.insee.fr) versus predicted by the demographic model in green.(EPS)Click here for additional data file.Figure S2Distribution of men aged 14 to 84. Data observed in France on 01/01/2006 in blue (www.insee.fr) versus predicted by the demographic model in green.(EPS)Click here for additional data file.Figure S3Number of new cases of cervical cancer due to HPV 16/18 for 100,000 women per year. Published data in blue (EPS)Click here for additional data file.Figure S4Female prevalence of HPV 16/18 infection since introduction of vaccination (t = 0) in each scenario.(TIF)Click here for additional data file.Figure S5Male prevalence of HPV 16/18 infection since introduction of vaccination (t = 0) in each scenario.(TIF)Click here for additional data file.Figure S6Evolution of cervical cancer incidence for French women  after introduction of vaccination (t = 0).(TIF)Click here for additional data file.Table S1Initial distribution in the model in the 4 sexual-activity groups.(DOC)Click here for additional data file.Table S2Mixing matrix between age-group. Proportion of individuals who have sexual contacts with partners in youngest age-group (<), the same age-group ( = ) or older age group (>).(DOC)Click here for additional data file.Table S3Model's parameters.(DOC)Click here for additional data file.Table S4Description of variables and parameters.(DOC)Click here for additional data file.Table S5French mortality rates.(DOC)Click here for additional data file.Table S6Distribution of French population aged 14 to 84 (01/01/2006), source: National Institute of Statistics (INSEE).(DOC)Click here for additional data file.Table S7Description of matrices used in implementation.(DOC)Click here for additional data file.


The decrease in human papillomavirus (HPV) vaccine prices may allow upscale already started vaccination programmes but the advantages of different options are unclear.Using a mathematical model of HPV16 and 18 transmission and data on vaccination coverage from Italy, we compared 3 options to upscale an already started programme targeting 11-year old girls (coverage 65%): a) coverage improvement (from 65% to 90%); b) addition of 11-year-old boys (coverage 65%); or c) 1-year catch-up of older girls (coverage 50%).The reduction of cervical HPV16/18 infection as compared to no vaccination (i.e. effectiveness against HPV16/18) increased from 76% to 98% with coverage improvement in girls and to 90% with the addition of boys. With higher coverage in girls, HPV16/18 infection cumulative probability by age 35 decreased from 25% to 8% with a 38% increase in vaccine number. The addition of boys decreased the cumulative probability to 18% with a 100% increase in the number of vaccinees. For any coverage in girls, the number of vaccinees to prevent 1 woman from being infected by HPV16/18 by age 35 was 1.5, whereas it was 2.7 for the addition of boys. Catch-up of older girls only moved forward the vaccination effectiveness by 2–5 years.Increasing vaccination coverage among girls is the most effective option for decreasing HPV16/18. If not achievable, vaccinating boys is justifiable if vaccine cost has at least halved, because this option would almost double the number of vaccinees. The debate on the best target population of human papillomavirus (HPV) vaccination programmes in high-income countries has been renewed by the decision to vaccinate boys in Australia ,2 and thThe impact of vaccinating adolescent girls  with or without catch-up of older girls has been explored using mathematical models -12. The per se, will be the earliest to be monitored. Three options were explored: a) coverage improvement of initially targeted girls; b) catch-up of a few additional female birth cohorts; and c) the addition of boys.In the present paper, we assess, as an example, different upscaling options in the vaccination programme that started in 2008 in Italy assuming that a fixed amount of resources has been allocated to HPV prevention. Our aim is to compare the effectiveness for HPV infection control of different options for an upscaled vaccination programme, in relation to the effectiveness of the existing baseline programme. We focused on viral endpoints , which, though not clinically relevant The transmission dynamic model of HPV infection used in the present paper has been extensively described elsewhere . BrieflyHPV16 and 18 cervical infections were modelled separately as independent infections . We evenFor each simulated upscale option, we present: 1) the effectiveness of vaccination as a function of calendar year after vaccination; and 2) the percent cumulative probability (CumProb) of HPV16/18 cervical infections by age 35 years according to birth cohort. Effectiveness was defined as the relative reduction in prevalence of HPV16/18 infections in women aged ≤35 years as compared to that in the absence of vaccination. Finally, we directly compared the different vaccination options for a limited number of birth-cohorts by calculating the number of subjects needed to vaccinate (NNV) in order to prevent a woman from being infected by HPV16/18 by age 35. The NNV was calculated assuming that birth cohorts were of the same size and included the same number of boys and girls. The corresponding number of vaccine doses may vary depending on the recommended vaccination schedule.The improvement of vaccination coverage from 65% to 90% in 11-year-old girls increased the effectiveness against cervical HPV16/18 infections within 30 years since vaccination introduction from 76% to 98% Figure . As a reThe addition of 11-year-old boys to the vaccination of 11-year-old girls would raise maximal effectiveness to 90%. For both vaccinating boys and increasing coverage, the maximal effectiveness was 99% Figure . The conCatch-up of 17-to-24 year-old women did not affect the long-term effectiveness but it substantially moved it forward compared to baseline vaccination Figure . The antTable Catch-up of older girls would lower the cumulative probability of HPV16/18 infections among women not initially targeted , with an expected cumulative probability of HPV16/18 cervical infections of 43.8% (IQR: 35.9 – 51.4). The herd-immunity is expected to be lower among older birth cohorts as a consequence of decrease in sexual mixing with male partners of the vaccinated cohorts. For example, HPV16/18 CumProb among women born in 1993 would overlap the one expected in absence of vaccination .The reduction of HPV16/18 CumProb by age 35 according to a) increase in 11-year-old girls’ coverage to 90%; or b) introduction of vaccination of 11-year-old boys in 2013 is shown in Table per capita would be reduced by at least 28%, while the boys’ vaccination option would be acceptable if costs reduction would be at least 50%.Figure A direct comparison between vaccination options, restricted to the 10 first targeted birth cohorts, showed that the NNV was 1.5 under both the baseline and the improved girls’ coverage option. NNV was 2.7 if boys were also vaccinated (Table Our results show that improving vaccination coverage in adolescent girls is the most effective upscale option for decreasing the burden of HPV16/18 cervical infections in women. The addition of adolescent boys would approximately double NNV compared to girls’ vaccination but it can be considered useful and cost-neutral if the coverage of girls cannot be further improved and the cost per vaccination has at least halved.A 1-year catch-up campaign of a few cohorts of older girls and younger women would move forward by about 3-to-5 years the impact of vaccination among targeted cohorts regardless of the vaccination strategy adopted for adolescent girls and boys. However, due to the higher probability of previous exposure to HPV16/18 infection, additional catch-up of older birth-cohorts would follow a diminishing return pattern. The catch-up of young women and improvement of vaccination coverage of 11-year-old adolescents would essentially benefit different birth-cohorts, i.e. those born in 2001 or earlier and after 2001, respectively.Coverage of 90% of 11-year-old girls would increase the number of vaccinated adolescents by about 40% and decrease to 8% the HPV16/18 CumProb by age 35. The addition of 11-year-old boys with 65% coverage would double the PNN and decrease to 18% HVP16/18 CumProb by age 35 Figure , the feaHowever, the cost of coverage improvement varies by setting, e.g., more expensive in on-demand programmes than in school- and/or by population-based invitations.ad hoc public clinics by active invitation between 1991 and 2003. Adolescent coverage reached 90% in most Italian regions [In Italy, for instance, vaccination against hepatitis B virus included catch-up of 12-year-old adolescents in  regions . Many co regions .Our study shows that the different vaccination options also provide indirect protection against HPV16/18 to unvaccinated women. This indirect protection results from the decline in HPV transmission in sexual network that includes a high proportion of vaccinated women. Vaccinated women can indirectly protect the unvaccinated women by sharing sexual partners, while vaccinated boys directly prevent the transmission of HPV16/18 to unvaccinated women.Our study has strengths and limitations. We focused on viral endpoints, although these are not clinically relevant outcomes, as they represent the earliest possible endpoints for monitoring vaccination programmes and the accuracy of model-based projections. We concentrated on HPV16/18 infections as information about natural history and vaccine cross-protection against other high-risk HPV types is limited. Restriction to virological endpoints up to age 35 minimizes the potential impact of different cervical screening practice on the interpretation of our findings . FurtherThe generalizability of estimates based on dynamic model projection is largely dependent on the quality of assumptions of the parameters that govern natural history and sexual circulation of HPV infection. To test the validity of our sets of parameter values, we independently calibrated our Italian data-based model to Swedish data. Allowing for demographic and behavioural differences between the two countries and populations, the sets of parameters that regulate the natural history of HPV16 and 18 infections were shown to be consistent, suggesting that our projections are robust . By contOur study only included estimates of vaccination benefit in women, although the reduction in incidence of HPV infection and HPV-associated cancers in men is an additional benefit of vaccination . HoweverDue to the rapidly changing price of HPV vaccination, we chose not to include the monetary costs of purchasing and delivering HPV vaccines. However, the percent increase in vaccinated individuals in each vaccination option, as well as the NNV to prevent one woman HPV16 or 18 infected by age 35 should be easily applicable to country-specific vaccination costs in any given year and recommended number of vaccine doses . NNV accCumProb: Cumulative probability; HPV: Human papillomavirus; IQR: Interquartile range; NNV: Number needed to vaccinate; NTCC: New technologies for cervical cancer.IB, FL, GR, SF declare that they have no competing interests. JD has acted as consultant and received research grants from Merck and SPMSD.IB, JD, GR and SF conceived and designed the study. IB and FL conceived, coded, and ran the transmission model. IB performed the analyses. GR and JD contributed to literature search, data collection and findings interpretation. IB and SF wrote the manuscript. All authors approved the final manuscript.


There have been no published studies of carcinogenic human papillomavirus (HPV)--the necessary cause of cervical cancer--in Haiti, a nation that has one of the greatest burdens of cervical cancer globally.Characterize prevalence of carcinogenic HPV and the prevalence of individual carcinogenic HPV genotypes in women with cervical precancer or cancer, cervical intraepithelial neoplasia grade 2 (CIN2) or more severe (CIN2+).Women  were screened for carcinogenic HPV by Hybrid Capture 2 . Carcinogenic HPV positives underwent colposcopy and visible lesions were biopsied. A subset of carcinogenic HPV positives was tested for individual HPV genotypes using a GP5+/6+ assay.trend < 0.001). Women with 3 or more sexual partners and who started sex before the age of 18 years had twice the age-adjusted prevalence of carcinogenic HPV of women with one partner and who started sex after the age of 21 . HPV16 and HPV35 were the most common HPV genotypes detected in CIN2+ and more common in women with CIN2+ than those without CIN2+. HPV16 and/or HPV18 were detected in 21.0% of CIN2 (n = 42), 46.2% of CIN3 (n = 52), and 80% of cancers (n = 5).The prevalence of carcinogenic HPV was 19.0%  and decreased with increasing age (pThe prevalence of carcinogenic HPV in Haiti was much greater than the prevalence in other Latin American countries. High carcinogenic HPV prevalence and a lack of cervical cancer screening may explain the high burden of cervical cancer in Haiti. Cervical cancer is a major cause of cancer mortality in women of Haiti. In an early study of cancers in Haiti , cervicaAmong the reasons for high incidence of and mortality from cervical cancer in Haiti is a lack of widespread screening for cervical precancer, cervical intraepithelial neoplasia grade 2 (CIN2) or CIN3, by cervical cytology (Papanicolaou test) or visual inspection with acetic acid with or without magnification (VIAM or VIA). Indeed, regular health exams are rare among the population. Furthermore, even with examinations once or a few times in a lifetime, the accuracy and quality of such exams can be compromised due to lack of quality infrastructure, medical review, quality control, and aggressive follow-up for intervention. Also, chronic inflammation in Haitian women who have never been screened can compromise an effective diagnosis from slide smears .Since the discovery of human papillomavirus (HPV) in cervical cancer by Harold Zur Hausen (2008 Nobel Laureate in Medicine) and colleagues more than 30 years ago ,5, therepopulation effectiveness guided by an understanding of the causal model of cervical carcinogenesis and by an application of these technologies in an age-appropriate manner relative to the exposure to HPV [The discovery of a single, necessary cause of cervical cancer has led to the development of prophylactic HPV vaccines for primary cancer prevention of HPV infections and molecular testing for carcinogenic HPV for secondary cancer prevention through the early detection of cervical precancer and cancer. Both have demonstrated high degrees of efficacy with maximum e to HPV .Using a comprehensive search strategy, our research has found that no detailed study on HPV prevalence in Haiti has been published to date, despite the importance that such data can provide for planning effective primary and secondary prevention programs to reduce the prevalence of cervical cancer . As partThis study was approved by the Western IRB  and by the Misyon Sante Fanmi Ayisyen IRB in Haiti.This study was conducted in two medical centers situated in the cities of Port-au-Prince and Leogane, Haiti. Women attending two cervical-cancer prevention clinics established by Family Health Ministries were invited to participate. Recruitment was done by word-of-mouth and local radio announcements. Women were eligible to participate if they (a) were aged 25 to 60 years of age, (b) reported having at least one sexual partner in their lifetime, (c) were not pregnant, (d) were not menstruating at time of screening, and (e) had not had a hysterectomy. A total of 9,771 women who met these eligibility criteria were enrolled.Trained personnel obtained written informed consent from all eligible women. The consent forms were translated into Haitian Kreyol, and bilingual personnel facilitated the consenting process. Each participant was required to sign the consent form to signify comprehension; illiterate participants provided consent by placing an X on the consent form. A subject ID number was assigned to identify each specimen. To ensure confidentiality, no other participant-identifiers such as demographic information were used outside the specimen collection site. digene® cervical brush , suspended in Specimen Transport Medium™ (STM) and stored at ambient temperature before being sent to Qiagen® for HPV testing.Trained personnel using a questionnaire designed to collect information on socio-economic demographics, reproductive health information, and contraceptive use interviewed eligible and consenting participants. Cervical samples were collected using the One day after collection specimens were shipped at ambient temperature and stored at 4°C at Qiagen until ready for testing . Specimens were tested for the presence of one or more of a pool of carcinogenic HPV  using Hybrid Capture 2  according to the package insert. A subset of HC2-positive specimens was tested for 49 individual HPV genotypes  using a modified version of GP5+/6+ PCR amplification and detection assay .This tesDNA was extracted from a 100-µL aliquot of the cervical specimen using the Qiagen QIAamp® Media MDx Kit according to the recommended protocol. The DNA was eluted from the columns with 100 µL of buffer AVE (RNase-free water containing 0.04% sodium azide) from the kit. A volume of 10 µL of extracted material was used in a 50-µL PCR reaction.The HPV genotyping results were classified hierarchically according to cancer risk ,14: HPV1Women who tested HC2 positive underwent routine colposcopy. Visible, acetowhite lesions were biopsied. Biopsies were read by a single pathologist at Hopital Sainte Croix in Leogane, Haiti. Women with CIN2/3 were treated with cryotherapy or hysterectomy based on clinical judgment. Women with cancer were referred to the General Hospital in Port-au-Prince or to Groupe de Support Contre Le Cancer, a support group in Haiti dedicated to cancer prevention and education.Of the 9,771 women enrolled, 9769 (99.9%) had HC2 results available and subsequent analyses were restricted to this group. Age-group  specific prevalence of carcinogenic HPV as detected by HC2 with binomial 95% confidence intervals (95% CI) was calculated. Pearson chi-square, Fisher’s exact tests, and/or a non-parametric test of trend  were usetrend < 0.001), from 33.4% (95%CI: 28.5-38.8%) in women aged 25-29 years of age to 14.4% (95%CI: 8.9%-21.7%) in women aged 55-60 years of age.The overall prevalence of carcinogenic HPV in the 9,769 women tested by HC2 was 19.0% (95%CI: 18.2-19.9%) 1. The ptrend < 0.001).Religion, marital status, age at first sex , lifetime number of sexual partners, and parity were all associated with testing HC2 positive . Notably, there was a trend of increasing likelihood of testing HC2 positive with increasing numbers of sexual partners and decreasing likelihood of testing HC2 positive with older age at first sex  by lifetime number of sexual partners  and category of age at first sex  2. Of thFinally, among HC2 positives , 1,608 (86.5%) were tested for HPV genotypes and 1,252 of the 1,608 (77.9%) had at least one detectable HPV genotype 3. WomenOf the 1252 confirmed HR-HPV positives , 1198 available patients were referred for colposcopy 4. Most Of those who tested positive for HPV genotypes, 231 of 1,252 (18.5%) had multiple carcinogenic HPV genotypes detected. HPV16 was the most common carcinogenic HPV genotype detected overall as well as among those with a single carcinogenic HPV genotype detected, and for all women diagnosed with CIN2+. Among women with CIN2+ diagnoses and single carcinogenic HPV infections detected, HPV16 (25.9%), HPV35 (19.8%), HPV52 (12.4%), HPV31 (11.1%), and HPV18 (9.9%) were the most common HPV genotypes detected whereas HPV39 and HPV59 were not detected. HPV16  and HPV35  were more common in women with CIN2+ than without CIN2+. HPV18, 31, 33, 52, 58, and 68 were equally common in women with CIN2+ as without CIN2+. HPV39, 45, 51, 56, and 59 were less common in women with CIN2+ than without CIN2+ (p < 0.05).trend < 0.001), from negative histology (11.9%) to cancer (40.0%). A similar increase was not observed for HPV18, or for any other HPV genotype (data not shown). Concomitantly, the percentage of positives for carcinogenic HPV genotypes other than HPV16 and HPV18 decreased with increasing severity of disease (ptrend < 0.001). HPV16 and HPV18 accounted for up to 21.4% of CIN2, 46.2% of CIN3, and 80% of cancers. HPV16- and/or HPV18-positive CIN2/3 occurred at younger median age than CIN2/3 due to other HPV genotypes .Categorizing the HPV results according to cancer risk 4, 15.8%To our knowledge, this is the first report of carcinogenic HPV prevalence and HPV genotypes in cervical disease in women living in Haiti. This was a large community-based sample of nearly 10,000 women living in Port-au-Prince and Leogane, Haiti, resulting in precise estimates of carcinogenic HPV prevalence by age, which can be used to guide primary and secondary cervical cancer prevention strategies. It is noteworthy that the prevalence of carcinogenic HPV was very high in this population compared to other populations in Latin America. As shown in We observed that the age of diagnosis of HPV16/18-positive CIN2/3 was approximately three years younger than the diagnosis of CIN2/3 related to other carcinogenic HPV types. This is consistent with previous reports of HPV16- or HPV16/18-CIN2/3, CIN2, or CIN3 being diagnosed at an earlier age than CIN2/3 due to other HPV genotypes –26. A siOne of the important limitations of this study was that only visible lesions were biopsied, undoubtedly leading to an under-ascertainment of disease; there were 42 CIN2+ (0.4%), 52 CIN3+ (0.5%), and 5 cancers (0.05%)  diagnosed. It has been repeatedly shown that taking more biopsies, including the taking of biopsies of normal-appearing tissue, increases the diagnostic yield of colposcopy for CIN2+ and CIN3+ ,28. Of nWe acknowledge several other limitations of this study. First, the prevalence of carcinogenic HPV genotypes was predicated on being HC2-positive and therefore any HPV genotype-specific biases of HC2 would influence these measurements. However, HC2 is clinically very sensitive for CIN2+  so theseIn conclusion, we found a very high prevalence of carcinogenic HPV in this population. The high prevalence of carcinogenic HPV infection and the absence of cervical cancer screening may explain the high burden of cervical cancer in Haiti ,3.