Modern plant breeding tends to focus on maximizing yield, with one of the most ubiquitous implementations being shorter-duration crop varieties. It is indisputable that these breeding efforts have resulted in greater yields in ideal circumstances; however, many farmed locations across Africa suffer from one or more conditions that limit the efficacy of modern short-duration hybrids. In view of global change and increased necessity for intensification, perennial grains and long-duration varieties offer a nature-based solution for improving farm productivity and smallholder livelihoods in suboptimal agricultural areas. Specific conditions where perennial grains should be considered include locations where biophysical and social constraints reduce agricultural system efficiency, and where conditions are optimal for crop growth. Using a time-series of remotely-sensed data, we locate the marginal agricultural lands of Africa, identifying suboptimal temperature and precipitation conditions for the dominant crop, i.e., maize, as well as optimal climate conditions for two perennial grains, pigeonpea and sorghum. We propose that perennial grains offer a lower impact, sustainable nature-based solution to this subset of climatic drivers of marginality. Using spatial analytic methods and satellite-derived climate information, we demonstrate the scalability of perennial pigeonpea and sorghum across Africa. As a nature-based solution, we argue that perennial grains offer smallholder farmers of marginal lands a sustainable solution for enhancing resilience and minimizing risk in confronting global change, while mitigating social and edaphic drivers of low and variable production. •Mapping suitability and scaling potential of perennial crops across Africa.•Targeting agricultural development through remote sensing-based classification.•Locating areas for deployment of nature-based sustainable land management strategies. Subsist1.2Sustainable land management is at the foundation of societal goals to produce food, fuel, and fodder in an environmentally sound and supportable manner over the long-term. How to achieve sustainable intensified agriculture is contested, with advocates promoting such various approaches as organic agriculture, agroecology, and conservation farming . At the Based on agroecology and conservation agriculture principles, nature-based solutions offer sustainable qualities, such as resilience to disturbance over variable time scales and minimal input requirements, as well as an aim toward general improved human well-being . Nature-1.3Cajanus cajan (L.) Millspaugh) is a perennial leguminous shrub commonly cultivated and consumed by smallholder farmers in the tropical and often marginal environments of Africa (Sorghum bicolor (L.) Moench) is a grass with perennial properties commonly grown by smallholder farmers in semi-arid regions of Africa  database ) by high22.1The methodology presented here consists of three major components. First, we identify the fundamental climate niches for maize, pigeonpea, and sorghum. Second, we present a range of suitability  for each crop based on temperature and precipitation conditions. Third, we locate the intersection between marginal maize areas and the optimal pigeonpea or sorghum climate niche.The fundamental climate niche  used for maize, pigeonpea, and sorghum is based on a literature review of tested crop performance . PigeonpFor the optimal range, we calculated a mean low-value and mean high-value from all optimal temperature and precipitation ranges collected in our review. From the values presented in 2.2The spatial distribution of climate variability was acquired using two remotely-sensed NASA products. Temperature data were gathered from NASA MODIS Land Surface Temperature (LST—MYD11B3)  and precMarginal agricultural lands are those places with suboptimal temperature and precipitation conditions for the dominant crop , as well as places with chronically low production levels and/or high interannual variability in production . MarginaAreas likely to receive maximum benefit from perennial deployment exist at the intersection between marginal dominant crop conditions  and the optimal climate niche for perennial grains  . We iden33.1Suitable temperature and precipitation conditions for maize, pigeonpea, and sorghum are spatially organized across Africa, following well-established agroecological zones e.g.,  Fig. 2)Fig. 2). Since suitable temperature ranges are similar among the crops under study, precipitation is the primary determinant of continental-scale suitability; however, temperature does reveal its importance when combined with precipitation, particularly at fine spatial scales . The mosOverall, we found that maize production is optimal on approximately 28.1% of agricultural land across Africa, suitable on 59.3%, and unsuitable on 12.6% , Table 23.2Within the optimal pigeonpea niche, 24.9% exhibits marginal agricultural productivity and suboptimal rainfall conditions for maize, 41.6% exhibits sole marginal agricultural productivity, and 20.9% exhibits optimal conditions for maize , Table 344.1Historically, most smallholder farmers in Africa have depended on intensively managed maize systems as a cash crop and staple food ; howeverPerennial grains offer benefits that encompass rural and marginal environment smallholder farming contexts, and should be promoted in locations where labor constraints reduce agricultural system efficiency, or where topography and farming practices increase erosion or depletion of soil organic matter. Integration of perennial pigeonpea or sorghum into maize-based farming systems shows wide spatial applicability across Africa. Though the optimal land area for sorghum cultivation appears of moderate size, low rainfall requirements permit it to fill a spatial niche that pigeonpea does not. This regional delineation of crop suitability between sorghum and pigeonpea is particularly evident along a horizontal stretch of the Sahel . This isPigeonpea diversification offers unique environmental benefits, particularly in locations where soil fertility decline is limiting crop yields. The ability of pigeonpea to biologically fix nitrogen has been proven to function in a smallholder farm context across a range of soil types, rehabilitating soils through input of 70–100 kg of nitrogen per hectare annually . Given tDespite the legacy cultivation of maize across much of Africa, and recent expansion into new areas of West and North Africa , there a4.2Sustainable land management is at the forefront of agronomic research, and nature-based solutions are emerging as long-term subsistence strategies. Following nature-based models, sustainable agricultural solutions for smallholder farms are innovations inspired by nature. Though many nature-based solution initiatives in the European context have been urban-centric , the cor


Background: Haitian women residing in the United States are disproportionately affected by cervical cancer. Human papillomavirus (HPV) vaccine has been licensed in the United States since 2006. Vaccination rates are less than optimal overall, and the rates are particularly low among young black women. We investigated barriers to HPV vaccination in a sample of Haitian American college women.Methods: Thirty self-identified Haitian American women, aged 17−26 years, were recruited from a large university campus in southeastern United States (n=30). They completed in-depth face-to-face interviews. The research team analyzed the transcripts using thematic analysis.Results: More than half of the participants (n=18) had not yet initiated the HPV vaccine series. Most of the unvaccinated participants stated that they had received a provider recommendation for the vaccine. Lack of provider recommendation, negative vaccine perception and attitudes, and side effect concerns constituted barriers to vaccination.Conclusions: Haitian American college women at high risk of cervical cancer have cited several barriers to HPV vaccination, with the most prominent being lack of physician recommendation. Healthcare providers should continue recommending the vaccine to college women as many of them may not have received a recommendation. When recommending the HPV vaccine, discussions should be framed with the intent to positively influence HPV vaccine perceptions and ultimately vaccine attitudes. Banister et al. conducted a study among European and African American females and found that the time from HPV acquisition to clearance was longer among African Americans (601 days) compared with European Americans (316 days).11 Subsequently, the bivalent vaccine 12 and the nonavalent vaccine (Gardasil 9)13 were licensed in 2009 and 2014, respectively. Any one of the vaccines confers protection against HPV types 16 and 18, which are most commonly associated with oral and anogenital cancers.14 However, vaccination rates remain low, particularly among groups at higher risk of HPV-related cancers.15 Approximately half of the female college population is infected with HPV at any given time.16In 2006, the quadrivalent HPV vaccine  was licensed in the United States.17 Only 49% of college women aged 18–26 years have been vaccinated,18 with black and Hispanic college women having lower rates compared with their white counterparts.18–20 Young Haitian women are at high risk of cervical cancer, but their vaccination rates are low. Although the rates of cervical cancer are higher among Haitians compared with African Americans, a previous study has reported lower HPV vaccination rates among Haitian (31%) compared with African American adolescents (47%).21 Lack of HPV knowledge and lack of HPV vaccine awareness among Haitian parents constitute barriers to getting their daughters vaccinated.22Although HPV infection is prevalent among college women, their HPV vaccination rates remain far below the Healthy People 2020 goal of 80% coverage.24 and for young adults to increase risky sexual behaviors.26 Several factors, including lack of HPV vaccine knowledge, lack of awareness, and lack of provider recommendation, have been identified as potential barriers to HPV vaccination.27Since the licensure of the vaccine, parents have expressed concerns that their adolescents may interpret receipt of the vaccine as a passport to initiate sexual activity28–36 Previous studies have also reported that healthcare providers face barriers to making the HPV vaccine recommendation. Findings revealed that many physicians were concerned about parents' negative attitudes toward vaccines and parents' adverse effect concerns,37–39 as well as inadequate insurance coverage and potential reimbursement issues.40Research studies have consistently indicated provider recommendation as a major HPV vaccine facilitator and the lack thereof as a barrier. The lack of provider recommendation has been consistently cited as the reason for young adults to not get the HPV vaccine and for parents to not get their adolescents vaccinated.42 However, studies investigating these factors among ethnic minorities that are disparately affected by cervical cancer are lacking, and these studies can facilitate message tailoring for ethnic minorities.As college women, young Haitian American women are at great risk of HPV acquisition, and they are also at a stage where they may play a major role in HPV vaccine decision-making for themselves. Given the disproportionate burden of cervical cancer among adult Haitian women, understanding factors that facilitate or hinder HPV vaccination in this population is crucial to ensuring optimal vaccination rates and ultimately reducing cervical cancer disparities. Several studies have investigated factors that influence HPV vaccine uptake among college women.43The present study investigated barriers to HPV vaccination among Haitian American college women. This study is part of a larger qualitative project that explored facilitators of and barriers to HPV vaccination among Haitian American college women to facilitate HPV vaccination in this population at high risk of cervical cancer. Although we interviewed both vaccinated and unvaccinated Haitian American women, this article focuses on the barriers to HPV vaccination among participants who were not yet vaccinated. The role of provider recommendation style in HPV vaccine uptake among Haitian American college women has been published elsewhere.Since our goal was to explore Haitian American college women's barriers to vaccination, we used a qualitative approach.Recruitment for this study took place at a large minority-serving university in the southeastern part of the United States. Thirty participants were recruited through an online psychology research pool known as Sona. Through Sona, students enrolled in psychology courses were screened for eligibility before scheduling their interviews; criteria included self-identifying as Haitian, female, and being between 17 and 26 years of age. We wanted to interview participants who were in the vaccine-eligible age group.The principal investigator conducted the individual interviews at a time selected by the participants. Study participants underwent a consent process, which included reading the letter of consent approved by the university's Institutional Review Board and asking questions to the interviewer. Participants then completed a demographic questionnaire that collected information about age, ethnic identity, and country of birth. For the few participants who were younger than 18, their parent's consent was obtained before the interview.45 Interviews began with focused questions to establish HPV vaccination knowledge and beliefs. Interview questions included the following: Have you ever heard of human papillomavirus or HPV? Where/how did you hear about it? What do you know about the vaccine? Where/how did you get this information? Who should get the HPV vaccine? Have you initiated the HPV vaccine series? What/who do you think influenced you to not get the vaccine?A series of semistructured, yet flexible, questions were developed based on relevant research.Interviews were conducted in a private conference room between June 2014 and March 2015, with each session lasting between 15 and 65 min. Each session was audio-taped and the interview length varied by participants' level of awareness of HPV and experience with HPV vaccine messages. Since the study population included only college-enrolled Haitian American women, the interviews were conducted in English.46 The interviews were transcribed and then verified by one study investigator to ensure completeness, accuracy of the discussion content, and a high quality of transcription. A preliminary coding framework related to HPV vaccination knowledge and attitudes was constructed by two study authors and the principal investigator who conducted the interviews after an in-depth reading of the transcripts.A thematic analysis was undertaken. Data collection and analysis proceeded simultaneously.a priori, but rather were derived from the data. Sections of text were coded by issue or theme; additional codes were added as new themes emerged. Themes and categories were then examined across the whole dataset and in relation to each specific interview. The research team then met to discuss and further refine each set of themes. Discrepancies were resolved by first revisiting and reviewing the data, and then through group discussion. Key themes were summarized, reviewed, and agreed upon by the study team members.Themes identified in this first stage were not specified n=18). The results presented here are organized around four major themes identified in the analysis: (1) lack of physician recommendation, (2) negative vaccine perceptions, (3) negative vaccine attitudes, and (4) side effect concerns  had not initiated the vaccine series; eight (26.7%) had received the first; and four (13.3%) had received all three HPV vaccine doses . Of the concerns .n=9)  .I remember one encounter with a physician…. He did not ask me. The initial question is always “Are you sexually active?” And I am like “no.” It would stop there. They would never ask me “Have you heard of this or would you like to get that?”n=5). One young woman cited the healthcare providers' recommendations for several vaccines as her reason for not remembering the recommendation for HPV specifically.A few stated that they could not recall their healthcare provider recommending the vaccine , the majority perceived HPV vaccine as a preventive measure for sexually active individuals (n=10). Five participants pointed out that they did not take the vaccine because (in their opinion) the vaccine is for sexually active women and they were not sexually active .A few of the 18 unvaccinated young women viewed HPV vaccine as a preventive measure for the sexually promiscuous and those who are having unprotected sex  (n=4).A few of those participants mentioned that the vaccine is not something they felt like they needed (n=3) . A few pBasically, I felt like that wasn't something I needed.…The fact that it [the vaccine] is not an urgency, but it is an option. It's not like when you are growing up and you have to take shots before school. So, if it is an option, why take it? It is not like someone is telling you this is beneficial.n=7). Two participants stated that they simply do not like vaccines, while three of those participants voiced their dislike for both vaccines and needles . A few participants who commented on side effect concerns mentioned their personal disclaimer for vaccines in general (n=3). The remainder of those who had side effect concerns provided various rationales for their concerns (n=5)  .I don't know anyone who has taken the vaccine. I don't know. It's a medication, and nowadays medications come with side effects.n=3). One participant stated that her mother felt it was necessary to wait and see how individuals who have taken the vaccine react to it.Newness of the vaccine has been cited among the reasons for nonvaccination (“Let's see how everybody else reacts to it.” She [my mother] was like “It is so new. You don't know what happens after people take it….”36Although the HPV vaccine has been available for about 10 years, several factors hinder vaccine uptake among Haitian American college women. Most of the unvaccinated participants have cited lack of physician recommendation as their reason for not receiving the vaccine. These findings reinforce previous studies that found lack of provider recommendation to be a barrier to vaccination.44 Study results indicate that Haitian American college women also value physician recommendations in their HPV vaccine decision-making. Thus, the lack of recommendation undermines the importance of the vaccine.Although a physician recommendation does not always result in immediate vaccine uptake, it is a very important factor in medical decision-making among Haitians. Specifically, Haitian mothers highly value physician recommendations when making medical decisions.47 a vaccine recommendation in the context of sexual activity is culturally inappropriate and will likely result in vaccine refusal.A few participants have mentioned that their healthcare provider would initially ask about their sexual activity status, and once they said they were not sexually active, the conversation would end there. Such interactions left participants with the impression that the vaccine was intended for young women who were sexually active. Providing a recommendation for the vaccine in this context is discordant with the guidelines as the vaccine is most effective before sexual debut. Moreover, because sexual abstinence is the cultural expectation for young, unmarried Haitian women,Unvaccinated participants have articulated their perception of the vaccine as a sexually transmitted infection preventive measure for sexually active women, women with multiple sex partners, and those who have unprotected sexual intercourse. Such HPV vaccine perceptions deter not only young women who are not sexually active or do not have multiple sex partners but also those who may be interested in the vaccine but are afraid of the stigma associated with sexually transmitted infections.48 In the present study, participants who held negative vaccine perceptions felt that the HPV vaccine was a preventive measure they needed.Unvaccinated participants have expressed negative vaccine attitudes. Several studies have reported a correlation between positive vaccine attitudes and HPV vaccine uptake.9 who found adult Haitian women to have fear of HPV vaccine due to its newness. In adolescents' and young adults' health decision-making, mothers play a central role.Some study participants voiced side effect concerns regarding the HPV vaccine. They mentioned that compared with the required vaccines, HPV vaccine has not been licensed long enough for them to be assured of its safety. A few participants mentioned that their mothers had side effect concerns because HPV vaccine was new compared with the vaccines required for school attendance. This finding lends support to results reported by Kobetz et al. 49 Moreover, some participants have also mentioned adverse effects that were based on television commercials prompting individuals who have taken certain medications to contact law firms for potential compensation. Concerns about the potential adverse effects of the vaccine have been cited among factors that constitute an obstacle to vaccination.50Several young women commented on their mothers' interaction with the provider and their mothers' view regarding the vaccine. Participants' comments lend support to previous studies that have found mothers to be a central parental figure in HPV vaccine decision-making.This study focused on Haitian American college women in a region where there is a large Haitian population. As students at a large state university, they have access to a full university health center that includes a women's clinic. Hence, the study sample is not representative of college-aged Haitian women, particularly those not attending college. Additionally, some participants mentioned their sexual activity status at the time of the recommendation, but their sexual activity status at the time of their interview was not collected due to the sensitivity of this issue in Haitian culture. Therefore, participants could not be probed specifically about the influence of their sexual activity status on their decision to not be vaccinated.Additionally, all interviews were conducted in English. Although all participants were enrolled in college, two had been living in the United States for fewer than 10 years. These participants could have been more comfortable expressing certain concepts and experiences in their native language; providing that option could have yielded a more detailed experience, especially from these two participants.Unvaccinated participants were not specifically asked what could have facilitated them receiving the vaccine. Furthermore, this was an early inquiry study among college-enrolled women from one university. Hence, study results are not generalizable to all Haitian college women residing in the United States. Although the current study had several limitations, it sheds light on some of the barriers to HPV vaccination among Haitian American college women. Study results suggest that these women have misperceptions about the vaccine. These findings are important to facilitate HPV vaccine uptake in this population.Study findings echo that lack of provider recommendation, side effect concerns, negative HPV vaccine perceptions, and attitudes constitute barriers to HPV vaccination among Haitian college women. Participants viewed HPV vaccine as new. Therefore, during medical visits, health practitioners should take the opportunity to not only make the recommendation to unvaccinated individuals but also to inform these patients that the vaccine has been licensed since 2006 and that its side effects are similar to those of required vaccines.Participants also perceived HPV vaccine as a preventive measure for a sexually transmitted infection. It is important that providers refrain from asking participants about their sexual activity when recommending the vaccine as that may reinforce the misconception that the vaccine is intended for sexually active or even promiscuous individuals. HPV vaccine is directed at the prevention of HPV-related cancers. Hence, it is vital that providers emphasize that HPV is a cancer prevention vaccine not only for these women who are at high risk of cervical cancer but also for all eligible patients. Moreover, sexual abstinence is expected of young Haitian women.Given that cultural expectation, providers should accentuate the fact that the vaccine is best taken before HPV exposure and that the vaccine confers less protection to sexually active individuals. Such accentuation can positively influence their HPV vaccine perception and would be culturally appropriate. Future research should investigate HPV vaccine uptake among Haitian adolescent boys and young men as HPV vaccine is recommended for both boys and girls.In light of the high burden of cervical cancer among Haitian women, the few studies addressing HPV vaccine uptake in the Haitian population are conducted among women. However, HPV-related morbidity affects both men and women. Therefore, studies examining HPV vaccine uptake among adolescent boys and young men from ethnic groups disproportionately affected by HPV-related morbidity are needed.College women in this ethnic group face several barriers to HPV vaccination. Study findings are indicative that Haitian American college women have negative perceptions and attitudes that constitute obstacles to vaccination. Despite the negative perceptions and attitudes and side effect concerns among unvaccinated participants, Haitian American college women highly value provider recommendations for medical decision-making. Their high esteem of provider recommendations provides an opportunity for education that will dispel HPV vaccine myths and help engender positive HPV vaccine perceptions. It is important for providers to be mindful of the positive influence of their recommendation on women who heavily rely on it to accept or at least consider the HPV vaccine.


The audiovisual intervention increased HPV vaccination acceptance for five items, p < 0.001 to p = 0.006. That HPV causes EGW, and that HPV vaccination prevents HPV-attributable diseases were better conveyed by the combined audiovisual and PHEH than the control 14-sentence counseling intervention alone.Human papilloma virus (HPV) vaccine was developed to reduce HPV-attributable cancers, external genital warts (EGW), and recurrent respiratory papillomatosis. Adolescent HPV vaccination series completion rates are less than 40% in the United States of America, but up to 80% in Australia and the United Kingdom. Population-based herd immunity requires 80% or greater vaccination series completion rates. Pro-vaccination counseling facilitates increased vaccination rates. Multimodal counseling interventions may increase HPV vaccination series non-completers’ HPV-attributable disease knowledge and HPV-attributable disease prophylaxis (vaccination) acceptance over a brief 14-sentence counseling intervention. An online, 4-group, randomized controlled trial, with 260 or more participants per group, found that parents were more likely to accept HPV vaccination offers for their children than were childless young adults for themselves (68.2% and 52.9%). A combined audiovisual and patient health education handout (PHEH) intervention raised knowledge of HPV vaccination purpose,  In the United States (U.S.), approximately 26,900 cases of high-risk human papilloma virus (HPV)-attributed genital and oropharyngeal cancers occur annually . OverallThe U.S. spent at least $700 million in 2009 on HPV-attributable diseases . Global In 2009, a school-based 65% 3-dose HPV vaccination rate for Australian females ages 12–26, reduced the incidence of female and male EGW by 16.7 and 20 percentage-points respectively ,14,15. HParental HPV-vaccination acceptance may be most strongly associated with attitude, habit, intention, and subjective norms, providing direction for vaccination education . Media cPublic education can address adverse events of vaccines in general, the HPV vaccine specifically, and refute the assumption that HPV vaccination results in rebound increased sexual activity . Public We performed a single-blind, quantitative, four group, probability sampling, simple randomized, pre-test/post-test online survey  with a mWhy vaccinate against HPV [Public Health Fact Sheet: Patient information about HPV and the HPV vaccine  they may have. Young adults could not also participate as parents. Interested persons progressed to the inclusion/exclusion criteria items. Consent was implied once a potential participant proceeded to the survey instrument screen. Of 2312 initial respondents, 1470 were eligible, and 1109 eligible participants (75.4%) completed the survey .The online survey host, SurveyMonkey Audience, directly invited potential participants from its database and maintained the anonymity of potential and actual study participants. Data lacking identifiers, IP, or email address tracking was collected via encrypted secure sockets layer/transport layer security technology (SSL/TLS) connections in February 2015. The survey lacked name, address, or contact information fields. Participant data storage followed the standard SurveyMonkey Audience anonymous data storage protocol: user authentication and user passwords for data access, and continued data encryption while stored in an audited secure data center. p < 0.05 ascertained a lack of normally distributed demographics, knowledge, and acceptance items responses. Therefore, count and frequency descriptive statistics were used for the sample description. Chi-square was used to ascertain randomization validity. Spearman’s rank correlation coefficient (ρ) was used for comparisons between interval and ordinal variables [Statistical analysis was performed using IBM SPSS Statistics , package Version 22. Normality testing with Kolmogorov-Smirnov and Shapiro-Wilk tests at ariables .χ2), Mann-Whitney U test with Bonferroni correction, and Wilcoxon signed-ranks test (T).Quantitative HPV knowledge and HPV vaccination acceptance items were analyzed for the 1109 respondents who completed the survey through the end of the quantitative post-test. Responses were extracted and analyzed as two groups, as well as individually. Given the lack of normality and the use of four study groups, two-tailed non-parametric tests at alpha level α ≤ 0.05 were employed: Kruskal-Wallis analysis of variance by ranks (Childless young adults who had not completed a HPV vaccination series and parents whose child(ren) had not completed a HPV vaccination series were the study population. Prior completion of the HPV vaccination series was the primary cause of study ineligibility . The stup = 0.029 and p = 0.038 respectively)  . Due to agree or strongly agree responses to the 11-item knowledge variable subscale was analyzed (χ2) of the 18.0% to 19.9% increases in the number of participants with knowledge subscale agree or strongly agree responses in Groups 2 and 3 indicated statistical significance, p = 0.038  as shown in p < 0.001. Group 3 achieved statistically significant knowledge improvement pertaining to the purposes of HPV vaccination, p = 0.02. Wilcoxon signed-ranks test identified six knowledge items with statistically significant changes in responses using the range of the 5-point Likert scale from pre-test to post-test, with small or medium effect sizes as shown in To determine differences in pre- to post-test knowledge of HPV-attributable diseases and prophylaxis between multimodal counseling interventions for HPV vaccination among series non-completers, the change in number of participants making analyzed . Kruskal = 0.038 . Follow-p = 0.027 and p = 0.032 respectively) and HPV vaccination acceptance (p = 0.005 and p = 0.032 respectively), resulting in more than half agree and strongly agree responses (p = 0.011), while the number of male children a parent had was significantly correlated (p = 0.028) with increased HPV knowledge resulting in more than half agree and strongly agree responses. To determine the effect, if any, of covariates on HPV knowledge and HPV vaccination acceptance, Spearman’s rank correlation coefficient (ρ) was calculated. Unadjusted ρ, demonstrated that parents’ age in years, and US generation status were significantly correlated with increased HPV knowledge  of the 12.2% to 12.6% increases in the number of participants with acceptance subscale agree or strongly agree responses in Groups 1 and 3 respectively ”, p = 0.002, “A7. HPV vaccination before teenage is a good idea”, p = 0.002, “A9. If the HPV vaccine were available, I/my child(ren) would be vaccinated against HPV”, p = 0.002, “A12. Despite cost I will vaccinate myself/my child(ren)”, p < 0.001, and “A13. If my doctor recommends I will vaccinate myself/my child(ren)”, p = 0.042. For Group 3, the combined audiovisual and PHEH intervention, there were seven such items: “A3. Research improves vaccines”, p = 0.001, “A5. HPV vaccination would prevent problems for myself/my child(ren)”, p < 0.001, “A7. HPV vaccination before teenage is a good idea”, p = 0.001, “A8. Teenagers should be able to get HPV vaccination without parental consent”, p = 0.023, “A11. Will only vaccinate myself/my child(ren) against HPV if required”, p = 0.002, “A12. Despite cost I will vaccinate myself/my child(ren)”, p < 0.001, and “A13. If my doctor recommends I will vaccinate myself/my child(ren)”, p = 0.05. To ascertain differences in reported HPV vaccination acceptance rates of HPV vaccination series non-completers across multimodal counseling interventions, the pre-test to post-test change in the number of participants responding ectively  did not The objective of this quantitative comparative online survey-based study was to evaluate whether multimodal counseling interventions increase HPV vaccination series non-completers’ knowledge of HPV-attributable disease and acceptance of HPV-attributable disease prophylaxis (vaccination), over a control 14-sentence counseling intervention. Given individuality, it is plausible that different counseling interventions will be necessary to reach different people. Different counseling interventions may have different efficacy. Counseling interventions can increase disease process and vaccination knowledge and acceptance by 9.2 to 15 percentage-points ,33,34. Hp = 0.038. The PHEH intervention, and the combined audiovisual and PHEH intervention, raised knowledge of HPV-attributable EGW, p < 0.001 , over a control 14-sentence counseling intervention. The selected consumer-based online survey population has different characteristics than a random-dialed telephone or college-based online survey population. The results showed that some disease and vaccination-specific information could be successfully communicated in the online format yielding changed perceptions. Foremost, that HPV causes EGW, and that HPV vaccination prevents HPV-attributable diseases and their sequelae were better conveyed by the combined audiovisual presentation and PHEH than the control 14-sentence counseling intervention alone.


To report the prevalence and incidence of low-risk human papillomavirus infection (LR-HPV) and anogenital warts (AGW) among women living with HIV (WLHIV) in Burkina Faso (BF) and South Africa (SA), and to explore HIV-related factors associated with these outcomes.We enrolled 1238 WLHIV  aged 25–50 years and followed them at three time points  after enrolment. Presence of AGW was assessed during gynaecological examination. Cervico-vaginal swabs for enrolment and month 16 follow-up visits were tested for HPV infection by Inno-LiPA® genotyping. Logistic regression was used to assess risk factors for prevalent infection or AGW. Cox regression was used to assess risk factors for incident AGW.Women in SA were more likely than those in BF to have prevalent LR-HPV infection  and incident LR-HPV infection . Prevalence of persistent LR-HPV was similar in the two countries , as were prevalence and incidence of AGW . HPV6 was associated with incident AGW (BF: adjusted Hazard Ratio (aHR) = 4.88; 95%CI: 1.36–17.45; SA: aHR = 5.02; 95%CI: 1.40–17.99). Prevalent LR-HPV ; persistent LR-HPV  and prevalent AGW  were each associated with low CD4+ counts (i.e. <200 vs. >500 cells/μL). Duration of ART and HIV plasma viral load were not associated with any LR-HPV infection or AGW outcomes.LR-HPV infection and AGW are common in WLHIV in sub-Saharan Africa. Type-specific HPV vaccines and effective ART with immunological reconstitution could reduce the burden of AGW in this population. Anogenital human papillomavirus (HPV) infection is the most frequent sexually transmitted infection (STI) globally. Low RiskThere is little literature on the epidemiology of LR-HPV infection and AGW in Sub-Saharan Africa. Regional variations in LR-HPV prevalence varies from 2% in Western Africa, 4% in Southern Africa and 8% in Eastern Africa. SimilaryThree vaccines against HPV have been licensed, two of wCandida albicans by Gram stain at both enrolment and endline visits. Blood samples were collected at enrolment to confirm HIV-1 serostatus, perform Herpes Simplex Virus-2 (HSV-2) and syphilis serologies as well as obtain baseline HIV-1 plasma viral load (PVL) measurement and CD4+ T-lymphocytes counts. The monitoring of CD4+ counts was done at subsequent 6-monthly visits.We conducted a prospective cohort study among WLHIV aged 25–50 years and residing in Ouagadougou, Burkina Faso (BF) and Johannesburg, South Africa (SA) between December 2011 and October 2012. A full description of the study design and procedures has been published elsewhere. Briefly,HIV-1 serostatus was diagnosed using two rapid tests according to national guidelines., 19 TestTreponema pallidum haemagglutination (TPHA) and rapid plasma reagin . Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis were detected using nucleic acid amplification tests, the Sacace simplex assays  in BF and the APTIMA Combo  in SA. The Nugent’s score was used for vaginal flora reading of Gram-stained vaginal smears, with diagnosis of bacterial vaginosis made for scores ≥7, and examined for presence of Candida.HSV-2 serology was performed using the Kalon® gG2 ELISA  and syphilis serology by a combination of a HPV DNA testing and genotyping was performed at the virology laboratory of University of Montpellier (UM) using INNO-LiPA HPV Genotyping Extra Assay . The assay is based on the amplification of a 65-bp fragment in the L1 gene and detects 28 HPV types, including all the high-risk or probable high-risk types  as well as the following LR HPV genotypes .≥1 of the 9 genotypes described above. LR-HPV type-specific persistence was defined as being positive for the same type at enrolment and endline. Type-specific LR-HPV incidence was defined as the proportion of women who were negative for a specific LR type at enrolment and positive for that type at endline. Prevalent AGW were defined as the presence of clinically-defined condyloma acuminata at the enrolment visit. Incident AGW were defined as the first documented occurrence of condyloma acuminata in a woman previously documented not to have AGW. Time to incident AGW was calculated from date of enrolment visit to the date of first AGW detection.Any LR-HPV type infection was defined as detection of a priori as known correlates for HPV and AGW acquisition. As LR-HPV prevalence was common, associations with exposure variables were estimated from prevalence ratios obtained from logistic regression using marginal standardization to estimate prevalence ratios, and the delta method to estimate 95% confidence intervals (CIs). Associations between LR-HPV persistence and exposure variables were estimated with generalized estimating equations to account for multiple LR-HPV infection and multiple infection states (persistence and clearance).. The prevalence of any LR-HPV was lower in BF (27.1%) than in SA (40.9%) (p<0.001), as were the prevalence of the following LR types: 11 , 44 , 70  and 74 . Type 6 prevalence was similar in both countries (BF 5.7% vs. SA 5.3%). Type 44 was the most prevalent LR-HPV type, for both countries . In bothOf the 1215 women with valid HPV results, 32 (2.6%) reported that they were not on ART at enrolment despite undetectable HIV-1 PVL . Given the uncertainty of their ART status, these women were excluded from HIV-related factors analyses. Further analyses were conducted on the remaining 1183 participants  to determine the effect of HIV-related factors on any LR-HPV prevalence . In bothOverall, 963/1238 (77.8%) WLHIV attended the endline visit at a median 16  months and the majority (922) had HPV-genotyping results at both enrolment and endline . Of these, 264 (28.7%) had incident LR-HPV of any type during follow-up. The incidence of any LR-HPV infection was lower in BF compared to SA . This was also true for most individual types  with the exception of types 44  and 69/71  which were significantly higher in BF compared to SA .A third of WLHIV (310/922) were defined as having persistent LR-HPV infection; the total number of persistent infections was 396 . The frequency of persistent infection of any LR-HPV at endline was similar in both countries . Persistence for individual types was largely similar between the two countries . A low COverall, 81 (6.7%) WLHIV had AGW detected at enrolment; the prevalence did not vary by country . In univariate analysis (data not shown), prevalent AGW were associated with age, number of partners in the last 3 months before enrolment, presence of genital ulcers for both countries and being HSV-2 seropositive in BF or having bacterial vaginosis in SA. Infection with any LR-HPV type, multiple LR-HPV infections, and infection with types 6  and 11  were significantly associated with prevalent AGW . In BF, A total of 32 new AGW events  were recorded for the 992  WLHIV who were followed up for a total of 1390 person-years. The overall AGW incidence was 2.30 per 100 person-years . In univariate analysis (data not shown), incident AGW were associated with age for both countries and number of partners in the last 3 months before enrolment in BF or having mycoplasma genitalium in SA. Infection with any LR-HPV at enrolment was associated with having an incident AGW; this association was statistically significant in BF  . PrevaleWe found that the prevalence and incidence of LR-HPV infection in this population were high and consistent with other studies of WLHIV in sub-Saharan Africa., 25, 26 per se against prevalent LR-HPV infection, incident LR-HPV infection and incident AGW, confirming other studies findings.[We found that low enrolment CD4+ cell count was associated with a higher prevalence and persistence of LR-HPV as well as a higher prevalence and incidence of AGW. This is consistent with previous studies reporting CD4+ count as a strong predictor of HPV infection and AGW development., 10 A lofindings., 11 ThisWe also found that, as reported in previous studies, non-HIV related factors such as alcohol use, number of recent sexual partners, changes in vaginal flora and coinfection with other STIs were significant co-factors for LR-HPV infection and AGW., 7 In coLimitations of the study include the absence of HIV-1 PVL monitoring, in particular at endline and the possible subjective nature of clinical examination for AGW detection without histological confirmation leading to possible misclassification. Cervical LR-HPV infection rather than vaginal/vulval LR-HPV infection was measured which would have been more appropriate given the frequent external location of AGW. This can lead to difficulties in ascribing causality. However, cervical HPV infection has been used previously in determining associations with AGW. Despite This study shows that WLHIV in sub-Saharan Africa are at high risk of LR-HPV infections and AGW. AGW were associated with HPV 6/11 and these findings support the argument for the use of quadri- or nano-valent HPV vaccines for the prevention of AGW among WLHIV. Effective use of ART with immunological reconstitution could also help control the burden of AGW among WLHIV in the region.S1 TableaIn BF, associations with LR-HPV were adjusted for alcohol use, condom use and number of pregnancies; bIn SA, associations with LR-HPV were adjusted for number of regular sex partners, number of pregnancies and number of lifetime sex partners; For Model 2: same adjustment as Model 1, in addition to enrolment CD4+ count; c Of the 156 infections in Burkina Faso at enrolment  using generalised estimating equations: nrolment , 5 were nrolment , 2 were (DOC)Click here for additional data file.S1 File(XLS)Click here for additional data file.


Human papillomavirus (HPV) DNA testing plays a main role in the management of cervical cancer, however to improve the specificity in cervical screening, there is a need to develop and validate different approaches that can identify women at risk for progressive disease.Nowadays, mRNA expression of viral E6 and E7 HPV oncogenes stands up as a potential biomarker to improve cervical screening. We aimed to validate a method for RNA extraction, detect HPV mRNA expression and, assess the relationship between E6/E7 mRNA expression and pathology of patients’ lesions and progression.This study included 50 specimens that had been previously genotyped as HPV16, 18, 31, 33 and/or 45. Cervical swabs were extracted with three different RNA extraction methods -Nuclisens manual extraction kit (bioMérieux), High Pure Viral RNA Kit (Roche) and RNeasy Plus Mini kit (Qiagen)-, and mRNA was detected with NucliSens EasyQ HPV version 1 test (bioMérieux) afterwards. Association of oncogene expression with pathology and lesion progression was analyzed for each extraction method.E6/E7 mRNA positivity rate was higher in samples analyzed with bioMérieux (62%), followed by Roche (24%) and Qiagen (6%). Women with lesions and lesion progression showed a higher prevalence of viral RNA expression than women that had not lesions or with lesion persistence. While bioMérieux revealed a higher sensitivity (77.27%), Roche presented a higher PPV (75%) and an increased specificity (89.28%).Extraction methods based on magnetic beads provided better RNA yield than those based in columns. Both Nuclisens manual extraction kit (bioMérieux) and High Pure Viral RNA Kit (Roche) seemed to be adequate for E6/E7 mRNA detection. However, none of them revealed both high sensitivity and specificity values. Further studies are needed to obtain and validate a standard gold method for RNA expression detection, to be included as part of the routine cervical screening program. High-risk Human papillomavirus (HR-HPV) infection persistence is a necessary feature to develop cervical cancer, which is the third most common cancer in women worldwide, and the second most common cancer in developing regions –3. CanceHPV genome has two oncogenes, E6 and E7, whose expression increased when these genes are deregulated . OncogenNowadays, cervical cancer screening is based on cytology and/or HPV DNA detection , 13. HPVOne of the most promising cervical cancer biomarkers is the mRNA expression of viral E6 and E7 oncogenes, since its association with the severity of cervical lesions is well described in the literature . In 2007The present study aimed to assess E6/E7 mRNA as a possible biomarker for cervical cancer by analyzing the relationship between HPV E6/E7 mRNA expression and the pathology and evolution of different lesions. As some authors have reported the importance of RNA input  prior to any HPV RNA assay –19, we an = 912) attending Consultation of Sexually Transmitted Diseases and Gynaecological consultation at Basurto University Hospital  were remitted to Clinical Microbiology and Infection Control Department to analyze their samples, when a possible HPV infection was suspected.From 2010 to 2014, all women  transport medium at room temperature until HPV presence or absence was studied.Lesions were classified by pathologists following Bethesda system: 1) Negative (no lesion was found) 2) Low-grade squamous intraepithelial lesion (LSIL) - atypical squamous cells of undetermined significance (ASCUS) included- and, 3) High-grade squamous intraepithelial lesion (HSIL).Cytology was repeated 2 years after samples collection and, results were categorized into three groups depending on lesion progression: 1) Persistence: women whose cytological results had not changed in the last 2 years, 2) Progression: women whose cytological results showed a worsened process, and 3) Regression: women who had cleared signs of infection.Written and informed consent was obtained from participants.The study adhered to the declaration of Helsinki and was approved by Ethical Committee of Clinical Research of Euskadi (Code: PI2014016).All methods were carried out in accordance with the approval guidelines.HPV genotyping was performed using Cobas® HPV Test  and Beta-globin was used as an internal control to ensure specimen adequacy.Cobas® HPV Test detects up to 14 HR-HPV genotypes, identifying HPV16 and 18 specifically, while detecting “other HR-HPV genotypes”  concurrently.Samples that had been positive for “other HR-HPV genotypes” with Cobas® HPV Test were therefore, subjected to Linear Array HPV Genotyping Test kit , to elucidate which specific HR-HPV genotypes were present in each specimen. Linear Array HPV Genotyping Test is a line-blot assay that detects 37 HPV genotypes .n = 50).All samples from women who were positive for HPV16, 18, 31, 33 and/or 45 were included for further RNA analysis (RNA was extracted with three different kits according to manufacturer’s instructions: 1) Nuclisens manual extraction kit -RNA was extracted from 200 μl of samples by NucliSENS Lysis Buffer and NucliSENS® miniMAG® and eluted in 60 μl of elution buffer-, 2) High Pure Viral RNA Kit  - RNA was extracted from 200 μl of sample and eluted in 50 μl of Elution Buffer- and, 3)RNeasy® Plus Mini kit  -RNA was extracted from 400 μl of sample and eluted in 50 μl of RNase-Free Water-.RNAse-Free water was used as negative control in each RNA extraction. Eluted RNA was stored at -20 °C until E6/E7 analysis (never exceeding 2 weeks) and at -80 °C, afterwards.Oncogene expression was analyzed in each sample three times (one for each RNA extraction method). Those samples that had been genotyped as positive for several targeted HPV genotypes  were analyzed once for each genotype and extraction method.E6/E7 mRNA was detected by NucliSens EasyQ HPV test version 1  following manufacturer’s instructions, including an internal control, human U1 small nuclear ribonucleoprotein specific protein A (U1A), to assess mRNA expression quality. Samples with no RNA expression were re-extracted and oncogene expression was analyzed once again.a)) and Cohen’s kappa coefficient (κ). Statistical results were categorized according to Landis and Koch classification: values lower than 0 indicates no agreement, from 0 to 0.20 slight agreement, from 0.21 to 0.40 fair agreement, from 0.41 to 0.60 moderate, from 0.61 to 0.80 substantial, and from 0.81 to 1 as nearly perfect agreement [Positive predictive value (PPV), Negative predictive value (NPV), sensitivity and specificity were calculated for each extraction method. The concordance between different extraction methods was studied by the relative observed agreement  varied from 19 to 63 years (mean age34.96 ± 10.63 years). Among these women, 42% (21/50) were infected with only one HPV genotype (single HPV infection) while 58% (29/50) were infected with more than one HPV genotypes (multiple HPV infection). However, only 4/29 multiple infections revealed the presence of more than one HPV targeted genotype . All four samples were multiple infections of 2 HPV genotypes.The age range of enrolled women  followed by HPV45 , HPV18 , HPV31  and HPV33 .According to Bethesda system, 8% of samples were classified as HSIL (4/50), 36% (18/50) as ASCUS or LSIL and 56% (28/50) as negative.E6/E7 mRNA positivity rate was 62% 31/50). Although the most detected genotype after DNA analysis was HPV16, the most expressed genotype was HPV33 followed by HPV18, HPV16, HPV31 and HPV45 , 54.84% (17/31) belonged to women who presented lesions (41.94% to women with ASCUS or LSIL and 12.90% to women with HSIL), while for mRNA negative specimens (19/50), 73.68% (14/19) corresponded to women without cervical lesions. All women with high-grade lesions were classified as positive for oncogene expression  of women. The most expressed genotype was HPV33 followed by HPV18, HPV45, HPV31 and HPV16 (Table 2/50 of wNine out of 12 (75%) women who were positive for E6/E7 mRNA expression had some type of lesion (50% women with ASCUS or LSIL and 25% with HSIL) , 65.79% 25/38) belonged to women without lesion, 31.58% (12/38) to women with ASCUS or LSIL and, 2.63% (1/38) to women with high-grade lesion. Concerning lesion evolution, none of tested women had infection clearance. Only 6.06% of women with lesion persistence were positive for oncogene expression while the percentage increased up to 58.82% for women with lesion progression  was detected between oncogene expression and type of lesion. Due to the low number of E6/E7 mRNA positive samples, data obtained with this method was excluded for comparison with other methods.Only 6% of all specimens (3/50) analyzed after Qiagen extraction, showed mRNA expression. No significant relationship (While the NPV was similar for both extraction methods (65.79% Roche vs. 73.68% bioMérieux), the PPV was higher for Roche than for bioMérieux . Roche extraction method also showed a higher specificity (89.28% vs.50%), however, its sensitivity was lower (40.90% vs. 77.27%) when comparing to the bioMérieux extraction method.Considering that viral oncogenes should be expressed in women with lesions but not in women without lesions, bioMérieux extraction method showed substantial and nearly perfect observed agreement whenever women presented some type of lesion (0.72 in LSILs and 1 in HSILs) whereas Roche extraction method, showed nearly perfect agreement (0.89) for women without lesion  whereas bioMérieux extraction method showed substantial concordance in women with worsened lesions (0.74).When comparing the 2 RNA extraction methods against each other, a moderate relative observed agreement was seen regarding E6/E7 mRNA detection rate (0.58) and lesion development (0.57 for women that showed persistance and 0.60 for women with worsened lesions). Concerning pathology, a substantial agreement was found in women without lesion or with high-grade lesions  while the concordance was just moderate when studying in women with low-grade lesions (0.50).Considering Cohen’s kappa coefficient, agreement between methods was fair regarding E6/E7 mRNA detection rate (0.26), and pathology (0.26 bioMérieux and 0.32 Roche). Concerning lesion progression, Roche extraction method showed moderate agreement (0.41) whereas bioMérieux agreement was fair (0.26)  and assess the difference found when analyzing E6 and E7 oncogene expression.Among the extraction methods, E6/E7 mRNA positivity rate was higher in samples analyzed with bioMérieux , followed by Roche 24%, 12/50) and Qiagen . These results are in agreement with other studies that compares these extraction methods for human immunodeficiency virus %, 12/50 , 26. DueBoth bioMérieux and Roche extraction methods showed similar results when comparing RNA expression, type of lesion and evolution. Women with lesions showed a higher prevalence of viral RNA expression  while women that had not lesions revealed a lower prevalence of viral mRNA (26.32% bioMérieux and 34.21% Roche). Women that had suffered from lesion progression were mostly positive for HPV mRNA (94.4% bioMérieux and 58.82% Roche), while viral expression positivity was found to be lower in women that had remained with the same type of lesion (43.75% bioMérieux and 6.06% Roche). These results agreed with other authors that suggested E6/E7 mRNA expression as a prognostic factor for high-grade lesions and confirmed viral oncogene expression association with severity of cervical lesions –29.We evaluated the concordance between bioMérieux and Roche with lesion type and evolution, applying two different coefficients, the relative observed agreement and Cohen’s kappa. The relative observed agreement was found to be from fair to nearly perfect for both extraction methods while Cohen’s kappa revealed a fair to moderate concordance. Agreement differences might be explained due to the low number of samples included in the study.As reported by Ovestad et al., a test for screening population should have both high sensitivity and specificity values . In our We demonstrated the importance of validating a protocol for HPV E6 and E7 oncogene expression detection. Extraction methods based on magnetic particles provided better RNA yield than those based in columns. Both Nuclisens manual extraction kit (bioMérieux) and High Pure Viral RNA Kit (Roche) seemed to be adequate for E6/E7 mRNA detection. However, none of them revealed both high sensitivity and specificity values. Sensitivity was proven to be essential when detecting viral mRNA expression, as certain genotypes as well as episomal forms, might not produce a high number of transcripts to transform cells. Further studies are needed to obtain and validate a standard gold method for RNA expression detection, to be included as part of the routine cervical screening method.


Human papillomaviruses (HPV) cause infections that are responsible for diverse clinical manifestations from benign conditions to invasive cancer. As different HPV types are associated with variable pathogenic potential, minor genetic variations within a given high-risk HPV type might also be associated with distinct oncogenic capacities, through variable ability of persistence or risk of progression to precancer/cancer. Most recent HPV variant studies in the cervix using latest sequencing technology confirmed that minor changes in the HPV genome can have a major influence on carcinogenesis and have revealed key data that help better understand the carcinogenicity of HPV at a molecular level. Here we review the limited number of studies on HPV genome variants in head and neck cancers (HNC) and discuss their implications for cancer research in the light of accumulated knowledge for the cervix. Challenges in transposing HPV variant studies from the lower anogenital to the upper aerodigestive tract are also discussed, highlighting the main gaps of knowledge in the field of HPV-induced HNC. Specifically in the head and neck region, the lack of characterisation of precancerous lesions and the difficulty in sampling normal tissue will challenge the development of accurate studies. Although there is so far no indication that HPV variant research in HNC could directly translate into clinical application, such research is expected to be useful to disentangle unanswered questions in the pathogenesis of HNC. Yet, history of HPV variant research suggests that, to be successful, studies will require large international collaborative efforts. Human papillomaviruses (HPV) cause infections that are responsible for diverse clinical manifestations from warts (papillomas) to invasive cancer. A dozen high-risk (HR) HPV types are powerful human carcinogens and the primary cause of cancer of the cervix and anogenital tract . In the It is well established that although all HPV are genetically related, their pathogenic characteristics differ widely . As diffIn the present article, we reviewed the limited number of studies on HPV genome variants in HNC and discussed their implications for cancer research in the light of accumulated knowledge in the cervix. Challenges in transposing HPV variant studies from cervical to HNC are also discussed, highlighting the main gaps of knowledge in the field of HPV-induced HNC.Papillomaviruses are small non-enveloped viruses with circular double-stranded DNA of around 7000–8000 nucleotides infecting skin and mucosa of a variety of mammals, reptiles and birds . PapilloAlphapapillomavirus, Betapapillomavrius), differences of 30–40% define “species” , and differences of 10–30% define “types” . Of note, the International Committee on Taxonomy of Viruses provides a taxonomic nomenclature only up to the species level [Papillomaviruses are subdivided in genus, species, types and subtypes according to degree of viral genetic variation. Evaluation of differences in the L1 open reading frame DNA sequence is considered sufficient up to type-level classification, as it is accepted that L1 is robust enough to fully determine these subdivisions . DiffereHPV “variants” are smaller genetic variations in the viral DNA sequence within a given HPV type. At the subtype level, the evaluation of the difference in the whole genome sequence is considered necessary . DiffereAt the subtype level, minor genetic variations that do not fit a phylogenetic tree are also characterised (hereinafter referred to as “non-lineage-specific HPV variants”) and correspond to more recent mutations. These non-synonymous single nucleotide changes that can appear independently from lineages are characterised by their DNA or amino acid substitution .Alphapapillomavirus genus  but widely differ in prevalence (related to evolutionary fitness) and risk of causing precancer/cancer. In the same manner, intra-type genetic variations might present differential pathogenic properties, through variable capacity to trigger immune response, ability to persist, or risk of progression to precancer/cancer. It is, for instance, conceivable that a minor variation in the E6 or E7 sequence may induce differential propensity of the corresponding protein to bind p53 or pRB and impact the risk of progression to cancer by modifying their capacity to inactivate the corresponding tumour suppressor functions.All twelve HR-HPV belong to the Risk associated to HPV variants in cervical carcinogenesis has been studied since the early 1990s , 13. TheHowever, globally, early studies on HPV variants in the cervix were judged as relatively disappointing. Inadequate sample size probably partly explains the inconsistencies between these studies with regard to the direction of the variants’ effect, but also prevented further evaluation of these observations –47. IndeWith recent development of next-generation methods, their increasing availability and adaptability to large-scale populations, promising findings have emerged on pathogenic effects related to HPV variants in cervical cancer. These greatly improved approaches pave the way for the evaluation of variants in other HPV-associated cancer sites such as cancer of the oropharynx.Mirabello et al. evaluated the association between HPV16 lineages and risk of precancer/cancer in 3200 women from a US cohort . This stIndeed, it was shown that previously defined “European” variants actually regrouped sublineages with substantially different risks of precancer/cancer. For instance, risk associated with sublineage A4 was markedly higher compared to A1/A2. In the same manner, risk associated with histology outcome showed strong heterogeneity. Odds ratio (OR) of glandular cancer for D2 vs A1/A2 sublineages was 137.3 (95% CI: 37.2–506.9) whereas OR of squamous cancer was 7.6 (95%CI: 1.4–39.8). This finding was corroborated by a comparable study using samples collected worldwide . AlthougIn addition, this study confirmed the early observation that some variants present a higher carcinogenic effect in women whose genetic background corresponds to that of the virus. For instance, Caucasian white women infected with A1/A2 variant were at a higher risk of CIN3+ compared to women of other genetic backgrounds. Similarly, Asian and Hispanic women had increased risk, although non-significant, associated with A4 and D2/D3 sublineages compared with other races/ethnicities. Of note, the magnitude of the effect of associations with genetic backgrounds was relatively low (OR≈1.5).An important and unexpected finding came from the same collaborative group who analysed more than 5000 HPV16 case control samples worldwide . It was HNC includes numerous tumours that generally share strong associations with tobacco and alcohol consumption . HPV16 iHPV-induced OPCs involve both genders, although with higher incidence in men compared to women . This seFew studies reporting HPV16 variants in HNC are available  and T350G in 108 tonsillar and cervical cancers in Swedish patients . In thisCritical differences between genital and upper aerodigestive tracts need to be underlined , 74, impThe major challenge for the head and neck consists in the lack of characterisation of the carcinogenetic steps from normal tissue to cancer. Although few studies have attempted to collect precancerous lesions in non-cancerous patients using cytology from in vivo –77 or exAn additional critical challenge exists when trying to assess whether certain HPV variants show differential risk of persistent infection. Indeed sampling non-cancerous tonsillar or oropharyngeal tissue to detect HPV infection is problematic. All sampling methods are imperfect due to specific limitations , 82: evaYet case-case comparisons including other HPV-induced cancer sites should be informative . The greThere is so far no indication that HPV variant research in HNC would be directly clinically relevant. However, such research could be useful to disentangle other unanswered questions including HPV genome integration –85, the In conclusion, our review suggests that the most recent HPV variant studies in cervical cancer are of importance in planning the evaluation of HPV heterogeneity in other HPV-associated cancer including HNC. HPV variant studies using recent sequencing technology have generated key data that should help better understand the carcinogenicity of HPV at a molecular level. If these successful studies have confirmed that minor changes in the HPV genome can have a major influence on carcinogenesis, they also highlight the crucial need for international collaborative efforts to allow appropriate in depth analyses.


Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. guidelines. Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients.This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard.This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening.NCT02401867ClinicalTrials.gov ID: The online version of this article (doi:10.1186/s12879-017-2539-x) contains supplementary material, which is available to authorized users. Cervical cancer is caused by a sexually transmitted infection with one of several high-risk strains of the human papillomavirus (hr-HPV) in 99.7% of cases . This anDespite myths that masculine-spectrum transgender people  – individuals assigned a female sex at birth who identify as male, man, trans man, or another diverse gender identity not corresponding to their assigned female sex at birth  – are atAs the majority (>80%) of TM do not undergo gender affirming genital surgery and therefore retain their cervix, American Congress of Obstetricians and Gynecologists (ACOG) recommend that these TM follow the same cervical cancer screening guidelines as cisgender women , and undSelf-collected hr.-HPV DNA testing as a primary cervical cancer screening technique –26 and sThe aims of this study were to 1) quantitatively and qualitatively assess the acceptability and clinical performance of a vaginal self-swab for hr.-HPV DNA testing compared to provider hr.-HPV and cervical cytologic cotesting among sexually active TM, and 2) investigate the prevalence of other STIs among sexually active TM. This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for prevention, screening, and diagnosis. We hypothesized that our findings would improve patient care, including attitudes about and comfort with screening, and delivery of preventive sexual health screening in this overlooked and underserved patient population, including potentially less-invasive, alternative screening strategies for TM patients.This biobehavioral mixed-methods study examined preventive sexual health screening in 150 TM patients in Boston, MA. Community-based participatory research principles (CBPR) , 36 wereThis study was conducted at The Fenway Institute at Fenway Health in Boston, MA. As of 2013, Fenway Health had approximately 650 TM patients actively engaged in medical care; by 2016 that number had increased to over 950 TM patients. All data were collected between April 2015 and September 2016. All study procedures were approved by the Fenway Health Institutional Review Board (FWA00000145).Individuals were eligible to participate in the one-time clinical study visit if they met the following criteria: 1) Ages 21–64 years ; 2) Assigned a female sex at birth and now identifies a man, trans man, male, trans masculine, FTM , transgender, genderqueer/non-binary, transsexual, and/or another diverse transgender identity; 3) Have a cervix; 4) Sexually active in the past 36 months (with partner(s) of any gender); 5) Able to speak and understand English; and 6) Willing and able to provide informed consent.The research team considered excluding individuals who had received the HPV vaccine, but decided to enroll individuals regardless of HPV vaccination status for the following reasons: 1) current cervical cancer screening guidelines are identical for HPV vaccinated and unvaccinated individuals; 2) in our formative qualitative work, 62% reported never having received any dose of the HPV vaccination (unpublished data); 3) some TM individuals who are vaccinated will not have been vaccinated until after sexual debut and may have already been exposed to HPV; 4) there is a substantial risk of recall bias when relying on HPV vaccination self-report, especially series completion; 5) given the relatively recent introduction of routine HPV vaccination recommendations, it is far less likely for our subjects over the age of 30 years to have received a vaccination series; and 6) no research has reported prevalence of HPV vaccination in TM individuals, thus collecting information about HPV vaccination and number of doses completed would be a valuable aspect of the study.The research team considered whether to enroll participants self-reporting a Pap test in the prior 3 years, as this would in reality represent over-screening. Ultimately, the research team decided to enroll individuals regardless of self-report of last screening date or result, as self-report of last date of cervical cancer screening has been shown to be an inaccurate measure of actual screening utilization –39. PartMultiple convenience and referral-based sampling techniques were used by study staff to identify and recruit potentially eligible participants from the catchment area of Fenway Health’s five clinics. Purposive sampling techniques were also used to ensure a diverse study sample with regards to age, race, and ethnicity. All recruitment was conducted by study staff who are also members of the TM community or allies.Active recruitment was conducted by working with the Fenway Health data informatics team to identify patients coming in for routine care who were potentially eligible for the study through the electronic medical record. Staff asked providers to provide information about the study to patients identified as potential participants, as well as a card containing contact information for the study.Potential participants were also recruited passively via the posting of study flyers at Fenway Health locations, as well as at community spaces frequented by TM individuals. Recruitment advertisements were posted to online platforms such as the Fenway research website, MyFenway and MyBorum , Facebook, transgender community list serves, paid advertisements on Apps such as Scruff and FetLife, and in other local media such as the 2016 Boston Pride Guide. A study-specific website and a Facebook page were also developed to aid in recruitment and dissemination of information about the study.Individuals interested in participating consented to eligibility screening prior to enrollment. All study visits occurred within 1 month of screening. When scheduling the study visit, eligible individuals were given the option of seeing either a cisgender male or cisgender female study provider, and told that they had the option of bringing a support person into the exam room during the Pap test to help the participant feel more comfortable.Informed Consent & Intake Paperwork – Written informed consent was obtained from each participant prior to the initiation of study procedures or assessments.Self-Administered Quantitative Survey – All participants completed a quantitative assessment via computer-assisted interview technology (CASI) via a touch-screen iPad in self-administered format to increase the accurate reporting of sensitive questions   . All counseling and testing procedures were consistent with HIV testing and counseling requirements set forth by the Massachusetts Department of Public Health. There were three scenarios in which a participant did not need to undergo HIV testing: 1) the participant did not consent to the test, 2) the participant was HIV-infected and can provide documentation, and 3) the participant had been tested for HIV in the last 2 months and could provide sufficient documentation of their HIV-negative status .Randomization – To guard against potential specimen collection ordering effects, participants were randomized to do either self- or provider-collection first. Participants did not have an option as to which order specimen collection was done. A randomization table was generated using Statistical Analysis Software (SAS) Version 9.4.Collection of Biological Specimens – See Table Self-Collection Procedures. Participants self-collected three swabs: 1) vaginal swabs hr.-HPV DNA, 2) vaginal swab for gonorrhea/chlamydia (GC/CT) testing, and 3) a rectal swab for GC/CT testing. Participants were instructed by study staff on specimen self-collection methods, and were provided an instruction sheet for reference during self-collection  were trained in specimen collection according to study protocol. The exam and collection process were standardized. Providers conducted a brief pre-exam assessment and medical history using a script adapted from the Center for Disease Control and Prevention’s  History  . Participants were invited to undergo the longer interview to maximize diversity in demographics  as well as to maximize diversity of opinion as expressed in the first part of the interview . The in-depth qualitative interview covered the previously described exit interview topics as well as additional domains to inform future clinical practice and research: 1) narrative history of preventive sexual health screening; 2) barriers and facilitators to screening utilization guided by Health Belief Model constructs ; 3) pastsensitivity = true positive/. Specificity, the probability of correcting detecting individuals without a condition, will be estimated as specificity = true negative/.The primary outcome variables of the study are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard. McNemar’s test is a two-sample test for binomial proportions for matched-pair data . An adjuHPV prevalence estimates - Overall, prevalence of hr.-HPV in the U.S. is 42.5% in females ages 14–59 years captured via self-collection of cervicovaginal swab [lowest among age 50–59 (23.5%) and highest among age 20–24 (43.3%)] [(43.3%)] . There a(43.3%)] . Given uConcordance of vaginal self-swab and provider cervical swab for hr.-HPV DNA testing – Comparing the concordance of the hr.-HPV DNA-positive results to the cervical provider swab hr.-HPV DNA test results (“gold standard” reference) using the McNemar’s test, a two-sample test for binomial proportions for matched-pair data. The null hypothesis is that the sensitivities of swab 1  and swab 2  are equivalent. Assuming a 15% hr.-HPV prevalence via vaginal self-swab, we selected a sample size of 150 to detect a 15% or more discordance between the two sampling approaches  was most often between 0.14%–22.2% (median 19%) [ian 19%) .Power for the adjusted McNemar’s test is dependent on multiple parameters, including hr.-HPV prevalence in our sample and the difference in detection rates between self/provider sampling methods.Qualitative data will be analyzed using a combination of traditional content analysis  and techThis study addresses critical gaps in current clinical knowledge of sexual health in TM individuals. We are the first to our knowledge to describe rates of cervical high-risk HPV DNA infection and of STIs in a study focused specifically on TM individuals. We are also the first to our knowledge to examine the role and performance of self-collected hr.-HPV DNA testing as a primary cervical cancer screening strategy in TM individuals. Given evidence that self-collected hr.-HPV DNA testing may improve screening rates in underscreened populations of cisgender women , this scAdditional file 1:Diagram & Definition of Terms. (PDF 311 kb)Additional file 2:Provider Assessment and Interaction Tool. (DOCX 34 kb)Additional file 3:Patient Satisfaction Survey. (DOC 48 kb)