Persistent infection with one of the most high-risk genotypes of human papillomavirus causes all cases of cervical cancer and a significant proportion of other genital cancers. The HPV virus, unlike any other infection that leads to cancer, is transmitted only through sexual intercourse and is less affected by the general changes and development in lifestyle and medical standards, so only vaccination and screening can prevent the HPV virus and cancers caused by it. Therefore, determining the prevalence and distribution of HPV genotypes are of utmost importance in screening strategies regarding cervical cancer and vaccination decisions against HPV that vary based on the geographical and cultural characteristics of the study area. As a result, this study aimed to determine the frequency of human papillomavirus and the distribution of this virus's genotypes in the general population of women living in 11 provinces of Iran.  This study is a community-based survey study. Sampling was done by the cluster sampling method. Women aged 15–59 years old from the general population living in 11 provinces of Iran were included in the study after considering the inclusion and exclusion criteria. Data were collected using a questionnaire and vaginal examination. The study was performed on 2562 vaginal specimens that were referred to the laboratory of the present study. HPV genome was detected by the nested MY-GP method and papillomavirus genotyping was performed using the PCR multiplex method to identify 19 papillomavirus genotypes.  The general prevalence of HPV in the 11 provinces was obtained at 2.4% (108 out of 2562 people). The highest prevalence of the virus was in the age group of 25–34 years. The prevalence of HPV was statistically significant among different provinces. Hormozgan province with 22 cases (5.9%) had the highest and Isfahan province with 6 cases (2.2%) had the lowest incidence of HPV. The prevalence of high-risk HPV and medium-risk HPV is 3%, and the prevalence of low-risk HPV was estimated to be 2.1% of the total female population. Also, the highest prevalence was related to genotype 16.  According to the high prevalence of the HPV virus in young age groups in Iran, it is necessary to pay attention to screening programs to reduce the incidence of cervical cancer. Human papillomavirus (HPV) is a small virus with a double-stranded DNA genome that tends to attach to the squamous epithelium of the skin layers  and mucoHelicobacter pylori, hepatitis B, C), is transmitted only through sexual intercourse and is less affected by the general changes and development in lifestyle and medical standards, so only vaccination and screening can prevent the HPV virus and cancers caused by it [The rate of incidence and prevalence of cancers associated with the HPV virus is on the rise . In 2018ed by it . In thised by it  and the ed by it  of this ed by it . Therefo The present study is a community-based survey study. The aim was to determine the frequency of human papillomavirus in Iranian women and to know the distribution of genotypes of this virus in the general population of women living in different provinces of Iran. 2631 samples were transferred to the laboratory for the present study. But the laboratory studies were performed on 2562 samples that had the necessary quality for analysis. Cluster sampling was done by first randomly selecting 11 universities from among the country's medical universities; then in each university, 3 urban areas and 2 rural areas that had the maximum difference in economic and social conditions were selected. Women who were members of households covered by selected medical university centers  were invited to participate in the HPV virus screening project as a public call for the prevention and early treatment of cervical cancer. In each cluster, the wide spectrum of the age group of the population was considered. Iranian females living in the mentioned geographical areas, ages 15–59 years, who were married or had a history of marriage, were precipitated in the study after signing a written consent. To gather data, a questionnaire, related to basic information, demographic characteristics, medical history, and lifestyle of the participants, as well as a section dedicated to clinical information related to gynecologic examination, was designed. The questionnaires were completed by the interviewers with a midwifery degree who had received the necessary training to conduct the interview. Vaginal examination and collecting vaginal discharge samples were performed by a gynecologist and a midwife in one of the selected centers' affiliate medical universities. Abnormal cases  were recorded in a questionnaire, and the patients in question were further evaluated and treated. During speculum examination, sampling was performed using a cytobrush; then, the brush containing cervical cells was placed inside the thin prep vial with a volume of 20 ml and then was subjected to a Pap smear test and HPV screening. After recording the patient's profile on the vial and slide, the samples were placed in a special refrigerator (with a temperature of 2–4°C) to maintain the cold chain and were transferred to two designated laboratories for the HPV test. Among the collected samples, the sample of 2561 women participating in the study was transferred to the virology laboratory of Dr. Masih Daneshvari Hospital. The present study is the result of a statistical analysis of samples sent from 11 provinces  to this laboratory.HPV genome was detected by the nested MY-GP method ; then, tThe present study was approved by the ethics committee of the Iran Ministry of Health and Shahid Beheshti University of Medical Sciences. All necessary permits for research implementation were obtained from the Vice-Chancellor of research and submitted to selected university centers. The objectives of the study were provided in writing to the management of medical centers. All subjects were free to participate in or leave the study, and written consent was obtained from those wishing to participate in the study. Participants in whom the HPV virus, genital diseases, epithelial cell abnormalities, and malignancies were diagnosed were referred to medical centers to complete diagnostic and treatment procedures. In all stages of the project, the principle of confidentiality of participants' information was maintained.p value of less than 0.05 was considered significant. To analyze the qualitative data of the test, χ2, and if needed ‘‘Fisher's Exact Test” was used. Due to the abnormal age distribution, the “Mann–Whitney test” was used to compare the average age.To analyze data, SPSS version 22 was used. In all tests, a The study was performed on 2562 women aged 15–59 years from the general population living in 11 provinces of Iran after considering the inclusion and exclusion criteria. The general prevalence of HPV in 11 provinces was obtained at 4.2% (108 out of 2562 people). The prevalence of high-risk/intermediate-risk and low-risk HPV genotypes was estimated to be 3% and 1.2% of the total female population, respectively . Among tp=0.38). There was no statistically significant difference in the prevalence of HPV in different age groups (p=0.56). But the most prevalence of HPV was related to the age group of 25–34 years (4.5%), and the lowest prevalence was related to the age group of 55 years and above (3.4%). There was a significant difference between the prevalence of HPV in different provinces (p=0.33). Hormozgan province with 22 cases (9.5%) had the highest and Isfahan province with 6 cases (2.2%) showed the lowest prevalence of HPV. Based on previous studies, it was suggested that age, occupation, and education may affect the differences, in the prevalence of the virus among the provinces, so to examine the effect of these three variables, logistic regression analysis was performed. The results of regression showed that after adjustment based on the mentioned variables, the prevalence of the virus was significantly different between provinces, and the highest prevalence was still related to Hormozgan province (results are not shown). There was a significant difference in the prevalence of HPV between the two groups of employed and housewives (p < 0.05); HPV's prevalence was significantly higher in working women than in housewives. There was a significant difference in the prevalence of HPV based on the number of deliveries (p < 0.01), and the prevalence of HPV was lower in women who had more deliveries (the number of deliveries was 2 ± 2 in the group affected by HPV Vs. 3 ± 2 in the nonaffected group). Statistically speaking, there were no significant differences in the prevalence of HPV in educational status, marital status, history of abortion and stillbirth, and the history of genital infections.p=0.53). Even though the prevalence of high-risk HPV genotypes was higher in Yazd and Semnan, no significant difference was seen in the prevalence of HPV genotypes among different provinces (p=0.33). Also, in terms of education, marriage, employment, history of abortion, stillbirth, and history of genital infections, no significant difference was observed between the three groups of high-risk, low-risk, and moderate-risk genotypes.Human papillomavirus plays an important role in the pathogenesis of cervical cancer, and awareness about the prevalence and distribution of its genotypes in adopting cervical cancer screening programs and deciding on vaccination against HPV is necessary. This study aimed to determine the frequency of human papillomavirus and the distribution of genotypes of the virus in the general population of women living in 11 provinces of Iran.Mycoplasma genitalium, Chlamydia trachomatis, and Neisseria gonorrhea) to be 38.6% [In the present study, the prevalence of HPV was obtained at 4.2%. Studies related to the prevalence of HPV in Iranian women have estimated the prevalence of the virus in different provinces to be 5.5%–36. 5% –24. The be 38.6% . Also, abe 38.6% . The HPVIn connection with the prevalence of HPV in other countries, it should be borne in mind that the virus is associated with cervical cancer, so its prevalence in different countries is affected by the prevalence of cervical cancer . In a meIn our study, the prevalence of high- and intermediate-risk HPV genotypes was 3% and the prevalence of low-risk HPV was estimated at 1.2%. Khodakarami et al. reported the prevalence of high-risk and low-risk HPV genotypes among the general population of women in Tehran and estimated to be 5.1% and 3.3%, respectively . Jamdar In the present study, the highest prevalence was related to genotype 16, followed by genotypes 66, 6/11, 42, 18, 39, 44, 53, 59, 43, 51, and 89. Some studies in Iran have identified several virus-related genotypes. Hamkar et al. in a study on women in different regions of Iran with normal cervical cytology showed that genotypes 16, 18, 66, and 11 followed by 6, 26, 31, 35, 44, 45, 51, 52, 53, 56, 67, 68, 73, 84, 89, and 90, respectively, are the genotypes observed in Iranian women . A meta-In the present study, the prevalence of genotypes 16 and 18 in the total study population was 1.1% and 0.28% and was almost similar to other studies conducted in Iran. Farahmand et al. showed the prevalence of 16 and 18 genotypes in women without cervical cancer at 1.8% and 1.2%, respectively . Malari p < 0.01). Many studies have examined the prevalence of HPV in different provinces of Iran, but a similar study that compared HPV in the provinces of the present study was not observed.The prevalence of HPV has a significant difference between provinces. Hormozgan province with 22 cases (9.5%) had the highest and Isfahan province with 6 cases (2.2%) had the lowest incidence of HPV  may play a role in the recent increase in the incidence of cervical cancer in younger age groups and the higher prevalence of cervical cancer [In the present study, there was no significant difference in the prevalence of HPV in different age groups. But the most prevalence of HPV was related to age groups of 25–34 years (4.5%) and the lowest prevalence was related to age groups 55 years and above (3.4%). The prevalence of HPV varies according to age in different countries and populations. Results of a review study by Smith et al. showed that the prevalence curve of HPV depending on the age and the geographical area can be descending, flat, or U Shape  . Jamdar l cancer .In the present study, the prevalence of HPV has no significant relationship with the history of genital infections, and only 4.76% of women with HPV have mentioned a history of genital infections. According to various studies, the prevalence of genital infections is to be more expected in women with HPV. It seems that the lack of awareness that many participants have regarding different types and symptoms of genital infections and bias recalling will be effective in this finding.In the present study, the number of deliveries is related to women being infected with HPV, and women with HPV have had fewer deliveries. Hamkar et al. in a study on women with normal cytology showed that the prevalence of HPV is higher in women without a history of childbirth . Other sThe high sample size and wide geographical areas are the strengths of our study. One of the limitations is the lack of study of women in some provinces, especially Tehran province.In the study, the prevalence of HPV is estimated in the general population of women, aged 15–59 in 11 provinces of Iran to be 4.21%. Also, the prevalence of high-risk and intermediate-risk HPV was shown to be 3.04%, and the prevalence of low-risk HPV was estimated to be 1.17% of the total female population. Hormozgan province has the highest and Isfahan province has the lowest HPV infections. The most prevalence of HPV was related to the age group of 25–34 years, and the lowest prevalence was related to the age group of 55 years and above. Its higher prevalence in young age groups indicates the need to pay attention to planning and policy-making for vaccination and screening programs.


Due to the increasing occurrence of these neoplasms on a global scale, it seems important to estimate the risk factors in the population. So far, data on the presence of oral HPV in the European population are scarce. Oral HPV was detected in 53 out of 461 healthy subjects (11.5%) in south-eastern Poland. Among the most common oncogenic types, HPV 16 was reported in four subjects (0.87%) and HPV 18 in three subjects (0.65%). Another high-risk type, HPV 45, was detected in nine subjects (1.95%). Low risk types  were detected in 25 cases, which constituted 5.4% of all tested samples. In adults and children, statistically more HPV positive cases have been reported in males than in females. A positive relationship was demonstrated between age and the amount of positive oral HPV. The presence of HPV was statistically more frequent in the population living in urban rather than in rural areas in all studied age groups ( Human papillomaviruses (HPV) constitute a genotypically diverse group of small nonenveloped, double-stranded DNA viruses that are mainly transmitted through sexual contact. HPV infects the epithelial cells of the skin and mucosa. Most HPV infections are asymptomatic and are cleared within 12–24 months after infection. However, some of these infections may persist and become life-threatening ,4. The HThe presence of oral HPV prevalence can cause a wide variety of lesions, from benign to malignant. One of the most common cancers in the head and neck region is oropharyngeal squamous cell carcinoma. HPV infects the mouth and throat, causing cancer of the oropharynx that covers the back of the throat, including the base of the tongue and tonsils . It is cThe aim of this study is to assess the prevalence of HPV in the oral cavity of a healthy population in south-eastern Poland. Information on the presence of specific genotypes in a healthy population and the examination of the correlation between viral infection and socio-demographic features is essential for future screening and early diagnosis of the oral lesions, HPV-related cancers, and other comorbidities.The present study involved a total of 461 healthy people, including 118 children aged 5–10 years, 97 adolescents aged 15–19 years, and 246 adults over 20 years of age. Oral swabs were collected from all individuals. Brush swabs were collected by a dentist during a preventive dental examination. Admission criteria included no head and neck neoplasm or precancerous lesions, no lesions associated with HPV infection, no previous diagnosis of anal or genital warts or tumors, no severe systemic condition or HIV, and good general health. People were divided according to the place of residence into rural or urban areas and classified into age groups. Additionally, the respondents were divided according to gender.A cytobrush was rubbed with medium pressure over the premolar and molar region of the cheeks 5 times, turned, and rubbed another 5 times. This procedure was performed both on the right and left cheeks. The cytobrush was then placed in an Eppendorf tube and frozen at −80 °C until the analysis.The viral genetic material was isolated using the QIAamp DNA Mini Kit  according to the manufacturer’s instructions. After isolation, the purity and yield of the obtained eluate were assessed using an Epoch spectrophotometer . The measurement was performed on the Take 3 plate  enabling measurement in microvolumes (2 μL). Microplate Reader Software Gen 5.2.0  was used to analyze the results. The isolates were stored at −20 °C until the test was performed. In order to check the quality of the obtained DNA (presence of polymerase chain reaction inhibitors), a test for β-globin was performed.HPV detection and genotyping were performed under the INNO-LiPA HPV Genotyping Extraassay  according to the manufacturer’s protocol. The kit is based on the amplification of a 65 bp fragment from the L1 region of the HPV genome with a SPF10 primer set. PCR products are subsequently typed with the reverse hybridization assay. As a quality control, primers amplifying a fragment of the human HLA-DPB1 gene are added to the HPV amplification kit to check the quality of the sample and the efficiency of the extraction. The quality control also used positive and negative control and conjugate control line. Assay includes all currently known high risk HPV genotypes and probable high risk HPV genotypes . In addition, this kit allows the detection of low-risk HPV genotypes  and some additional genotypes . After DNA extraction, the samples were amplified by PCR (40 cycles) using Inno-LiPA HPV Genotyping Extra Amp according to the manufacturer’s instructions.PCR amplification was performed in a reaction mixture including excess deoxynucleoside 5’-triphosphates (dNTPs) containing deoxyuridine triphosphate, biotinylated primers, thermostable DNA polymerase, and uracil-N-glycosylase (UNG). After 40 cycles of PCR reaction, the multi-amplified biotinylated target sequence was acquired. Thereafter, hybridization of the amplified product was performed on the strip, followed by thorough washing. Conjugate and substrate were then added, causing color development. The strips were read visually using a manufacturer’s reference guide when they were completely dry.p < 0.05.The socio-demographic characteristics of the patients and the difference in the frequency of HPV between different groups of people were determined using the Pearson chi-square test. The statistical significance was defined as The research was approved by the Medical University of Lublin Ethics Committee and is in accordance with the GCP  regulations . Written consent was obtained from the respondents and from parents in the case of children and youth. The presence of HPV was statistically more common in the population living in the urban area in all studied age groups. In adults and children, statistically more HPV positive cases have been reported in men than in women. Additionally, in the case of youth, more HPV positive cases in men than in women were not statistically significant . OverallThe incidence of HPV varies in different populations and depends on the type of clinical material and the research method used . The preHPV is associated with many different cancers. One of them is oropharyngeal cancer, which is one of the most common subtypes of head and neck cancers, with significant morbidity and mortality. Recently, HPV has been recognized as an etiological factor in this neoplasm . The incCancer prevention is important, as confirmed by recent data suggesting that oropharyngeal cancer incidence is increasing and may be due to the presence of oncogenic HPV types. In addition, the effectiveness of prophylactic HPV vaccination is less known for oropharyngeal cancer than for anogenital or cervical cancer . TherefoIn conclusion, our study showed that the presence of oral HPV (both oncogenic and non-oncogenic) was low in the healthy population living in south-eastern Poland. The number of positive HPV cases was higher with the age of the subject. Moreover, HPV was more frequently detected in males and in people living in urban areas. It should be emphasized that further socio-epidemiological studies are needed to broaden the knowledge about the presence of oral HPV in the oral cavity. Our study has several limitations, such as the lack of information on risk factors that could be associated with the presence of specific genotypes in the studied population, such as smoking, alcohol consumption, sexual behavior, vaccination status, or piercing in the oral cavity. It should be noted that the detection of HPV genetic material depends on the method of collecting the material from the oral cavity, such as saliva or swab. In addition, various PCR methods are used to detect HPV DNA. It should be noted that in most studies on the presence of HPV, samples are taken from visible lesions in the oral cavity, while, in our study, the material was obtained from a healthy oral cavity . MoreoveThe presence of HPV in the oral cavity of healthy subjects in south-eastern Poland was low at 11.5%. Prevalence of HPV in the oral cavity was more often detected in the elderly, and the lowest HPV detection was in children. In addition, in our study, oral HPV was found more often in males than in females. The presence of HPV in the oral cavity was higher in people living in urban areas than in rural areas. Overall, the presence of high-risk HPV, such as HPV 16 and HPV 18, was low in our study. Moreover, the presence of low-risk HPV in the oral cavity of the study population was 5.4%.Summarizing, this study provides information on the presence of HPV genotypes in the oral cavity of a healthy population in south-eastern Poland and investigates the relationship between socio-epidemiological features and the presence of HPV in the oral cavity in healthy subjects. HPV is the cause of many cancers and a better understanding of its epidemiology and infection-related characteristics is crucial for effective and targeted preventive measures. Further research is needed to investigate the presence of HPV in this part of Europe, and thus detect early and reduce oral lesions, HPV-related cancers, and other comorbidities.


There is limited data on human papillomaviruses (HPV) prevalence in transpeople due to low acceptance rate of screening methods. HPV tests from self-collected urine are gender-neutral, have a high acceptance, and have a comparable accuracy in females to clinician-collected samples. The aim of this study was to evaluate both the HPV prevalence in the urine in a large cohort of 200 transpeople with common risk profiles and the acceptability of such screening method.The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. 200 transpeople have been enrolled between May and October 2021. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills.Subjects were asked to answer a survey concerning gender identity, established risk factors for HPV infections as well as their preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample. Five patients not able to provide urine were excluded. HPV genotyping was performed using a validated multiplex real-time PCR assay, which simultaneously detects 28 HPV genotypes. This trial is registered at ClinicalTrials.gov, NCT04864951.p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Overall, 79·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected HPV screening.Overall HPV positivity was 19·0% (37/195), 24·2% in female to male, 11·8% in male to female, 26·3% in genderqueer/non binary/other subjects, 27·9% in subjects currently having a cervix, and 26·0% in subjects born with cervix. Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (HPV testing in self-collected urine samples provides a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.None. At the time of trial design (October 2020), we searched PubMed for all article types using search terms: “HPV prevalence” + “transgender” + “transmen” + “transfemale” with no restrictions on date. Non-English/French/German articles were excluded. We excluded all studies that focused on HPV vaccination coverage and not HPV infection rates, and studies that did not distinguish between transvestites, men who have sex with men, or transgender women. No meta-analysis has ever been conducted, reviews point out the lack of data.Persistent infections with high-risk genotypes of human papillomaviruses (HPV) can cause precancerous lesions and lead to invasive cancer if untreated. There are only a few publications about HPV prevalence in transpeople, especially with common risk profiles e.g. non sex-workers.We present a non-invasive HPV screening method with high acceptance in a vulnerable population.This large study describes an HPV prevalence of 19·0% (37/195) in self-collected urine of transpeople with common risk profiles. Furthermore, detailed data for female to male, male to female or genderqueer/non binary/other non-binary transpeople with current or former presence of a cervix is presented.Independent of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infections (p = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Therefore, 379·0% (154/195) of transpeople would prefer urine HPV tests to provider-collected cytology-based screening.HPV testing of self-collected urine may provide a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.Alt-text: Unlabelled boxPersistent infections with high-risk genotypes of human papillomaviruses (HPV) can cause precancerous lesions and lead to cancer if untreated. Approximately 99% of all cervical cancers, 88% of anal cancer, 70% of vaginal cancer, 25% of vulvar cancer, 30% of penile cancer, and up to 22% of oropharyngeal cancers are due to persistent HPV infections.There is limited literature data on HPV prevalence in transpeople with common risk profiles and obtained mostly in small cohorts, but it is generally assumed that it is as high or even higher than in cispeople ranging from 16·0% (21/131) to 21·4% (3/14) in female to male (FtM), 11·5% (6/52) in neovaginal, and from 52·4% to 88·6%  in anal samples in male to female (MtF).11Independently of national health systems or screening strategies, acceptance of cytology- or HPV-based screening is lower for transmen than for ciswomen especially because of the need for genital examination.,Devices for self-collected urine are licensed gender-neutral, have a high acceptance, and the same HPV testing accuracy as clinician-collected samples in people with a cervix.,Although a penile swab from the external urethral meatus, the glans, the coronal sulcus, and the shaft is currently the gold standard for research purposes, most previous MtF studies used anal sampling even in presence of a penis.11The aim of this study was to evaluate the HPV prevalence in the urine of a large cohort of 200 transpeople and the acceptance of this HPV-based screening.To the best of our knowledge, this is the largest study on HPV prevalence in transpeople with common risk profiles, e.g. non sex-workers, conducted so far. Additionally, it is the first study to determine HPV in urine of transpeople.The study was conducted at the outpatient clinic for transpeople at the Department of Obstetrics and Gynaecology, Medical University of Vienna, Austria. All 203 transpeople who attended the outpatient clinic for hormonal treatment monitoring on a scheduled study day were assessed for eligibility between May and October 2021, three declined to participate, 200 were included in this study. Inclusion criteria were gender identity dysphoria, age over 18 years, and adequate language skills. All eligible patients were invited to participate in the study regardless of gender reassignment surgery. After the allocation number was assigned, subjects were asked to fill out a survey with questions concerning gender identity, sexual orientation, number of sexual partners, history of cytology- or HPV-based screening, HPV vaccine status, smoking, preference regarding urine or provider-collected cytology-/HPV-based screening, and to provide a urine sample (see online supplementary text 1). Two informed consent forms, one survey and the prefilled collector tube for self-collected urine were labelled with the subject´s allocation number. All subjects received the results of the HPV test by mail up to the 3 weeks after examination, and, in the case of an HPV positive result, further examinations and counselling at the Medical University of Vienna, outside the study settings, were offered.Out of 200 eligible patients, five patients were not able to provide a urine sample during the visit and were excluded from the study.,Urine samples were collected using Colli-Pee FV-5000® series prefilled with 3·4 millilitres (ml) Urine Conservation Medium  allowing a collection of 9-12 ml first-void urine. This collection method has been used for HPV prevalence assessments to monitor the impact of HPV vaccination in Bhutan and Rwanda and is currently used in an HPV prevalence study in Thailand.The labelled samples were shipped to the Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Slovenia for HPV testing.After arrival in the laboratory urine samples were stored at 4°C and processed within 3 days. Briefly, the urine samples were thoroughly vortexed, 5 ml of the urine was transferred to a 15-ml tube, the remaining urine was aliquoted into 2-ml microcentrifuge tubes, and stored at −80°C. Cells were pelleted by centrifugation at 800 rcf for 10 min and all but approximately 200 µl of the supernatant was discarded. Cells were resuspended in the remaining supernatant solution. DNA was extracted from 200 µl of the sample using the QIAamp DNA Mini Kit . The DNA was eluted in 50 µl of buffer AE into a 1·5 ml microcentrifuge tube. If not processed immediately, the isolated DNA was stored at −20°C.HPV detection and genotyping was performed using the widely used and well validated multiplex real-time PCR assay, Anyplex II HPV 28 Detection , which simultaneously detects 28 HPV genotypes  and an internal control. Five µl of isolate was used in two wells of the run. One negative control and three positive controls from the kit were used in each PCR run. Analysis of the results was performed automatically using Seegene Viewer software according to the manufacturer's instructions. In the Ljubljana laboratory, Anyplex II HPV 28 Detection kit demonstrated 100% proficiency (100% sensitivity and 100% specificity) when testing 2019 and 2021 HPV Labnet international genotyping proficiency panels consisting of 44 blinded specimens and prepared by WHO International HPV Reference Center .Approval for this study was obtained from the Ethical Review Board of the Medical University of Vienna (IRB 1186/2021). This study follows the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline. The study was registered on clinicaltrials.gov (NCT04864951). All patients provided written, informed consent.The primary outcome measure was HPV prevalence in the urine of transpeople. Secondary, known risk factors for HPV infection and persistence were analysed. Furthermore, acceptance of HPV-based screening using urine samples was evaluated.Nominal variables were reported as numbers and frequencies, and continuous variables as medians and interquartile ranges. Nominal variables between groups were compared using the Chi square test, and continuous variables were compared between groups using the Mann-Whitney-U-Test as they were non-normally distributed according to a Kolmogorov-Smirnov Test. All statistical tests were 2-sided. Significant parameters were entered in a multivariate logistic regression model. All analyses were performed using SPSS statistics for Windows, version 27·0 , and p-values < 0·05 were considered statistically significant.There was no funding. All authors had full access to the data and were responsible for the decision to submit for publication.203 transpeople were invited to participate in the study and three of them declined, therefore the willingness to participate in this study was 98·5% (200/203). A total of 200 transpeople were enrolled, but five individuals had to be excluded due to missing urine samples  was 19·0% (37/195), 24·2% (22/91) in FtM, 11·8% (10/85) in MtF, 26·3% (5/19) in genderqueer/non binary/other subjects, 27·9% (24/86) in subjects currently having a cervix, and 26·0% (27/104) in subjects born with cervix . All samp = 0·008), yet 42·3% (44/104) have never attended cervical cancer screening. Subjects who underwent screening at least once described that they experienced the pain during examination of 6 grade (4-8) on the visual analogue scale  and would therefore prefer an urine HPV test to cytology-based screening in 88·3% (53/60), 7 subjects stated that they did not know, no one would prefer cytology-based screening. In addition, subjects with a neovagina underwent cytology-based screening in 21·7% (5/23) and would prefer urine HPV test to cytology-based screening in 80·0% (4/5). Overall, 79·0% (154/195) would prefer urine HPV tests to provider-collected cytology-based screening, 21·0% (41/195) did not know, no one preferred a cytology-based screening.Independently of gender reassignment surgery, being born with a cervix was associated with a higher risk of HPV infection  of cervical high grade squamous intraepithelial lesion (HSIL) were diagnosed and treated with a large loop excision of the transformation zone (LLETZ); another one was treated with Imiquimod  due to condyloma. Three instead underwent gender reassignment surgery with hysterectomy with bilateral salpingo-oophorectomy in the six months following the study, no dysplasia was found in the surgical specimen .Combined HPV prevalence in the urine samples obtained from 195 transpeople in this study was 19·0% for the 28 targeted HPV genotypes. HPV prevalence in subjects currently having a cervix in this study was higher  than previously described by Reisner et al. .,,HPV prevalence in MtF was 11·8% (10/85) which is comparable to 11·5% (6/52) HPV positivity in neovaginal HPV sampling described by Van der Sluis et al.,Nevertheless, while the analytical sensitivity of HPV testing in urine from a penile urethra has substantially increased and study protocols were adopted, it still appears to be inferior to swabs.Regarding the acceptance of study participation of 98·5% (200/203), only Loverrro et al. included subjects during the visit of the outpatient clinic for hormonal treatment monitoring and reported a participation rate of 87·5% (35/40).Pain during genital examination is considerably higher in FtM (6 (4-8) on the VAS) than in ciswomen whose pain during speculum insertion was described with less than 2 on the VAS (1·7 (0-7·5)). For comparison, pain during speculum insertion and biopsy for HPV-associated lesions was described with 3·0 (0-8·5) on the VAS.,,Childhood sexual abuse was described by 19% in transpeople, being the highest in FtM.The reported HPV vaccination rate of 10·3% in the study population is low. Even if we analyse only those subjects who had had the possibility to be vaccinated against HPV since 2014, when Austria implemented its gender-neutral children's HPV vaccination program, vaccine uptake rate is 17·4%.The combination of a rate of childhood sexual abuse in transpeople that is twice as high as in cispeople, a modest HPV vaccination rate amongst transpeople, and a low acceptance of cytology- or HPV-based screening puts transpeople at particularly high-risk for HPV-related cancers.Limitations of this study are that childhood sexual abuse was not evaluated and the presence of HPV was only analysed in the urine and thus not compared to the sample type used in previously studies, e.g., provider-collected cervical, penile or anal swabs or self-collected swabs for hrHPV DNA detection. Furthermore, in Austria, transpeople must submit a clinical-psychological, a psychiatric, and a psychotherapeutic statement before starting hormonal treatment as well as before gender reassignment surgery. All but one subject had public health insurance. We investigated a Central European sample in a high resource country, therefore findings from this single centre study may not be generalised for different populations around the world. Moreover, due to the study setting, a self-reporting bias may have occurred, whereby especially the relevant questions regarding the number of sexual partners, pain during smear collection, preference for urine or smear collection, and nicotine consumption cannot be verified in the medical records. In addition, HPV testing protocol used has neither been validated from urine from a penile urethra nor in individuals without a cervix.The recommendation made for victims of sexual abuse to start HPV screening at age 18 and to provide awareness programs with generous access to HPV vaccination, is equally applicable to transpeople.In conclusion, this is the largest study on HPV prevalence in transpeople with common risk profiles conducted so far and the first to determine HPV in the urine of transpeople. HPV infections are common and we identified persons at risk. Our data show that HPV testing of self-collected urine has a high acceptance rate in transpeople. HPV testing of self-collected urine may provide a unique opportunity for screening of this hard-to-reach population and should be evaluated in further studies.Sophie Pils: the idea for the article, the literature search, the project's and the manuscript's conception and design, acquisition of data, statistical analyses, drafting the article and revising it for intellectual content, final approval of the version to be published.Jana Mlakar: the project's and the manuscript's conception and design, laboratory analysis, final approval of the version to be published.Mario Poljak: the project's and the manuscript's conception and design, the literature search, laboratory analysis, drafting the article and revising it for intellectual content, final approval of the version to be published.Grega Gimpelj Domjanič: the project's and the manuscript's conception and design, acquisition of data, final approval of the version to be published.Ulrike Kaufmann: the project's and the manuscript's conception and design, acquisition of data, drafting the article and revising it for intellectual content, final approval of the version to be published.Stephanie Springer: the project's and the manuscript's conception and design, acquisition of data, statistical analyses, drafting the article and revising it for intellectual content, final approval of the version to be published.Andreas Salat: acquisition of data, drafting the article and revising it for intellectual content, final approval of the version to be published.Eva Langthaler: acquisition of data, drafting the article and revising it for intellectual content, final approval of the version to be published.Elmar A. Joura: the idea for the article, the literature search, the project's and the manuscript's conception and design, acquisition of data, drafting the article and revising it for intellectual content, final approval of the version to be published.Anonymized data will be shared with a signed data access agreement with publication on request (Sophie.pils@meduniwien.ac.at). Study protocol will be shared with publication on request (Sophie.pils@meduniwien.ac.at).Elmar A. Joura reports advisory board fees, lecture fees and grants from Merck, and advisory board fees and lecture fees from Roche Diagnostics all outside of this study. Sophie Pils reports lecture fees from Merck outside of this study. Jana Mlakar, Mario Poljak, Grega Gimpelj Domjanič, Ulrike Kaufmann, Stephanie Springer, Andreas Salat, and Eva Langthaler report no conflict of interest.


This process influenced first time treatment users of the Veterans Affairs by deterring treatment-seeking behavior but was not found to affect veterans who had already initiated treatment. Despite the experience of stigma and commodification of their suffering through disability and diagnostic screening, veterans still sought disability compensation. Veterans viewed this compensation as acknowledgment of their loss and validation of their sacrifice.Posttraumatic Stress Disorder continues to be a highly stigmatized disease for the veteran population and stigma, experienced as a mark of discredit or shame, continues to be identified as the main deterrent in treatment seeking. Little attention has been paid to how the process of obtaining service-connected disability status can amplify veterans’ perceptions of being stigmatized. The following ethnographic study identified how combat veterans experienced stigma in processing through Veterans Affairs care and the effects of linking a Posttraumatic Stress Disorder diagnosis with disability compensation. Stigma was identified in two inter-related areas: 1) the structural level in the Veterans Affairs disability claims process and 2) the individual level in interactions with Veterans Affairs service providers. Findings based on veterans’ narratives suggest that the disability claims process, requiring multiple repetitions of personal trauma, coupled with perceptions of institutional stigmas of malingering, created  The convergent relationship between Posttraumatic Stress Disorder (PTSD), veterans’ experiences with PTSD-related stigma, and the need to be diagnosed with PTSD to receive Veterans Benefits Administration (VBA)  disabiliAfter two decades of military conflicts in Iraq and Afghanistan, the number of war veterans diagnosed with PTSD continues to rise. A RAND study conducted in 2008 estimated PTSD prevalence for these veterans at 13.8% .While treatment seeking for PTSD among veterans remains a serious public health issue, PTSD also remains the most prevalent compensable mental health disorder in the VBA’s disability system. PTSD claims have more than tripled in the last decade. About 22%  of all veterans who receive disability compensation through the VBA 4,944,275) have these benefits because they suffer from PTSD  PTSD symptom criterion B4/5, C2, D2/6, E1/5/6 . One malIn addition to veterans’ experience of symptom aggravation, the trauma pitch placed veterans’ pride and identity at stake, making veterans:…clam up in the compensation and pension exam and as a result get a 10% rating when they deserve a 50% rating.- Male, Iraq veteran and claims officer…the stuff you see and do (at war) is not something you want others to see, people getting killed … you have a persona you have to keep. Pride is a big thing.- Male, Afghanistan/Iraq veteran and claims officerWhen I’m told to tell my story time and time again, I try to downplay it. I won’t say how bad it was… tell all the details because I don’t feel like telling someone about the people that were killed, you know, dying moments. I don’t feel people deserve to know those moments. Those were my moments. I don’t want people to take that away from me, tell me how to think about it, how to feel about it.- Female, Afghanistan/Iraq veteranThese “dying moments”, intense personal experiences of war, were not something veterans wanted to corrupt in any way. They hold significant meaning and putting them into words diminished them. Veterans cherished and took ownership of these experiences and although they lost loved ones, they did not want to lose the fragments of their memories, or what it meant “to be a veteran”. And yet, these memories felt like they lost value upon every retelling:Having to tell people over and over makes it fake, not real… it desensitizes you. I don’t want that to happen.- Female, Afghanistan/Iraq veteranAltering the trauma memories in this way was a dehumanizing process that was experienced as insensitive care and having “to remember” in a non-reverent way felt shameful.It’s a PERSONAL THING, it was terrible and it gets diluted when you keep having to tell people about it. And then it gets mangled by docs. They break it down into clinical terms and that takes away from the experience and the memories. You have honor and respect for people you get deployed with, then it gets turned into some med student project where they are matching up the symptoms with the diagram in their textbook.- Male, Iraq veteranMemories particularly became corrupted in a technical manner through this transformation of personal experience into professional expertise . For veterans, this diagnostic process depersonalized traumatic events by turning them into quantifiable symptoms, scores, and statistics: “I think they downgrade (scores) because they need positive evidence in light of the public criticism, they are receiving… so now I’m a positive statistic” . One such scale, the Combat Exposure Scale includes questions like: “What percentage of the soldiers in your unit were killed (KIA), wounded or missing in action (MIA)?: (1) None; (2) 1–25%; (3) 26–50%; (4) 51–75%; (5) 76% or more” and “How often did you fire rounds at the enemy?” Depersonalizing experiences in this way contributed to the detachment that veterans already felt.As experiences became “diluted” through every round of assessments, veterans unanimously expressed anger at the depersonalized bureaucratic process that was required for them to receive compensation. Veterans became angry both when they needed to tell everything in detail in order to get a high rating  and when the VA awarded them a lower rating than they thought they merited.The claims process was described as:…very impersonal, I feel like they don’t care.- Male, Iraq veteranAnother male, Iraq veteran stated that when he went for his TBI test:…there were four med students in there, their trainer and my doctor. They were asking me questions and I felt like they were cross-examining me to see if my statement was the same (as my claim) and my story held up.TBI and PTSD have many of the same symptoms so often veterans will go through screening for both if they have had a head injury or were exposed to a concussive blast.The continuous and multiple evaluations made veterans not only feel like they had to keep their story straight (difficult and stressful because memory is affected by trauma) but more significantly, it made them feel like they had to defend their reactions to war:I have to justify why I have an issue, why I feel the way I do. It makes you feel bad… I think they are looking for inconsistencies in the story… I go in one day and tell them I saw 5 IEDs (improvised explosive devices) and the next time they ask I say it was 3 IEDS… I betray my own convictions entering that building because I don’t think the VA is in the business of helping veterans at the expense of these providers who are there to help…- Male, Iraq veteranProviders also struggled with the claims process and its quantification, in particular, the need to generate diagnosis rather than treat symptoms:The most painful experience of your life gets turned into a pain-scale and there is something really wrong and invalidating about that… they (veterans) know things about themselves we only know intellectually.- VA psychologist 1Some seasoned providers digressed from these screening tools to offer a more sensitive evaluation. The psychologists in particular felt that the parameters of these tools were very limiting:…certainly I can check off boxes, I can record symptoms, but I feel like that, you know, by doing that you lose a lot of the qualitative richness of each person’s experience… you lose some of these other contributing issues that are outside those check boxes like the guilt, the grief, the changes in identity and world view, and that I really, really, really, hate.- VA psychologist 2Veterans often expressed empathy for providers, viewing them as victims of the system. The impersonal nature of the VA was chalked up to “…people were overworked and just going through the motions.” Despite this empathy for VHA mental health providers there was a general distrust and fear of incompetency on the part of VBA, compensation, and pension (“comp and pen”) evaluators, and the rating system in general. Staff were sometimes perceived by veterans as under-trained in military culture, war work and its impacts. One particularly disparaging story sums up the anxiety and anger that the compensation process can generate:She  wouldn’t even look at me in the face and she was reading my file: “knocked out by IEDs, mortars.” I had numerous concussions and she said there was not enough evidence. That’s because I was infantry! Your corpsman (medic) would push out with 40 Marines… that (incident) wasn’t documented because I was not on base! We were getting shot at. She did not understand that. Then I almost had a panic attack because she did not know what an IED was. Here she is, totally ignorant of my injuries. The lady who is in charge of my disability has no idea what’s going on!-Male, Afghanistan/Iraq veteranAlthough VA policies have changed to relax the evidentiary standard that establishes the link between trauma and service, stories like this circulate through the “Joe Network” and are difficult for the VA to recover from. These compensation evaluation experiences made some veterans question the competence of VHA mental health providers and contributed to veterans delaying or avoiding treatment and deterring reapplication for rating increases or appealing a denied claim.The institutional perception of VA is that they (veterans) are coming to the treatment setting with ulterior motives.- VA psychologist 2Stigma also unfolded on an individual level in the claims process. Some veterans felt as if their evaluators automatically labeled them a fraud and experienced outright stigma in their claims process: “My comp and pen nurse made the comment ‘Who is telling you what to say when coming in for your exam?’ She’s not following the ‘benefit of the doubt’ requirement in the 38 CFR” (this is the VA’s Schedule for Rating Disabilities) (Afghanistan/Iraq veteran and VA disability rater). However, many understood the logic behind the system and condemned those veterans that were faking their symptoms for compensation.He (comp and pen examiner) said “Expect 10%, we’ll see you later.” (He thought I was) more or less just looking for a handout and unfortunately there are a lot of people in the VA system looking for a handout, which screws everything up for the people who actually need it.- Male, Afghanistan/Iraq veteranAs one male, Afghanistan veteran described those who are fraudulently gaming the system:There’s a military name for them, Blue Falcons, they just care about themselves and don’t think about how their actions affect everyone else. They are the ones who sneak a candy bar in (during training) and the rest of us have to do push-ups while he eats it.Built into the VA claims process is the need to produce evidence of trauma, or a “verifiable stressor.” Not surprisingly, at the time of this study all the veteran participants felt they had to “prove” they experienced trauma to their individual assessors. In other words, there was a feeling of judgment before the process even started. As a result of having to produce this evidence repeatedly, veterans felt that the VA did not believe them, care about them, or want to compensate them.You feel like you are giving a testimony. I told you the story. It’s on record. It’s the same story. Why do I have to do that for level 3 and 4? It’s intruding.- Male, Iraq veteranTheir job is basically to deny you and so they don’t want to know you personally.- Male, Iraq veteranIt is your responsibility to prove why you deserve compensation. If you don’t get those records to them (even if they have them) they won’t compensate you. They don’t help you. They don’t want to pay… You get so frustrated you just give up.- Female, Iraq veteranThis bureaucratic necessity of providing evidence of trauma created anxiety in most participants.It was very nerve-racking… because they ask you so many personal questions and its doctors you don’t deal with on a regular basis, it’s not YOUR doctors (the ones) that actually might care about you. It’s their job specifically to see random people every day. Their decision is what the disability will be based on, your percentage, and that’s a huge deal, and that like really scared me.Male, Afghanistan/Iraq veteranThe percentage is a big deal because it translates directly to healthcare benefits and financial assistance.This perspective of veterans, that the VA does not want to compensate them, is in stark contrast to the providers in this study: “Everyone I work with gives the vet the benefit of the doubt. We all hate the comp and pen process. We care about the vets and hate to put them through this” (VA psychologist 1). At this particular VA medical center, mental health providers were required to do a quota of compensation and pension exams per month. This dual role that crosses clinical and administrative services created conflict for many because it “muddies the water” of treatment as well as the therapeutic relationship:Our lane is clinical. Our lane is not benefits. Do not cross out of that lane and begin to make statements, write letters, tell people ‘You need to be 100 percent certified’. Do not do that. If you do that you are not helping the veteran.- VA psychiatristWhile there was some provider resentment towards veterans who used them as a tool to game the system, it was intertwined with a genuine concern over the long-term effects of disability compensation on the future potential and livelihoods of young veterans. Yet, a number of veterans felt their injuries  were not being taken seriously because their age and bodies did not reflect their pain.I feel I get a little shafted when I go to the medical center because they look at me like a 25-year-old kid that should be healthy. And I will complain about “Oh my back is screwed up, this and that” and if an 80-year-old says that they are jumping through hoops trying to get braces trying to do this, this, and this, and when they hear someone like me bitch, I think they think “Oh yeah he is just being a whiner or a complainer, he is just trying to get money.”- Male, Iraq veteranEven though veterans felt more stigmatized when it came to physical complaints, the interplay of bodily function and physical appearance was linked to PTSD symptoms. For most this played out in their symptoms of hypervigilance, anxiety, and depression. For example, if the body was “jacked” (slang for messed up) then hypervigilance was more difficult to manage, thereby creating more anxiety.I went to the VA last week and they kept making comments of how much I work out because I am a bigger guy, and I don’t look like I’m overweight or something. Yeah, I try and take care of my body, I was marine infantry and that was pretty implemented into my life. But I am fucked up, I am jacked. I mean this weekend I could not even turn my head. And it bothered me so much because I feel vulnerable. I feel like I am not 100% so anytime I do a crazy movement, and me being a “crazy veteran” and me always thinking in fighting mode, well…- Male, Afghanistan/Iraq veteranMany providers felt that, at some level, compensation hindered treatment through the possibility of incentivizing illness.Here’s our problem as VA providers… we are training as mental health providers to help someone who is distressed and sick. The problem is we have people coming in with different motivations—they need to have me writing in their chart… to convince them (VBA) that ‘I am sick so I can get my paycheck and you are a tool that is going to help me with that… I need a letter from Dr. L telling me that I am really sick, and I can’t work anymore’. That would be counter-therapeutic for me to do that… I have been used sometimes and it bothers me to this day.- VA psychiatrist, Afghanistan/Iraq veteranProviders wanted what was best for their veterans, but many felt conflicted in encouraging disability compensation, also referred to as the “golden handcuffs.” As one psychiatric nurse put it:I will be really honest with you, that’s (compensation) a huge struggle for me… With all of my heart I want to get people into the system and I want to get them connected with every benefit they deserve, however… (you) have a 22 or 23 year-old sitting in your chair and then you are kind of like giving them all these things (benefits)… up front the need is there, believe me, I have worked with plenty of people who come home broken, have a mortgage payment, they have a family, they can’t get a job due to symptoms and… so of course we get them compensated to the highest level possible that we can to help them in that area, but yet then… where is the incentive to get them into a different mindset? Again, when I have people sitting there in my office and I am working with them and I develop that relationship, I always find myself asking them out loud you know, what were your dreams when you were a kid?For a number of veterans, the perceived moral judgment of medical providers and the shame veterans felt about their trauma, made veterans hesitant to disclose the full details of their war experience. This was despite the understanding that one’s disability percentage is “based on how messed up you are” .I don’t want to admit my most personal disabilities. I’m ashamed of what I did and especially ashamed of how it affected me to the point where I need help and then am labeled.- Male, Iraq veteranI’m not going to tell a total fucking stranger the deep-rooted feeling… how I lost guys… how I killed… that’s part of who you are, you don’t just tell these stories… you don’t talk about traumatic stuff because it brings back bad thoughts and feelings. It’s embarrassing to yourself.- Male, Iraq veteranEven if the person is a health professional, they are still human, they are still going to judge you.- Male, Afghanistan/Iraq veteran and claims officerThese nine interrelated themes identified above describe how stigma was experienced by one group of Iraq and Afghanistan veterans possessing or seeking a disability determination for their war-related psychological injuries. The stigma experiences that emerged during the VA claims process, from the perspectives of these veterans, were entangled in systemic bureaucratic processes but also in the individual personal interactions with VA providers .trauma pitch, conceptualized as the repeated telling of intimate trauma experiences to “strangers” (VA bureaucrats and clinicians) is at the core of systemic level stigma processes. The trauma pitch involved the many appointments and screenings veterans were required to go through in seeking a disability rating. These multiple screenings led to an inadvertent exacerbation of the PTSD symptoms of anxiety, alienation, depression, and anger, and were brought on by bureaucratic processes.This ethnography focused on two main research questions: How stigma was experienced by veterans claiming disability for PTSD and the effects of linking a diagnosis to disability ratings and compensation. I have identified nine interrelated areas that contributed to stigma experiences in the VA disability determination process from the veteran perspective . I argueIn addition to symptom aggravation, the trauma pitch placed veterans’ pride and identity at stake. Veterans face different stigmas as they begin to reintegrate into a new social, economic and political context. This is a social context where disability ratings are often relied upon for support and survival in the same manner a soldier’s squad and the military were relied upon at war. Ethnographic studies in psychology , sociolowith, rather than avoidance of, the bureaucratic processes of diagnosis, treatment and disability claims and compensation.To transform stigmatization into negative consequences social power is necessary . For theDisability benefits are one possible way of intervening in the stigma cycle , but as While all these stigmas were tangible and part of veterans’ lived experience , at the The VA is a Cabinet-level executive branch department of the United States federal government and a complex bureaucracy. The VHA is separate from the VBA, and surprisingly this was a split that the veterans in this study were not aware of. Veterans saw health care providers through the VHA for a diagnosis and compensation evaluators through the VBA for their disability rating. To muddle things more, these compensation evaluators were also VHA providers, which created conflict for their therapeutic practice. These two settings, the clinical and the administrative, were co-mingled, and veterans thought all their appointments were part of one process. Confusion was compounded when veterans thought they were at the hospital for a therapy intake: three of the ten participants who finished the study did not even realize they were going through the disability claims process, having initiated contact with the VHA to start treatment. These veterans were automatically “put into the system” which included application for a disability rating. One of the participants in this study received a “surprise” check of over $3,000 in back pay for a claim he did not even know he started. As one provider put it, “At this point they want a listening ear and instead someone is typing away at their computer” to document the details for a claim.www.ebenefits.va.gov. At the time of this publication, the average time to process a claim was three to four months [All claims’ personnel felt it was critical for veterans to have a service officer lead them through the disability claims process, “They should not attempt this bureaucratic process on their own”. At the time of this study, veterans did not know what the status of their claim was for up to ten months. Improvements have been made since this study was completed as veterans can now track their claim electronically to see where it is in the process by registering for eBenefits at r months . VHA andr months .In addition to lack of awareness of bureaucratic process, there also existed a significant diversity in the meanings of disability ratings between veterans, service providers and VA. It was this gap in veterans’ personal understanding of ratings, in contrast to broader institutional definitions, where stigma emerged. For example, from the veteran point of view, a disability rating was often a validation of their war trauma. The rating provided a stamp of truth in a system, they believed, was designed to catch frauds. A disability rating was viewed as a form of acknowledgement for their suffering and something they “deserved” for their sacrifice. This echoes the quantitative research of Sayer et al.  who founIn contrast, from a clinician perspective, “claims is not about validation, treatment is” and disability compensation is about “what you can and cannot do” (related to functioning in society). As a result of this difference in meaning, veterans went through the claims process feeling that their trauma had not been recognized, and often felt their ratings were unfair and inaccurate. The perspective of clinicians in this study, that disability compensation can serve as “golden handcuffs” and be counter-therapeutic contrasts the epidemiological study by Murdoch et al. , who fouVeterans felt the meaning of their service was reduced to scores and percentages. They felt they were rated for their “experiences”  and not the impact of those experiences on their everyday lives. This is understandable considering the tools used to screen for PTSD such as the Combat Exposure Scale  that heloccupational tasks. Certainly, someone can be severely impaired but not disabled: in other words, still able to work. This was evidenced by some veterans who with 50–90% ratings (moderate to highly impaired) were able to hold down full-time jobs. As one provider put it, “The reason for compensation got lost somewhere because the idea is that if you are 30% service connected, 30% of your earning potential has been eaten away.” Earning potential is ambiguous also. Theoretically it might be reduced through no longer being able to live out one’s dream. For example, one veteran planned on becoming a physician, but because of traumatic brain war-related injuries, now works in low-level administration. To push the question of impairment and disability further, veterans could be seriously impaired in their social lives, with certain types of employment still manageable. Veterans’ perception of social impairment included inability to initiate and maintain relationships, engage in activities with friends and family and in general, have a “social life”.Linked to conflicts of meaning, on a systemic level, an ambiguity between the meanings of impairment and disability and their relationship to a rating emerged. The Posttraumatic Stress Disorder General Rating Formula for Mental Disorders used at the VBA rates for impairment that affects the performance of This study suggests that the screening tools used for PTSD can have a negative impact on veterans through quantifying and devaluing their trauma and service. Clinicians felt the screening tools left out important layers of PTSD experience such as guilt and shame and that the diagnostic criteria were too limiting. The consensus was that PTSD could present with only a few severe symptoms and in “splitting” experience into symptom criteria and “checking boxes” a formal diagnosis was not established. A PTSD diagnosis was viewed as a “communication tool” but not a clinical tool. In other words, it was a way to communicate with the VBA or other care providers what was going on, but secondary to work therapeutically with specific symptoms and behaviors to improve quality of life. These findings are similar to those of Jackson, et al. , which fThis study has several limitations. It was conducted in a Midwest state in an urban area with a participant sample that was mostly White. A majority were combat veterans and one third were deployed for their first time at the beginning of the Iraq war. This means, for one third of this sample, their first contact with VA was at a time when VA was not prepared for a young cohort of veterans with unique needs that the VA was unaccustomed to serving. Also, early Iraq war deployment generally equates to more trauma exposure, symptom severity, and discomfort interacting with providers and institutions. Several of the veterans in this study had first contact with VA before more lenient policy changes surrounding PTSD claims and verifiable stressors was instituted (in 2010). As such, these formative results may not be generalizable to diverse or recent veteran populations.Self-report biases may have been a limitation due to the nature of the topics explored, as well as the population of study, who tend to be proud in presenting themselves. However, by including three phases of interviews over 12 months, this research design attempted to mitigate these biases and build trust and comfort between the researcher and participants. Recollection bias was a limitation in that memory loss itself is a symptom of PTSD.bureaugenic effects. In addition to veterans’ experience of symptom aggravation, the bureaugenic effects of the trauma pitch placed veterans’ identity at stake: military values of group loyalty and honor were threatened through the objectification of their sacrifices. This threat to identity was further intensified through the screening tools that quantified traumas and calculated percentages of disability, placing a monetary value on loss. Paradoxically, veterans viewed this commodification of suffering via disability compensation as a validation of those losses and sacrifices.In this ethnographic study I have identified how bureaucratic forms of care created stigma and exacerbated PTSD symptoms for 10 combat veterans seeking treatment and disability compensation for PTSD. This study elucidated the multi layered process veterans navigated to qualify and receive compensation for their war-related psychological injuries. The VA disability claims process, entangled with treatment and diagnosis seeking, required multiple recounting of personal trauma, and was experienced by veterans as a “trauma pitch”. This process not only worsened veterans’ perception of being judged and stigmatized, but inadvertently exacerbated PTSD symptoms of anxiety, alienation, depression, and anger. The increase of these symptoms brought on by institutional processes are conceptualized in this study as All too often, we think of bureaucratic red tape as the daunting task of filling out paperwork, following excessive protocols, or the process of navigating various low-level rules that frustrate and anger us. For veterans and other populations that are in a vulnerable state, the impacts on mental health can be far more detrimental. This ethnographic study brings to light the need for institutions to be aware of how their bureaucratic processes impact the people they serve, and how stigma and ill-being are propagated through these institutional procedures. The veterans in this study engaged in the disability process to make meaning of their suffering. They pursued a service-connected disability rating to authenticate their trauma and validate their sacrifices. This is not the purpose of disability compensation. In many cultures and societies this acknowledgment, validation, and support, is the role of the communities the veterans come home to.


Cervical cancer remains a leading cause of morbidity and mortality amongst females in Latin America (LATAM). Cervical cancer is a preventable disease and HPV vaccination is a main key strategy towards its elimination. This study analyzes HPV vaccine implementation current status and the main barriers to achieve adequate coverage in the region. Data from the nineteen sovereign states of LATAM  were collected, including year of HPV vaccine implementation, gender and age targets, the number of doses included in the public program and coverage by dose. Sixteen out of the 19 evaluated countries have already implemented HPV vaccination programs. However, despite its proven efficacy and safety, HPV vaccine uptake in LATAM has been lower than expected. There is an evident decline in adhesion, mainly regarding the second dose. Several reasons are probably involved, of note: limited knowledge of HPV and HPV vaccine, misguided safety concerns, high cost, cultural barriers, and the Covid19 pandemic. Proper strategies to overcome these barriers are needed to ensure successful uptake. Effective policies are: adopting the one dose schedule, delivering the vaccine on both health center and schools, and advising health professionals to recommend the vaccine. Further research regarding HPV vaccine hesitancy in Latin America is needed. The natural history of the disease involves persistent high-risk HPV infection, followed by the development of precancerous cervical lesions and progression to invasive cervical cancer, process that may take some years, providing a window of opportunity for secondary prevention with screening tests. These lesions can be successfully treated when diagnosed early. Besides, the existence of a primary infectious etiologic agent allows primary prevention with prophylactic HPV vaccines capable of reducing the incidence of causative infections. Thus, cervical cancer is considered a preventable and treatable disease .Due to the preventable nature of cervical cancer, in May 2018, the World Health Organization (WHO) made a call to action for the global elimination of the disease as a public health problem. Elimination occurs when incidence rates scale down to less than four cases per 100,000 women, which would be possible through a strategy comprising three targets for 2030: 90% HPV vaccination coverage for girls from 15 years of age, 70% screening coverage with high-performance tests of women by the ages of 35 and 45, and adequate management and treatment of 90% of precancerous lesions and invasive cancers ; further, we performed a narrative review addressing local obstacles to achieving adequate numbers and strategies to overcome them.LA HPV vaccine coverage status has been consistently below WHO’s targets . Hence, To our knowledge, this is the first study to present information on the vaccination status of all countries in latin america individually.Data regarding nineteen sovereign states of LATAM was gathered, including all the Portuguese and Spanish-speaking nations located to the south of the United States - comprising Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Uruguay, and Venezuela. Our primary source of information was the WHO/UNICEF Joint Reporting Form on Immunization (JRF) online portal . When avWe also conducted a search at PubMed with the terms “(latin america) AND (HPV vaccine)” that found 65 papers published between 2012 and 2022. After also conducting a snowball search, we’ve selected 15 papers to include at the narrative review.The main results are summarized in Out of the 19 evaluated countries in 2022, three - Cuba, Venezuela, and Nicaragua - still have not introduced the HPV vaccine as Public health police . Among tAlthough Latin America has a consistent history of high vaccination coverage with highly efficient national immunization programs , HPV vacLatin American countries have received support from governments and the Pan American Health Organization (PAHO) to implement vaccination programs, initially focusing on girls. Despite significant advances, vaccine uptake is below expected, and there is no standardized protocol to be adopted regarding the type of vaccine, number and intervals of doses, and age range .The WHO Cervical Cancer Elimination Modelling Consortium (CCEMC) was created to facilitate the strategic planning of the global elimination strategy. It consists of three independent models that reproduce the natural history of cervical cancers, which have been used in combination to evaluate the impact of potential intervention scenarios regarding HPV vaccination and cervical cancer screening .Based on that, CCEMC presented three models of protocols for reducing the incidence of cervical cancer in LMICs. Achieving women’s vaccination targets can reduce the disease by 60%. Vaccination and screening for HPV, on the other hand, can lead to a 96% reduction; and vaccination associated with two HPV screenings can lead to 100% elimination of the disease in LMICs. 80% of LA and Caribbean countries that already have HPV vaccination implemented could eliminate the disease .Canfell et al. modeled the impact of WHO’s strategies on cervical cancer mortality in all 78 LMICs. Estimating a mortality rate of 13.2 per 100,000 women in 2020, they forecasted that vaccination alone would reduce cervical cancer mortality by merely 0.1% in 10 years, compared to the status quo. Additional twice-lifetime screening and cancer treatment would reduce it by 34.2%. In 50 years, the reductions would be 61.7% with vaccination and 92.3% with all three interventions. In 100 years, vaccination alone would reduce mortality by 89.5%, while the implementation of the triple-intervention strategy would reduce mortality by 98.6%, averting more than 60 million deaths  over the lifetimes of the intervention cohorts for a total 10-year program cost of US $3.2 billion .The main barriers to HPV vaccination in Latin America are limited knowledge of HPV and its consequences, misguided safety concerns, the cost to constrained health systems, and cultural barriers  9)..9).As an illustration of this lack of knowledge about HPV, a recent Brazilian cross-sectional study found that 40.0% of participants reported having heard about HPV, and only 8.6% had heard of HPV vaccines. Once informed of the existence of HPV vaccines, about 94% of the participants reported that they would get vaccinated and/or vaccinate their teenage children if vaccines were available in the public health system . In the Many parents also cite safety concerns as the main reason for refusing to vaccinate their children . For exaBesides that, because of the nature of HPV as a sexually transmitted infection and cultural taboos, there is an unfounded belief that the HPV vaccine would increase adolescent sexual activity decreasing vaccine confidence. Parents fear that vaccination would encourage risky sexual behavior . However, this association was proven inexistent . In 2022According to a systematic review published by the Journal of Pediatric Nurse, the most effective intervention to promote HPV vaccine uptake is strong recommendations by practitioners and nurses. Providers should also inform parents about the vaccine’s safety as part of their recommendation to dispel these misconceptions and improve acceptance . A crossAccording to a cross-sectional study, maternal HPV vaccine acceptance in Argentina was high; however, it substantially decreased when vaccination was not free-of-charge . TherefoRecently the WHO Strategic Advisory Group of Experts on Immunization (SAGE) published a review that can be game-changing. They concluded that a single-dose Human Papillomavirus (HPV) vaccine delivers protection against HPV that is comparable to 2 or 3 dose schedules. Adopting a single-dose strategy would allow more girls to access this life-saving intervention. Therefore, SAGE recommends updating dose schedules for HPV as follows: one or two-dose schedule for the primary target of girls aged 9-14, one or two-dose schedule for young women aged 15-20, and two doses with a 6-month interval for women older than 21 . A Cervical cancer remains a significant public health issue in Latin-American countries. Most countries have incorporated HPV vaccination into their National Immunization Programs. However, in most countries, vaccine targets were not achieved. Cuba, Venezuela, and Nicaragua have not incorporated HPV vaccination in their health policies so far, and this action is an urgent need for cervical cancer elimination in the region.Strategies such as health providers’ recommendations, school-based associated with health facilities delivery, and one dose schedule could be helpful to achieving universal vaccination coverage in LA countries, contributing to eliminating deaths caused by cervical cancer.Strategies such as information, providers’ recommendations, health centers integrated with school-based delivery, and one dose schedule could be useful to achieve universal vaccination coverage in LA countries, contributing to the goal of eliminating deaths caused by cervical cancer.The authors indicated in parenthesis made substantial contributions to the following tasks of research: Conceptualization: ANR, APGG, KKM; methodology: MGF, AMN, ANR, CMV; formal analysis: MGF, AMN; writing-original draft preparation: MGF, AMN, ANR, LCB, DAPA; writingreview and editing: MGF, AMN, DAPA, ANR, RSL, visualization: MGF, AMN, ANR, APGG.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Blue nevi are melanocytic proliferations that are reminiscent of embryonal neural crest–derived melanocytic precursors.Blue nevi most commonly arise in children and young adults as either congenital or acquired lesions. In addition, blue nevi have a general 2:1 predilection for women than for men. There are multiple variants of blue nevi, and these include common, cellular, amelanotic, combined, sclerosing or desmoplastic, epithelioid, and subungual. The 2 most common subtypes are common and cellular blue nevi.,Common blue nevi are flat or dome shaped with a smooth surface and are typically 0.5 to 1 cm in diameter.The purpose of this case report is to present a unique presentation of a large, benign, late-onset, blue nevus.2 bluish, homogenous patch with overlying whitish scales was visualized on the apex of his scalp , revealed folliculitis, with no signs of architectural changes that would indicate malignancy. The patient continues to follow-up every 4 to 6 months and has agreed to additional biopsies for monitoring of the nevus.Three scouting biopsies were performed to sample different areas of the nevus at a follow-up appointment. The biopsy report, showing a benign blue nevus with other changes , A-C, reBRAFV600E mutation is the culprit behind the proliferation and premature arrest in melanocytes.GNAQ gene, and ∼15% of blue nevi present with mutations in the GNA11 gene.,SF3B1 and BAP1 genes.Blue nevi are clinically diagnosed using dermatoscopes and have been described to have a steel blue color that gradually fades into the surrounding skin.Biopsy and pathologic evaluation are the gold standards to rule out malignancy.Blue nevi range in size, and malignancy may be suspected if a lesion is found to be larger than 6 mm in diameter. Although there are no definitive size guidelines available regarding blue nevi, the literature often applies the same parameters that govern conventional nevi to blue nevi. Studies have suggested that nevi >20 cm are at a 5% to 60% increased risk of becoming malignant. Medium-sized nevi that range between 1.5 to 19.9 cm have a <5% increased risk of becoming malignant. Additional observational studies are important for enhancing our understanding of the relationship between the size of blue nevi and the risk associated with their transformation into malignant melanomas.Typically, a benign nevus that is acquired throughout the lifetime of a patient requires no treatment other than longitudinal monitoring. It is critical to note that acquired nevi may increase the risk of melanoma, and, as a result, patients should be counseled on sun protection and undergo full-body skin examinations. Although small and stable blue nevi, often ranging from 0.5 to 3 cm, require no clinical intervention, late-onset atypical lesions should be biopsied because of reports of melanoma arising from cellular blue nevi.None disclosed.


Sexual activity was categorized as “never” or “ever” had oral and/or vaginal sex. Outcome variables were HPV vaccine initiation, defined as receipt of ≥1 dose, and completion, defined as receipt of ≥3 doses. Multivariable logistic regression models estimated the association between sexual activity and HPV vaccine uptake, adjusting for sociodemographic factors. Approximately 18% of students reported never engaging in sexual activity. Overall, 45.5% initiated the HPV vaccine, and 16.5% completed the vaccine series. After adjusting for covariates, compared to students that reported never engaging in sexual activity, those that had ever engaged in sexual activity were more likely to have initiated the vaccine series ; however, no difference was observed for completion. HPV vaccination was low; sexually naïve students were less likely to initiate the HPV vaccine. Since sexually naïve students may benefit from receiving the HPV vaccination, targeted interventions should be implemented towards this population to help increase vaccination rates and prevent HPV-associated diseases.HPV vaccination is most effective if received before initiation of sexual activity. Previous studies suggested that young adult women who were not sexually active were not interested in receiving the vaccine because they did not think it was necessary. Whether this misperception is still prevalent today—and also shared by men—is unknown. This study examined whether sexual activity was associated with HPV vaccine uptake (initiation and completion) among university students. A cross-sectional study was conducted between February and May 2021 among students ( Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States  with an It is estimated that the HPV vaccine could prevent over 90% of HPV-attributable cancers . The AdvThe primary risk factors for acquiring HPV are generally associated with sexual activity ,21. The We conducted a cross-sectional study among college students enrolled at a public Midwestern university. The school enrolls students from all 50 states as well as more than 100 countries. The questionnaire was administered using SurveyMonkey, it was distributed online to randomly selected enrolled students between February and May 2021. The questionnaire elicited sociodemographic information, sexual behavior , as well as questions regarding HPV vaccination history . Participants were informed of the anonymous nature of the survey and the objective of the study, and informed consent was obtained. The introductory email included a link to the questionnaire (SurveyMonkey). Responses to the questionnaire were recorded anonymously. Participation was noncompulsory and there were no incentives offered for participation. We excluded students who were over 38 years old. The survey was distributed online to 3142 randomly selected students and 1089 completed the survey for a response rate of 34.7%. After limiting the data to students who were between 18 and 38 years (who constituted over 95% of the student body), a total of 951 students  were included in the study. The upper age was selected because students who were between the ages of 18 and 26 years in 2021 would have been eligible to have received the HPV vaccine, based on the year of licensure in the US. The study was approved by the Southern Illinois University Institutional Review Board.Have you ever received an HPV shot or vaccine? The vaccines are sometimes called CERVARIX or GARDASIL”. Participants who responded yes were subsequently asked how many doses of the HPV vaccine they had received. Participants who had received ≥1 dose were deemed to have initiated the vaccination series, while participants with ≥3 vaccine doses were deemed to have completed the series. The secondary outcome was willingness to receive the vaccine. Participants who had not received the vaccine were asked how likely they were to receive the vaccine if offered. For regression analysis, we grouped responses extremely likely and very likely as “willing to receive the vaccine” and extremely unlikely, very unlikely, and somewhat likely as “unwilling to receive the vaccine”.The main outcome variable was HPV vaccination uptake. HPV vaccine initiation was assessed with the question ““Have you ever had vaginal sexual intercourse?”, and “Have you ever had oral sex?” Responses were categorized as “never” for those that responded no oral and no vaginal sex, or “ever” for those that had ever had oral and/or vaginal sex. To further examine the effects of sexual behavior and HPV vaccination, we examined the number of sexual partners and age of sexual debut among students who were sexually active. Number of sexual partners was categorized as “1–3” or “≥4” and age of sexual debut as “≤15 years”, “16–17 years”, or “≥18 years”. We also assessed frequency of using protection during vaginal sex into one of three categories .The main independent variable was sexual activity assessed with these questions: Covariates included age, gender , race/ethnicity , relationship status , country of birth , residential area before college , and year of study .n = 795), multivariable logistic regression models estimated the association between vaccine uptake, and number of sexual partners and age of sexual debut adjusting for the covariates listed above. In the subgroup of unvaccinated students (n = 518), a multivariable logistic regression examined the association between willingness to get vaccinated, and age, sex, race/ethnicity, relationship status, country of birth, academic level, rural-urban status, and sexual activity. Adjusted odds ratios with their corresponding 95% confidence intervals were reported. Analyses were performed using SAS statistical software version 9.4 . All statistical analyses were 2-tailed, and the significance level was set at p < 0.05.Descriptive statistics were used to analyze characteristics of the study participants. Sociodemographic characteristics and sexual behavioral risk factors were compared by sexual activity using chi-square tests for categorical variables and independent samples t-test for continuous variables. Next, two multivariable logistic regression models were used to examine the association between HPV vaccine uptake and sexual activity. Adjustments for age, sex, race/ethnicity, relationship status, country of birth, academic level, and rural-urban status were made. In the subgroup of sexually active students (p < 0.0001), single and not dating , and were freshman/sophomores .p = 0.0048); however, completion rates were similar (p = 0.0739). Completion rates were similar by age of oral sexual debut  had initiated the HPV vaccine, while less than one fifth (16.5%) completed the vaccination series. These initiation and completion results are similar to findings from other studies involving college students or 18–26-year-olds ,26,27,28We found that students who had never engaged in any sexual activity were less likely to initiate the HPV vaccine compared to those who had ever engaged in sexual activity. Our finding is consistent with previous studies conducted over a decade ago and found that students who are not sexually active see less need for the vaccine ,24. The Given the general lack of awareness and knowledge about HPV vaccination and HPV-associated cancers ,30,31, pStudents who lived in rural areas before college were less likely to have initiated the HPV vaccination series than their urban counterparts. This finding is similar to findings from Swiecki-Sikora et al. and Adjei Boakye et al. who reported lower HPV vaccination rates among adolescents in rural communities compared to urban communities ,34. LoweThis study has several limitations. First, although findings are consistent with prior studies among college students ,24,25, sIn the current college population, rates of both HPV vaccine initiation and completion were low. Sexual activity was an independent predictor of HPV vaccine initiation, where sexually naïve students were less likely to receive the vaccine. Further, college students from rural areas and males were less likely to receive the vaccine. Increasing HPV vaccination is the only primary preventative measure for lowering HPV infection rates, especially in the high-risk college student population. Uptake of the HPV vaccination series should be encouraged on college campuses as it will decrease rates of HPV infection and HPV-associated cancers. Future work should focus on finding the most optimal ways to increase HPV vaccination among college students. Engaging college students in the development of such interventions will help identify effective strategies that can be tailored to their needs. Future research should solicit students’ input regarding intervention content, distribution channels, and components that resonate with the target population.