In women with persistent HR-HPV infection, the five-year cumulative incidence of CIN 2+ was 6% (95% CI = 1.6–10.2) versus 2%  in women without HPV infection. An HIV viremia of >200 copies/mL, a CD4+ cell count of <200 cells/µL, persistent HR-HPV infection, and smoking ≥10 cigarettes/day were all independent and statistically significant risk factors associated with the development of CIN2+ during follow-up. Conclusions: WLWH with good immune status and negative Pap smear and HR-HPV test have a low risk for CIN2+.Background: Women living with Human Immunodeficiency Virus are at higher risk of cervical cancer and precancer compared to women without HIV infection. The aim of the study is to evaluate the risk factors for the development of CIN2+ in a cohort of WLWH with negative colposcopy and cytology during a long follow-up period. Methods: We enrolled, in a multicentric retrospective cohort study, WLWH who attended the colposcopic services from 1999 to 2019. Patients with a normal Pap smear, a negative HR-HPV test, and at least one year of follow-up were considered for the anlysis. Results: The five-year cumulative incidence of histologically confirmed HSIL was 8.3% (95% CI = 2.6–13.6) among subjects with a CD4+ cell count of <200 cells/µL at any visit and 2.1% (95% CI = 0.7–3.4,  Women living with the Human Immunodeficiency Virus (WLWH) are at higher risk of cervical cancer and precancer compared with women without HIV infection . GloballHIV infection and related immunosuppression are associated with a higher rate of acquisition, a reduced rate of clearance, and an increased persistence of Human Papillomavirus (HPV) infection ,5. ProloWhile the surgical treatment of cervical cancer precursors is highly effective in immunocompetent women, with eradication in about 90% of cases, a lower efficacy has been reported in women living with HIV, in whom high rates of persistent and recurrent disease have been found in several studies [The severity of immunosuppression, as indicated by a low CD4+ cell count and high HIV RNA viral load, appears to strongly affect high-risk HPV (HR-HPV) incidence and persistence and cervical lesion incidence and progression ,10.The impact on HPV pathogenesis of antiretroviral therapy (ART), which allows for the prolonged suppression of HIV replication and improved immune status, is still unclear, and studies evaluating this association reported conflicting results. However, increasing evidence in the literature indicates that the use of highly active antiretroviral therapy (HAART) seems to be associated with reduced HPV disease progression, especially if started at a higher CD4+ cell count and used over longer durations by adherent patients ,11.Several screening strategies have been proposed to prevent cervical cancer in WLWH, either with cytology alone or HR-HPV cotesting, generally characterized by shorter monitoring intervals depending on the immunological condition of the patient ,13. HoweIn HIV-positive women, cervical cancer screening based on HPV test was reported as positive several more fold than in the general population, and around 25–35% of women affected by HIV reported an abnormal Pap smear result (ASC-US+) during gynecological follow-up . BecauseThere are few data reported in the literature about the risk of high-grade cervical lesions in women living with HIV with a negative Pap smear and without detectable HPV infection. In this study, we evaluated the risk factors for the development of CIN2+ in a large cohort of WLWH with normal cytology and negative HPV test and normal colposcopy during a long follow-up period with the aim of identifying the most useful predictors of cervical neoplasia.We performed a multicentric, retrospective cohort study that involved two Italian centers: IRCCS Fondazione Policlinico San Matteo, Pavia, and Luigi Sacco Hospital, ASST-Fatebenefratelli-Sacco, University of Milan, Milan. All WLWH who attended the colposcopic services of the two institutions from 1999 to 2019 were retrospectively identified by searching the clinical databases.Those patients who presented at entry with a normal Pap smear and a negative HR-HPV test and who had at least one year of follow-up were selected for the analysis. Exclusion criteria were: age 21 years or older, ongoing pregnancy, treatment for CIN or total hysterectomy before enrollment. Institutional Review Board (IRB) approval by our institution was obtained .Anamnestic items about sociodemographic and clinical features were compiled after structured interviews during enrollment and the follow-up. All patients were evaluated every 6–12 months according to an established protocol, including a Pap smear, HPV test, and colposcopy with targeted biopsies if necessary. Abnormalities in cervical cytology were classified according to the most recent Bethesda system terminology . CytologThe colposcopic examination was performed by two experienced gynecologists (BG and AA) certified by the Italian Society of Colposcopy and Cervico-Vaginal Pathology (SICPCV). Targeted cervical biopsies were obtained in all cases where a cervical lesion was suspected and in all cases of high-grade squamous cervical lesions (HSIL), irrespective of the colposcopic impression. Endocervical curettage was performed, according to the clinician’s judgment, when the extent of the lesion or the squamocolumnar junction was not entirely visible (transformation zone type 3). Histopathologic results were reported according to Lower Anogenital Squamous Terminology (LAST) as LSIL (CIN1), HSIL (CIN2), HSIL (CIN3), or HSIL (CIN2/3) . The useUnivariate statistical analysis was carried out with Kruskal–Wallis analysis of variance and the chi-square test to compare continuous and categorical variables, respectively. The Bonferroni method for multiple comparisons was used to evaluate partitioned chi-square tests in multiway contingency tables. We did not estimate a preliminary sample size because this was not a randomized study but a retrospective cohort study. To evaluate the independent effects of age, CD4+ cell count, HIV viral load, HR-HPV infection, and smoking, we used a stepwise ordered logistic regression model. All the analyses were carried out with STATA 13.0 .Out of a total of 904 WLWH seen on a regular basis over a period of 20 years, 599 (66.3%) had a normal Pap smear, a negative HR-HPV test, and a normal colposcopy and were included in the study. They had a minimum of two years of follow-up, a median follow-up time of 84.3 months (IQR = 31–167), and a median of five visits (IQR 3–7). The main characteristics of the study population are shown in At the time of inclusion 50.75% (304/599) of women were receiving HAART, 20.37% (122/599) were receiving pre-HAART, while 28.9% (173/599) did not use any drugs; the median CD 4+ cell count was 454 cells/µL (IQR 294–600), and a low HIV viral load (<200 copies/mL) was found in 69.3% (415/599) of patients. During the follow-up, an incident HR-HPV infection was diagnosed in 280 patients (46.7%), and in 20.7% (124/599), the infection persisted for more than two years. The overall incidence of HR-HPV was 43.6% in women with normal cytology and increased with the severity of cervical lesions (62% in CIN1 and 70% in CIN2+). HPV-16 type has been found in 7.5% of cases, and multiple infections have been detected in 12.2% of cases; 53.3% (319/599) of women remained negative to HR-HPV testing.The incidence of ASC-H or HSIL on a Pap smear was 9.2% (95% CI = 7–12). A histologically proven HSIL (CIN2+) was found in 30 patients , while LSIL (CIN1) was diagnosed in 58 women . No cases of invasive cervical cancer were detected during the study period.p < 0.001), a higher number of visits , a higher number of sexual partners  and a higher number of daily cigarettes smoked . HR-HPV persistence and multiple HR-HPV infections were significantly associated with the development of any grade of CIN, while a CD4+ cell count of <200 cells/µL and an HIV viremia of >200 copies/mL at any follow-up visit were associated with an increased incidence of CIN2+. HIV transmission routes did not play a significant role in the development of CIN. Similarly, the use and type of antiretroviral therapy were not found to be significantly associated with the risk of CIN.p = 0.001) in women with a CD4+ cell count of persistently >200 cells/µL.The five-year cumulative incidence of histologically confirmed HSIL was 8.3% (95% CI = 2.6–13.6) among subjects with a CD4+ cell count of <200 cells/µL at any visit and 2.1%  in women without HPV infection. To evaluate the independent effects of age, CD4+ cell count, HIV viral load, HR-HPV infection, and smoking, we used a stepwise ordered logistic regression model. CIN incidence was modeled as a three-level variable ; the age of the subjects was considered a potential confounder and was forced into the model. The results of this modeling are reported in In women with persistent HR-HPV infection, the five-year cumulative incidence of CIN 2+ was 6% (95% CI = 1.6–10.2) versus 2%  cases of CIN2+ in a cohort of 599 women living with HIV with concurrent negative cytology and an HR-HPV test at enrollment during a long-term follow-up of 20 years. Importantly, no cases of cervical cancer were diagnosed during all periods of observation. Similarly, Keller et al.  reportedAmong immunocompetent women (CD4+ cell count of >200 cells/µL), we observed a five-year cumulative incidence of histological CIN2+ of 2.1% , significantly different from that found in more immunosuppressed women . This result is in agreement with those reported by Robbins et al. , who shoIn our study, low CD4+ cell count (<200 cells/µL) and high HIV viremia (>200 copies/mL) at any visit, persistent HR-HPV positivity, and smoking ≥10 cigarettes/day seemed to play an independent role in the development of CIN2+.Immunosuppression, described by a low CD4+ cell count and a high HIV viral load, is considered a well-recognized risk factor for cervical neoplasia and its precursors . SeveralThe interpretation of these observations is still debated because of the heterogeneity of CD4+ endpoints  used in the studies.Similarly to our results, Clifford et al.  demonstrThe possible role of antiretroviral therapy in controlling HPV pathogenesis is still unclear. Some studies found that ART is associated with a reduction of HPV-related disease, while others found no impact of ART on cervical pathology . These cThe overall HR-HPV cumulative incidence of 47% found in our study is consistent with the data literature. Heard et al.  observedWe found only 6% of women reported HPV16 incident infection and 1.6% HPV16 persistent infection; 20.7% of women showed persistent HR-HPV infection during follow-up.In our study, the prolonged duration (more than two years) of oncogenic HPV infection appeared strongly associated with the risk of CIN2+ with an odds ratio of 3.43 (95% CI 1.97–6.01) compared to women without HPV infection or with transient one. As in the general population, the persistence of oncogenic HPV infection is the main factor for the development of cervical neoplasia. Several studies showed that WLWH with HPV infection lasting longer than six months had a higher incidence of CIN than those with transient infection ,29,30. HAnother significant result of our study is the role of cigarette smoking as an independent risk factor for CIN2+ after correcting for other variables. In our cohort of women living with HIV, 55% smoked, and about 60% of them smoked more than 10 cigarettes per day. Smoking is a modifiable risk factor for cancer. Patients at risk for HIV have relatively high rates of smoking compared to the general population, and over 70–85% of some HIV-infected populations smoke . SmokingThe major strengths of our study are the large cohort of cytologically and virologically negative WLWH considered for the analysis, the extensive look at clinical data, and the long-term follow-up (a median of 7 and up to 20 years). Furthermore, we used restrictive criteria to define both the outcome  and the status of HPV infection (defined as persistent when lasting longer than two years).The limitations of this study are its retrospective nature and the possible selection bias due to the enrollment of patients from two referral centers for cervical pathology and sexually transmitted diseases. The women included in the study were followed by a specific program of screening that was not universally adopted. Some patients did not participate in all planned visits.Moreover, HR-HPV testing and genotyping were not performed in all the included women because they only entered clinical practice in 2002. In addition, generalizations from these data may be limited because of the heterogeneous immunologic management of the women enrolled in the study and because of the temporal changes in antiretroviral therapy use over a very long follow-up period.In conclusion, in HIV-positive women with negative HR-HPV test and normal Pap smear, the maintenance of an efficient and stable immune status, as indicated by a high CD4+ cell count and suppressed HIV viral load, appeared to be the main factor predicting a low risk for high-grade cervical lesions and cancer. Providing these conditions are met, WLWH could be screened in the same way as the general population. A decrease in immunological function, such as low CD4+ cell count and increased HIV viral load, should prompt the intensification of the screening. All women living with HIV should be counseled to abandon the habit of smoking.


What pregnancy characteristics and maternal outcomes are associated with amniotic fluid embolism (AFE)?In this cohort study of 14.6 million deliveries in the National Inpatient Sample from 2016 to 2019, the incidence of AFE was 6.0 per 100 000 deliveries, and placental accreta spectrum was associated with a 10-times increased risk of AFE. Amniotic fluid embolism was associated with other severe maternal morbidities, including coagulopathy, cardiac arrest, and adult respiratory distress syndrome; failure-to-rescue rate after AFE was 17% overall but could exceed 30% in the setting of placental pathology or other comorbidities.This national-level analysis confirmed the dismal outcomes of pregnancies complicated by AFE and suggests that placental accreta spectrum may be associated with AFE. This cohort study of 14.6 million deliveries in the National Inpatient Sample from 2016 to 2019 examines the associated risks factors and maternal outcomes of amniotic fluid embolism. Amniotic fluid embolism (AFE) is an uncommon pregnancy complication but is associated with high maternal mortality. Because of the rarity of AFE, associated risks factors and maternal outcomes have been relatively understudied.To examine the clinical, pregnancy, and delivery characteristics and the maternal outcomes related to AFE in a recent period in the US.This retrospective cohort study examined hospital deliveries from January 1, 2016, to December 31, 2019, from the Healthcare Cost and Utilization Project’s National Inpatient Sample.The primary outcome was clinical, pregnancy, and delivery characteristics of AFE, assessed with a multivariable binary logistic regression model. The coprimary outcome was failure to rescue, defined as maternal mortality after AFE. Associations with other severe maternal morbidity indicators and failure to rescue per clinical and pregnancy characteristics were also assessed.A total of 14 684 135 deliveries were examined, with AFE diagnosed in 880 women, corresponding to an incidence rate of 6.0 per 100 000 deliveries. The cohort-level median patient age was 29 years . In a multivariable analysis, (1) patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of placental accreta spectrum (PAS), placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE. Among these characteristics, PAS had the largest association with AFE . When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE . Patients who had AFE were more likely to have coagulopathy , cardiac arrest , and adult respiratory distress syndrome . The failure-to-rescue rate after AFE was 17.0% overall. However, the failure-to-rescue rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators: 45.8% for AFE, cardiac arrest, and coagulopathy; 43.2% for AFE, shock, and cardiac rhythm conversion; and 38.6% for AFE, cardiac arrest, coagulopathy, and shock. The failure-to-rescue rate after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placental abruption.This contemporaneous, national-level analysis validated previously known risk factors for AFE and confirmed the dismal outcomes of pregnancy complicated by AFE. The association between PAS and AFE, which was not previously reported, warrants further investigation. Furthermore, there is a paucity of recent US data on maternal outcomes after AFE. Thus, the objective of the current study was to examine the pregnancy characteristics and maternal outcomes related to AFE from 2016 to 2019 in the US.Although the exact pathophysiologic mechanism is unknown, several risk factors are identified for AFE based on maternal, fetal, placental, and delivery factors.16 The NIS represents hospital discharge data for more than 90% of the US population using survey weights based on a random sampling of 20% of hospitalized patients annually. The data set is both publicly available and deidentified; thus, this study was deemed exempt by the University of Southern California Institutional Review Board. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.17This retrospective cohort study used the National Inpatient Sample (NIS), which is distributed as part of the Healthcare Cost and Utilization Project by the Agency for Healthcare Research and Quality.International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes in the NIS program and to assess the complete year. Case identification for vaginal and cesarean delivery was determined per the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and ICD-10 Procedure Classification System (ICD-10-PCS) codes and the diagnosis-related group codes  definition,15 for AFE : (1) patient demographic characteristics, (2) pregnancy characteristics, (3) hospital parameters, and (4) delivery data, including severe maternal morbidity (SMM). The ICD-10 codes for the measured covariates were consistent during the study period , year of delivery , race and ethnicity  as determined by the NIS program, primary expected payer , census-level median household income (every quartile), obesity, allergic spectrum , substance use , and grand multiparity. Race and ethnicity were evaluated because this information is associated with pregnancy characteristics and outcomes.Pregnancy characteristics included maternal factors , placental pathology factors , fetal factors , uterine factors , and membranous factors (premature rupture of membrane [preterm or term] and chorioamnionitis).Hospital information included bed capacity , hospital location and teaching status , and hospital region in the US .20 mode of delivery , manual removal of placenta, and SMM other than AFE per the CDC definition for a total of 20 indicators .18Delivery data included gestational age at delivery , induction of labor,P < .05 in univariable analysis, and a parsimonious, conditional backward-selection method was used with the stopping rule of P < .05 in the final model.21 This analytic approach was preplanned because of the assumption that the number of AFEs is likely small. Multicollinearity was assessed among covariates. Effect size for AFE was expressed with an adjusted odds ratio (aOR), corresponding to a 95% CI.The first step of the analysis was to identify the independent characteristics associated with AFE at delivery. A binary logistic regression model was used for multivariable analysis. The initial selection criteria were 2 automatic interaction detector method with a stopping rule of a maximum of 3 layers was used to identify the unique combination patterns to other SMM indicators.22The next step of analysis was to assess the failure-to-rescue rate . First, the failure-to-rescue rate was examined in each SMM indicator, including AFE, in a bivariate fashion. Second, other SMM indicators independently associated with AFE were assessed with a multivariable binary logistic regression model . Failure-to-rescue rates were then assessed based on the combination pattern of AFE and other SMM indicators. A recursive partitioning analysis with χSeveral sensitivity analyses were undertaken to assess the robustness of the analytic findings. First, a classification tree was constructed to examine the incidence of AFE per the clinical and pregnancy characteristics. All the independent characteristics associated with AFE were entered into the model. Second, the failure-to-rescue rate associated with AFE was assessed per the clinical and pregnancy characteristics. Specifically, the outcomes were assessed in the setting of placental pathology  and per maternal age. These factors were selected in a post hoc approach. Third, PAS subtypes were assessed .Fourth, the association between PAS and postpartum hemorrhage was assessed. This assessment was based on the rationale that although postpartum hemorrhage is not a CDC-defined SMM, this metric represents a key delivery outcome. Fifth, the delivery factors were excluded in the risk factor analysis. Sixth, cohort-level trend analysis was performed to examine the time-specific change in the at-risk groups for AFE , assessed with the Cochran-Armitage trend test. This analysis was exploratory, and these pregnancy and prepregnancy factors were selected based on the post hoc observation.P < .05 was considered statistically significant. Cases with missing information were grouped as 1 category in each variable. SPSS statistical software, version 28.0 (IBM Inc) was used for all analyses.The weighted values for national estimates provided by the NIS program were used for analysis, and statistical interpretation was based on a 2-tailed hypothesis. A P = .04 for trend) . The incidence of AFE only slightly increased from 5.2 to 6.5 per 100 000 deliveries from 2016 to 2019  patient factors of older age, Asian and Black race, Western US region, pregestational hypertension, asthma, illicit substance use, and grand multiparity; (2) pregnancy factors of PAS, placental abruption, uterine rupture, polyhydramnios, chorioamnionitis, preeclampsia, fetal growth restriction, and fetal demise; and (3) delivery factors of early gestational age, cervical ripening, cesarean delivery, operative delivery, and manual removal were associated with AFE . These pAmong these independent characteristics, PAS had the greatest association with AFE  . Among tP < .001), followed by placental abruption and gestational age in the second layer allocation. The most common group was term vaginal delivery (57.8%), with the incidence of AFE being 1.2 per 100 000 deliveries. Patients who had PAS, placental abruption, and late-preterm to early-term delivery had the highest incidence rate of AFE.A 3-layer classification tree model identified 14 unique patterns for AFE (eTable 4 in the P < .001).Crude failure-to-rescue rates of 21 SMM indicators, including AFE, are shown in Among the SMM indicators, 8 indicators were independently associated with AFE . Of thosFailure to rescue after AFE also exceeded 30% when AFE occurred in the setting of placental pathology: 42.9% for AFE and PAS and 31.3% for AFE and placenta abruption . Among pP < .001 for trend for all) ; placental abruption, from 10.9 to 11.3 per 1000 deliveries (3.7% relative increase); and age 40 years or older, from 30.7 to 34.2 per 1000 deliveries (11.4% relative increase) ,27 the failure-to-rescue rate after AFE is particularly high  and among the highest maternal mortality indicators . The incidence rate of AFE can be high when placental abruption occurs in patients with PAS during late-preterm or early-term gestation (eTable 4 in the Amniotic fluid embolism was diagnosed in 6 in 100 000 deliveries at the cohort level. When the aforementioned classic criteria (AFE that co-occurred with cardiac arrest and coagulopathy) were applied in a post hoc fashion , the inc29Because of the rarity of AFE, many health care professionals, particularly trainees, may not be familiar with the disease entity. This gap in knowledge can be further exacerbated by overlapping clinical syndromes, leading to a delay in recognition. The current study expands existing knowledge on the risk factors and mortality of AFE. The high failure-to-rescue rate underscores the urgent need for increased training, such as through simulations, to reinforce a standardized management strategy.30 Second, whether reduction of the cesarean delivery rate can ultimately reduce the risk of AFE merits further investigation given AFE’s association with PAS.Several research questions are also raised by the association between PAS and AFE. First, the role of abnormal uterine perfusion as a possible mediator of these 2 pregnancy events warrants further investigation.ICD-10 code alone using the administrative-type database without exact medical record review. In addition, the specific diagnostic criteria of AFE in each facility was not available, which may affect the exposure-outcome association. Previous studies31 suggested that the incidence of AFE appears to be varied across the different diagnostic criteria of AFE. Likewise, accuracy of data for other covariates was not assessable, and this study cannot exclude the possibility of misclassification in an indefinite number of patients, introducing a potential bias of unknown degree.This study has several limitations. Most importantly, the diagnosis of AFE was based on the Unmeasured bias is inherent to this type of study. For example, the chronology between delivery factors and AFE was not available, limiting the ability to determine causality. This limitation particularly applies to interventions such as cesarean and operative deliveries for which the development of AFE may have prompted the need for immediate delivery. This limitation also applies to the chronology of AFE and other SMM indicators. It is therefore unknown whether other indicators occurred at the time of AFE diagnosis or were the consequence of AFE. Neonatal information, health care profressional type, and exact cause of death were also not available. Other factors that are relevant to this subject but were not examined include prolonged stage of labor, placental implantation site other than placenta previa, and delivery anesthesia.28 Other studies11 suggested the importance of high-quality cardiopulmonary resuscitation; correction of coagulopathy, including tranexamic acid use; and extracorporeal membrane oxygenation use for AFE management, but these procedures were not assessed in this study. Ascertainment bias is another limitation. In addition to the data-capturing schema, it may be possible that the clinical diagnosis of AFE was made more often in the setting of known risk factors. Finally, generalizability of the results was not assessed and warrants further research.This study only provided the risk factors and mortality outcome, and the effect of therapeutic resuscitation for AFE on failure to rescue was not evaluated. It is unknown whether adherence to the Society for Maternal-Fetal Medicine checklist for initial management of AFE is associated with improved maternal outcome.This cohort study confirms that AFE is a rare pregnancy complication but is associated with significant maternal outcome. Further research is needed to address the proposed hypotheses as discussed earlier, with particular emphasis on the association between PAS and AFE. Given the rarity of AFE, national and international collaborative efforts would be useful to overcome the type 2 error. Establishing and distributing the universal diagnostic criteria for AFE is also imperative.


The effect of cervical screening on cervical adenocarcinoma has been variable, possibly because the risk associated with the precursor atypical glandular cells (AGC) is not well known. A cohort of all 885 women in the capital region of Sweden with AGC, a concomitant human papillomavirus (HPV) analysis, and a histopathology was followed until 2019. Cumulative incidence proportions of cervical intraepithelial lesion grade 3 or worse (CIN3+) by HPV type was determined by 1‐Kaplan‐Meier estimates. Hazard ratios (HR) for CIN3+ or for invasive cancer were estimated with Cox regression. After 2 years of follow‐up, the cumulative incidence proportions of CIN3+ were 80% , 58% (95% CI: 50‐60%) and 10% (95% CI: 5‐18%) among HPV16/18 positive, “other HPV” positive and HPV‐negative women, respectively. Among the 300 women with HPV16/18 positive AGC, 217 developed CIN3+ of which 35 were invasive cervical cancer. The 2‐year cumulative invasive cancer risk for HPV16/18 positive AGC was 17% (95% CI: 12‐24%). Primary HPV‐screening had a similar yield of CIN3+ as cytology screening, albeit HPV‐negative AGC is by design not detected by HPV screening. Among 241 women with HPV‐negative AGC, 11 developed CIN3+ mostly after clinically indicated samples. We found no significant risk differences depending on age or sampling indication. The low CIN3+ risk after HPV‐negative AGC implies safety of primary HPV screening. The high risk of invasive cervical cancer after HPV16/18 positive AGC implies that management of this finding is a priority in cervical screening. What's new?The impact of cervical screening on cervical adenocarcinoma prevention has been variable, possibly because the cancer risk associated with the precursor atypical glandular cells (AGC) is not well known. Here, the authors show that atypical glandular cells (AGC) positive for high‐risk human papilloma virus (HPV)16/18 confer very high risk of invasive cervical cancer (17%), whereas HPV‐negative AGC confer very little risk. The low invasive cancer risk after HPV‐negative AGC testing provides reassurance that HPV‐based primary screening is safe. The high cancer risk after HPV16/18‐positive AGC testing warrants a more ambitious and urgent management of women with this lesion. ADCAcxcervical adenocarcinomaAGCatypical glandular cellsAIScervical adenocarcinoma in situASCUSatypical squamous cells of undetermined significanceCIconfidence intervalCIN3+cervical intraepithelial lesion grade 3 or worseERBethical review boardHPVhuman papillomavirusHRhazard ratioHSILhigh‐grade squamous intraepithelial lesionICCinvasive cervical cancerLBCliquid‐based cytologyLSILlow‐grade squamous intraepithelial lesionsNKCxthe Swedish national cervical screening registryRHSrandomized healthcare studySCCcervical squamous cell carcinomaSCCAsquamous cell cancerSNOMEDsystematized nomenclature of medicine1Cervical screening with cytology has been effective in reducing the incidence of cervical squamous cell carcinoma (SCC). However, the effect has been smaller and variable regarding prevention of cervical adenocarcinoma (ADCAcx). Indeed, many countries have even experienced an incidence increase in cervical adenocarcinoma in situ (AIS) and ADCAcx, in particular among women under the age of 50.ADCAcx is commonly not diagnosed until invasive cancer has already developed, resulting in poor prognosis.The proportion of cervical samples with AGC in cytology may vary from 0.18% to 0.74%.Different types of HPV have different cancer risks, with HPV16 and 18 having the highest risks. While HPV16 can cause all histological types of cervical cancer, HPV18 is particularly associated with ADCAcx.AGC is of paramount importance for cervical screening strategies for several reasons: Most of the improved cancer‐protective effect seen with HPV‐based screening was seen for prevention of ADCAcxWe sought to provide a solid evidence base on the progressive potential of AGC in a setting suitable for this. The organized screening program in the capital region in Sweden decided on February 17, 2014 to introduce reflex HPV testing for all women with AGC, while retaining the same management guidelines for both HPV‐positive and HPV‐negative women with AGC. At the same date, the central laboratory introduced reflex HPV testing of all samples diagnosed with AGC . We had previously evaluated HPV reflex testing of atypical squamous cells of undetermined significance (ASCUS) and low‐grade squamous intraepithelial lesions (LSIL) in a randomized manner.22.1The cervical screening program in Sweden targets all women ages 23 to 70. At the time of the study, 3‐year intervals were used between ages 23 to 50 and 5‐year intervals were used over the age of 50. Samples can also be taken outside of the program if a physician decides that there is a clinical indication to do so. In the region of Stockholm, HPV‐based screening was piloted in a randomized healthcare study (RHS) between 2014 and 2016, where all resident women ages 30 and above were randomized to either HPV‐based screening or cytology‐based screening.The choice of test for clinically indicated samples was mostly primary cytology with reflex HPV testing in the early years, but co‐testing was increasingly used in recent years.The regional screening registry collects data on all cytologies and cervical histopathologies in the region, also from outside the program. All regional registries in the country send in their data to the Swedish national cervical screening registry (NKCx).The population‐based cohort in this study was defined as all women resident in the capital region of Sweden who had had a cervical sample with an AGC diagnosis between February 17, 2014 and December 31, 2018 . Adenocarcinoma in situ (AIS) is not included in the AGC diagnoses. Sub‐diagnoses of AGC (AGC no other specification and AGC favor neoplasia) are not used in Sweden. Comparison with the NKCx identified if a corresponding HPV test (result within 40 days of the cytology) had been done and if there was a subsequent histopathological follow‐up. As per national guidelines, all women with an AGC should be referred for colposcopy‐directed biopsy with histopathological assessment. The registry follow‐up of the study ended on December 31, 2019.All cervical cytology samples used the liquid based cytology, LBC (ThinPrep) technology. The samples were taken with plastic spatula and endocervical brush . The cells were collected from the ectocervix and endocervix of the uterus and suspended in PreservCyt, a methanol‐based fixative medium, according to the manufacturer's recommendation . LBC samples were transferred to cytology glass slides using ThinPrep processors (Hologic), before Pap staining. The cell suspension was used for HPV DNA analysis using the Cobas 4800 HPV test (Roche), with decapping of ThinPrep vials . HPV types detected using Cobas included HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68, where HPV16 and HPV18 were detected in separate channels and the remaining HPV types (“other”) were detected in a pooled group. All LBC samples were prepared and evaluated at the Department of Pathology & Cancer Diagnostics, Medical Diagnostics Karolinska, Stockholm, Sweden. Cytological diagnoses were classified according to the Systematized Nomenclature of Medicine (SNOMED) code system. The Bethesda nomenclature was used, except that there was no subgrouping within the AGC diagnosis.2.2The main outcome of interest was cervical intraepithelial neoplasia grade 3 or worse (CIN3+), including adenocarcinoma in situ and invasive cervical cancer. The risk for CIN3+ was evaluated by HPV type, hierarchically classified as HPV16 positive, HPV18 positive (not 16 positive), “other HPV” positive (not 16 or 18 positive), or HPV negative. Cumulative incidence proportions of CIN3+ by HPV status were calculated using 1‐Kaplan‐Meier (KM) estimate. Follow‐up time was calculated from the date of the index AGC sample to the first diagnosis of CIN3+ or the date of the last histopathological sample taken during study follow‐up if no CIN3+ was detected.To estimate the relative risk for CIN3+ by HPV type among women with AGC; hazard ratios (HR) were calculated using Cox proportional hazards regression model. Unadjusted HRs with corresponding 95% confidence intervals (CI) were calculated for HPV‐positive AGC  as well as for age in 5‐year categories with women under 30 as a reference for the models including women with a primary cytology sample or a clinically indicated sample. Age 30 to 34 was used as the reference for the models including women with a primary HPV sample given that this analysis method was recommended from age 30 and above (very few observations for primary HPV tests before 30).All analyses were stratified by the primary analysis of the index sample, accounting for the period of the RHS by splitting the organized cytology and HPV samples into randomized and nonrandomized.Data preparation was performed in SAS 9.4  and the analysis was performed in STATA 16 .3A total of 885 women with an AGC diagnosis between February 17, 2014 and December 31, 2018 were identified. There were 616 women who were screened by the organized program and 269 women who had an AGC in a sample from clinical testing. In total, 369 CIN3+ cases were identified during follow‐up  of which 11 CIN3+ cases were among women with an HPV‐negative index AGC sample   and there were about twice as high proportions of normal/mild/moderate histopathologies after an AGC with “other HPV” (203/344 women) than after an AGC positive for HPV16/18 (83/300 women).The risk to develop invasive cervical cancer (ICC) differed strongly by the HPV status of the index AGC sample Figure . For HPVThe Hazard ratios were compared by age group, but no statistically significant differences were seen Table . The HazWe also recorded whether the women with AGC had developed an endometrial cancer. Fourteen women had had an endometrial cancer on follow‐up. Thirteen of these women had had an HPV‐negative AGC.Finally, we compared whether the proportion of detected invasive cancers differed by primary HPV or primary cytology. As described above, almost 400 000 women were randomized to either primary HPV screening or primary cytology screening. There were four invasive cancers after AGC in the primary cytology arm and five invasive cancers after AGC in the primary HPV arm (no significant difference). The highest proportion of ICC was detected among the 169 women with AGC after primary HPV screening was introduced for all women (15 cases of ICC).44.1We find that HPV16/18 positive AGC has an extremely high risk for CIN3/AIS in subsequent histopathology and, even more striking, for cervical cancer. In contrast, a majority (54%) of the AGC detected by cytology in the most comparable group  does not result in any substantial loss in diagnostic accuracy. Rather, it has been proposed that after the introduction of liquid‐based cytology and HPV screening, AGC may have become easier to detect.Primary HPV screening has been shown to be superior in protection against invasive cervical cancer,The study reported in the paper has been performed by the authors, unless clearly specified in the text. Ingrid Norman: data curation, lead, investigation, writing—review & editing. Klara Miriam Elfström: data curation, supporting, supervision, supporting, formal analyses, supporting, writing—review & editing. Maria Hortlund: formal analyses, supporting, writing—review & editing. Anders Hjerpe: supervision. Joakim Dillner: conceptualization, funding acquisition, project administration, resources, supervision, lead, validation, writing—original draft, writing—review & editing. Emel Yilmaz: formal analyses, lead, visualization, writing—review & editing. All authors have approved the final version for submission.This study was supported by the Swedish Association of Local Authorities and Regions for the Swedish National Cervical Screening Registry; and by the Swedish Cancer Society (18 0443 and 20 1198 PjF to Joakim Dillner).The authors declare no conflict of interest.The study was approved by the ethical review board (ERB) of the Stockholm Region (Decision number 16/1103‐31). The ERB decided that consent was not required and thus all women resident in the population of the region could be included in the study.


HPV vaccine can block the infection of high-risk human papillomavirus and is an important measure to effectively reduce the incidence of cervical cancer and precancerous lesions. However, the HPV vaccination rate is still low in China. There are many factors. Therefore, it is important to study the influencing factors to provide basis for promoting the formulation of vaccination strategies.t-test and binary Logistic regression analysis were used to screen the influencing factors of HPV vaccination. Restricted cubic spline model was used to analyze the influence trend of self-efficacy and family health on HPV vaccination rate.This study used a multi-stage sampling method to conduct a face-to-face questionnaire survey on women in different regions of China. The new general self-efficacy scale was used to measure the self-efficacy of the respondents. The short form of family health scale measured their family health. The 2 =27.64, P<0.001) and non-linear ; The poor family health hindered HPV vaccination, and the association strength was statistically significant  and non-linear .(1) The HPV vaccination rate was low, especially in the ≤18 group. The place of residence, capita household income/month, individual self-efficacy and family health had a significant impact on HPV vaccination. (2) The restricted cubic spline model showed that self-efficacy positively promoted HPV vaccination, the correlation strength was statistically significant (χIt is necessary to strengthen the health education of HPV vaccination knowledge in the population to eliminate the hesitancy of vaccination. Free HPV vaccination strategies should be developed and encourage people of appropriate age to receive as early as possible. Self-efficacy and family health should be enhanced to increase HPV vaccination rate, so as to achieve the goal of reducing the incidence of cervical cancer and protecting women's health. Cervical cancer seriously endangers women's health. Worldwide, it ranks the fourth most frequent cancer in women. There were estimated 604,000 new cases and 342,000 deaths from cervical cancer in 2020 . In ChinThe developed HPV vaccine can block the persistent infection of high-risk HPV, thereby effectively reduce the incidence of cervical cancer and precancerous lesions. The promotion of HPV vaccination among the appropriate age groups is an effective measure to prevent cervical cancer . CompareHowever, the current situation of HPV vaccination in many countries is not optimistic. Global HPV immunization coverage was estimated at 12.2% in 2018 . HPV vacIn this study, from July to September 2021, we selected 2–6 cities from each province and autonomous region in Chinese Mainland by random number table method, and 120 cities were included. Based on the results of the “2021 Seventh National Population Census”, a sample survey was conducted by gender, age, urban and rural distribution and other quota attributes. Meanwhile, we collected investigators from all over the country in China and conducted unified training for the investigators before issuing the questionnaires. The investigators distributed the questionnaire to the public in their respective areas through the link of the questionnaire star platform “WJX” . Before the survey, the subjects were informed and agreed, and then invited to click the questionnaire link to answer. A total of 5,994 women questionnaires were collected and we screened 5,959 valid questionnaires, with the 99.4% effective rate. 4,340 cases (72.8%) lived in urban areas, 1,619 cases (27.2%) lived in rural areas. There were 1,896 cases (31.8%) with capita household income/month ≤3,000 yuan, 2,303 cases (38.6%) with 3,001–6,000 yuan, 962 cases (16.1%) with 6,001–9,000 yuan, and 798 cases (13.4%) with ≥9,001 yuan. 623 cases (10.5 %) were ≤ 18 years old, 3,006 cases (50.4 %) were 19–40 years old, 1,906 cases (32.0 %) were 41–65 years old, and 424 cases (7.1 %) were ≥65 years old. The marital status was 2,427 (40.7%) unmarried and 3,532 (59.3%) married. There were 1,378 cases (23.1%) with education level of junior high school and below, 988 cases (16.6%) with secondary and high school, 759 cases (12.7%) with college, and 2,834 cases (47.6%) with a university degree and above. The medical expenses of 4,651 cases (78.1%) were paid by medical insurance or public funds, while 1,308 cases (21.9%) were self-paid.Inclusion criteria: ① Respondents read the informed consent form and participate in this study voluntarily. ② They are able to complete the online questionnaire or with the help of investigators. ③ Respondents have basic cognitive ability and understand the meaning of each item in the questionnaire. Exclusion criteria: ① Questionnaires with unqualified addresses. ② Questionnaires from male respondents. ③ Questionnaires with conflicting information.To ensure the scientificity and effectiveness of the questionnaire, it is divided into two parts: basic information  and standard scales .Perceived Social Support Scale (PSSS) . The scaNew General Self-Efficacy Scale (NGSES) . The scaHealth Literacy Scale, a 12-item short-form HL questionnaire (HLS-SF12) . Health A Short Form of the Family Health Scale (FHS-SF), The FHS-SF contains four dimensions: family social and emotional health processes, family healthy lifestyle, family health resources, and family external social supports . The Cro2 tests were used to compare the rate and mean between the two groups, and the scale scores were expressed as mean ± standard deviation (s). Binary logistic regression was used for multivariate analysis. Restricted cubic spline model was used to analyze the influence trend of self-efficacy scale and family health on HPV vaccination rate. All tests were two-sided, and the significance level was set at 0.05.In this study, SPSS25.0 was used for statistical analysis of the data, t and χTwo rounds of pre investigation and two rounds of expert consultation were completed before the formal investigation. Trained investigators handed out questionnaires to investigators face to face and register codes. We immediately summarized, evaluated and fed back the collected questionnaires. The logic check and data filtering were performed back-to-back by two people. Once singular values were found in the data, it was necessary to find the original questionnaire and check with the investigators to ensure the reliability and authenticity of the data.P < 0.05), But it did not show marked differences in marital status, type of medical insurance and the perceive social support (P > 0.05).The survey found that the number of unvaccinated women was greater than that of vaccinated women . There w2 test, the significant factors were further analyzed by binary Logistic regression. Age, Place of residence, Capita household income/month, highest education levelsl, the HLS-SF12, the FHS-SF, and the NGSES were used as independent variables, and the HPV vaccination status was used as the dependent variable. The assigned values are shown in Based on the results of t and χP = 0.002). The influence of age on HPV vaccination is statistically significant (P < 0.001). The influence of capita household income/month on HPV vaccination is statistically significant (P < 0.001). Family health had a negative impact on HPV vaccination . The influence of self-efficacy on HPV vaccination is statistically significant .The binary logistic regression equation was constructed by incorporating place of residence, highest education level, multiple scales, etc. The results show that 2 = 27.64, P < 0.001) in a non-linear manner . The effect on HPV vaccination was not significant when self-efficacy was below the value of 29 of P50, and when it reached above the value of 29 of P50, the effect on HPV vaccination was significantly enhanced with an increase in self-efficacy, which had a facilitative effect  were selected based on NGSES scores, with the value of the reference point (at HR/OR = 1) being the median P50 and the OR (95% CI) of the P25 and P75 nodes: 0.974 (0.892–1.065), respectively 1.1703 (1.103–1.241). After controlling for confounders such as age, household income, literacy, and family health scale, the results revealed that the association between self-efficacy and HPV vaccination was statistically significant  in a non-linear fashion . When the FHS-SF value was lower than P50 (38), the hindering effect on HPV vaccination was significant, and the negative effect weakened or disappeared as the family health level increased  were selected based on the scores of the FHS-SF, with the value of the reference point (at HR/OR = 1) being the median P50 and the OR (95% CI) of the P25 and P75 nodes: 1.264 (1.174–1.360), respectively 0.906 (0.823–0.998). After controlling for confounders such as age, household income, literacy, and self-efficacy, the results revealed that the association between the FHS-SF and vaccination was statistically significant . Which overcomes the defects of regression and shows the influence of nonlinear relationship more intuitively . The splSelf-efficacy affects people's choices and behaviors, and HPV vaccination intention is positively correlated with self-efficacy . SchaefeFamily health is a resource of the family unit that develops from the intersection of the health, interactions of each family member, and the family's social, emotional, economic, medical resources. This study confirmed that family health affects the HPV vaccination of family members. After adjusting the confounding factors, the restricted cubic spline model was used to analyze the relationship between the family health scale score and the HPV vaccine coverage, which showed a nonlinear association.When the score is <38, the curve is declining, indicating that when the family health scale score is <P50, the vaccination rate is significantly affected, and poor family health is an obstacle to HPV vaccination. Once P50 was reached, the change in HPV vaccination rates leveled off as the family Health Scale score increased. It may be that when the family health scale score reaches the median above, the negative influence of family health status on HPV vaccination was relieved. Low awareness and acceptance of HPV vaccine among parents in the family will prevent their children from receiving HPV vaccine , 21. PeoIn order to reduce the incidence rate and mortality of cervical cancer, the World Health Organization (WHO) announced the global strategic goal of 2030, advocating that the vaccination rate of 15 year old girls against HPV should reach more than 90% . HoweverMen who have sex with men (MSM) are at a high risk of infecting HPV . Men shoIn this cross-sectional survey, we found that the HPV vaccination rate in Chinese women was still relatively low, There is an urgent need to increase the vaccination rate in the appropriate age women, especially in the optimal age population for HPV vaccination. In addition to the differences between rural and urban residential areas, the family monthly income gap have a significant influence on the HPV vaccination rate, and self-efficacy and family health also have an effect. It is necessary to strengthen the scientific publicity of HPV vaccine in rural areas and people with low education level to improve the awareness of HPV vaccine. Take the enhancement of self-efficacy and family health as the target to improve the vaccination rate, eliminate people's worries and hesitations about HPV vaccination, and improve the awareness of disease prevention. The state actively promotes the free vaccination program for young people. At the same time, the government and health departments continue to improve vaccination regulatory policies to ensure vaccine safety. More people can be effectively protected by vaccination and the incidence of cervical cancer can be reduced.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of Jinnan University . Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.Writing-original draft, review, and editing: XY. Project administration and supervision: YW. Investigation: YN, PG, and WY. Methodology: FW. Software and writing—original draft: MZ and YH. All authors contributed to the article and approved the submitted version.


This study aimed to compare the variability of HPV16/18/52/58 subtype infections in patients with different cervical lesions, to explore the guiding significance of persistent positive HPV subtypes 52 and 58 in the stratified management of cervical lesions, and to determine the appropriate management model.This study was conducted through a retrospective analysis of 244,218 patients who underwent HPV testing at the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University from September 2014 to December 2020 to examine the distribution of different types of HPV infection. From March 2015 to September 2017, 3,014 patients with known HPV underwent colposcopy to analyze high-risk HPV infection for different cervical lesions. Meanwhile, from September 2014 to December 2020, 1,616 patients positive for HPV16/18/52/58 alone with normal TCT who underwent colposcopy in our hospital were retrospectively analyzed for the occurrence of cervical and vulvovaginal lesions, with colposcopic biopsy pathology results serving as the gold standard for statistical analysis.p < 0.05). A total of 1,616 patients with normal TCT who were referred for colposcopy due to HPV16/18/52/58 infection were further analyzed. Based on pathological findings in lesions of HSIL and CC, HPV16 is the most common, followed by HPV58 and then HPV18 (p < 0.05). In the 1,616 patients analyzed, high-grade vulvovaginal lesions were detected, with HPV58 being the most common, followed by HPV16 and then HPV52 (p < 0.05).Analysis of 244,218 patients who had HPV tested revealed that the top 3 high-risk HPV types were HPV52, HPV58, and HPV16. Further analysis of 3,014 patients showed that 78.04% of patients referred for colposcopy had HPV16/18/52/58 alone. Among high-grade squamous intraepithelial lesions (HSIL) and cervical cancer, the most common is HPV16, followed by HPV58 and then HPV52 (1. In patients with positive HPV58 alone and normal TCT, the indications for colposcopy may be relaxed, with particular attention paid to the possibility of vulvar and vaginal lesions.2. Patients with a positive HPV type 52 alone and normal TCT may be considered for a follow-up review and, if necessary, a colposcopy.3. The development of a more suitable HPV vaccine for the Asian population, such as HPV16/18/52/58, may better protect women’s health. Cervical cancer is the 4th most common cancer among women  and is mPersistent high-risk human papillomavirus (HR-HPV) infection with HPV is a major cause of cervical precancer and cervical cancer. By the time the HPV vaccine for cervical cancer became available in 2006, human research on the correlation between HPV and cervical disease had come a long way in just a few decades, with tremendous achievements in the understanding and study of HPV, with studies reported from all over the world. However, studies on cervical disease due to different subtypes of HPV infection have been reported inconsistently, and the interactions between the various subtypes of infection are inconsistent. More than 150 types of HPV have been identified, with more than 40 of which can cause cervical lesions. HPV testing is widely used to screen for cervical cancer and has significantly reduced the incidence and mortality rate of the disease.This paper focuses on the analysis of four high-risk subtypes of HPV16/18/52/58 in different cervical lesions to understand the HPV infection in different cervical lesions. According to studies, the ranking of HR-HPV subtypes varies depending on the level of cervical lesions, with HPV52, HPV58, and HPV16 having the greatest impact on the health of Chinese women . HPV18, From September 2014 to December 2020, 244,218 patients aged 17–91 years, with a mean age of 39.9 ± 10.47 years, were tested for HPV at the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University. Of the 244,218 patients, 1,616 patients aged 18–83 years, with a mean age of 41 ± 10.59 years, underwent colposcopy for HPV16/18/52/58 alone positive with normal TCT. Meanwhile, from March 2015 to September 2017, 3,014 patients with known HPV aged 17–82 years, with a mean age of 41.38 ± 10.67 years, underwent colposcopy.Cervical scrape specimens were gently collected from the squamocolumnar junction of the cervix using a sampling brush and were stored at 4°C prior to HPV genotyping. The genotype of HPV was determined using a 27-HPV genotyping kit from TellgenplexTMxMAP™ , which detects 17 high-risk types  according to the manufacturer’s instructions. Patients were grouped according to HPV16, HPV18, HPV52, and HPV58 infections. The HPV16/18/52/58 group indicates positivity for HPV species alone, whereas other groups include other types of infections or mixed infections.in situ (AIS), and adenocarcinoma; and (3) other malignant neoplasms.Cells were collected from the ectocervix and the cervical canal using a cervical canal brush, and the cells attached to the small brush were eluted in vials containing cell preservation solution and sent to the pathology department . The cytological diagnosis was made using The Bethesda System (TBS) classification criteria (TBS 2001 Revised). The cytological diagnosis was made using The Bethesda System (TBS) classification criteria (TBS 2001 Revised). The TBS classification included the following: 1. Negative, no intraepithelial lesion cells and malignant cells (NILM); 2. Abnormal epithelial cells: (1) Atypical squamous cells (ASC), including squamous epithelial cells of undetermined significance (ASC-US) and atypical squamous epithelial cells in which HSIL cannot be excluded (ASC-H),squamous low-grade intraepithelial lesions (LSIL), HSIL, and squamous cell carcinoma (SCC); (2) Abnormal glandular epithelial cells: atypical glandular cells (AGC), adenocarcinoma Those with normal cytology but positive for HPV16 and HPV18 or those with HPV52 and HPV58 infection for more than 6 months with 2 consecutive positive tests will most likely need to have a colposcopy.The standard procedure for colposcopy is used. A full colposcopic assessment of the cervical transformation zone is performed, and a multipoint biopsy plus endocervical curettage (ECC), if necessary, is performed on suspicious areas. For those without significant colposcopic abnormalities but at high risk of precancerous lesions or invasive cancer, a routine 4-point random biopsy of the cervix at 3, 6, 9, and 12 points plus endocervical curettage, if necessary, is performed. All tissues taken were sent separately for histological examination, and the pathological diagnosis was the gold standard for evaluation. The classification criteria for evaluation include the following: (1) normal or inflammatory; (2) LSIL; (3) HSIL; and (4) cervical cancer, including cervical invasive squamous carcinoma and adenocarcinoma. The colposcopic biopsy pathology results were the gold standard for statistical analysis.p < 0.05.SPSS22.0 software was used for the statistical data analysis. Statistics data are presented as frequencies and proportions. The Chi-square or Fisher’s exact test was used for the comparison of proportions between groups. A Spearman correlation was used for statistical and correlation analyses, and differences were considered statistically significant at Of the 3,014 patients, the highest proportion of patients referred for colposcopy had HPV16 infection, followed by HPV52 and then HPV58 and HPV18. There were no statistical differences between the age groups.p < 0.05). Among normal and LSIL, HPV16 was relatively common with HPV52, followed by HPV18 and HPV58, but no statistically significant difference (p > 0.05) was observed.As shown in As shown in p < 0.05), HPV58 positive (10.71%) > HPV18 positive (5.96%) , and HPV18 positive (5.96%) > HPV52 positive (5.17%)  .As shown in The occurrence of cervical cancer or precancerous lesions is closely linked to persistent infection with high-risk HPV types, and according to the World Health Organization, there are nearly 500,000 new cases of cervical cancer each year, of which more than 100,000 occur in China, home to about one-third of the world’s population (In our data analysis, the top 3 HPV infections in the population were HPV52, HPV58, and HPV16, indicating that HPV52 and 58 infections are more common in the population. The relatively high detection rate of HPV52 and HPV58 among pathological findings suggesting high-grade cervical lesions and cervical cancer again indicates the presence of a higher rate of HPV52 and HPV58 infection in high-grade cervical lesions in addition to HPV16 and HPV18 types . In addiA meta-analysis showed that the prevalence of HR-HPV infection in women with normal cervical fluid-based cytology was 11.7% . In thisThere is no screening strategy for vulvovaginal high-grade lesions and cancer, given that many vaginal  and vulvThere is a limitation in this study. According to the guideline, patients with HPV16/18 infection are immediately referred for colposcopy, but patients with HPV52/58 infection are not all referred for colposcopy and tissue biopsy if TCT test results are normal. The sample included in this study is only a portion of the overall total number of samples. Thus, there is bias here. We will further expand the sample size.1. In patients with positive HPV58 alone and normal TCT, the indications for colposcopy may be relaxed, with particular attention paid to the possibility of vulvar and vaginal lesions.2. Patients with a positive HPV type 52 alone and normal TCT may be considered for a follow-up review and, if necessary, a colposcopy.3. The development of a more suitable HPV vaccine for the Asian population, such as HPV16/18/52/58, may better protect women’s health.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.BY proposed the research object, collected the data, analyzed the data, and wrote the article. QX has contributed equally to this Work, is considered as co-first author. ZZ collected and analyzed the data. JZ, YX, and LH collected the data. YH proposed the research object and analyzed the data. QT proposed the research, collected and analyzed the data, is considered as co-corresponding author. JC collected, analyzed, wrote portion the manuscript and found the right journal, is the corresponding author of this paper. All authors listed have made a substantial, direct, and intellectual contribution to the work.This research was partially supported by Wenzhou Science and Technology Bureau Project–Y20190417.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.


The live streaming market is becoming increasingly competitive, and relative performance information regarding broadcasters is available to all participants in the live streaming industry, exacerbating the level of competition. Using data from 42,166 live streams by 293 broadcasters, we investigated two benefits of relative performance information in relation to the live streaming business and how these effects vary when the broadcaster appears competent, trustworthy, likable, or attractive. On the basis of economic and social comparison theory, as well as insights from the herd behavior and beauty premium literature, we predicted and found that relative performance information can improve live streaming performance by either increasing broadcaster effort (the effort-eliciting effect) or encouraging viewer participation , with these effects being stronger when broadcasters look more competent, trustworthy, likable, or attractive. The findings of this study contribute to the live streaming literature by demonstrating that providing relative performance information in the live streaming business can yield both effort-eliciting and informational benefits. The advent of the 5G era has provided an unprecedented opportunity for the development of the live streaming business. Furthermore, the COVID-19 pandemic has contributed to the rapid rise of the “stay-at-home economy,” which has significantly boosted live streaming consumption . Given tThe quintessential characteristic of a live stream is that a broadcaster generates and delivers real-time content to an audience, who consumes the content by joining the virtual showroom hosted by the broadcaster. In the process of content consumption, viewers interact with the broadcaster in two distinct ways, which in turn shape the content creation process . One typThe prospects for the live streaming industry have attracted the interest of researchers, and because the broadcaster and viewers are the central elements of a live stream, a growing number of studies have focused on the behavior and characteristics of the participants . In thisThe public accessibility of RPI impacts the behavior of both broadcasters and viewers. From the broadcaster’s perspective, RPI enables broadcasters to know their performance ranking in the market, thereby encouraging social comparisons and driving them to raise their effort level to improve their live streaming performance . YY, a subsidiary of JOYY, is an online live streaming entertainment provider that offers a variety of content including singing, dancing, talk shows, gaming, and other live streaming programs. As one of the most popular live streaming platforms in China, YY reported that the average number of monthly active mobile users of YY reached 274.7 million in the first quarter of 2022.Our data included 42,166 live streams by 293 broadcasters between 1 May 2020 and 31 October 2020. We obtained our study sample and data in two steps. First, we selected the broadcasters. To obtain an adequate sample size, two members of the research team were required to randomly choose broadcasters by opening YY each night between 8 pm and 10 pm for seven consecutive nights prior to 1 May 2020.During the live stream, viewers interact with the broadcaster by commenting, tipping, and sending “likes.” Among the various viewer behaviors, tipping is the most obvious way for viewers to express their appreciation of the broadcaster. Tip income provides significant revenue for live streaming firms, and is also a primary source of revenue for broadcasters. YY and Toubang have created a list that discloses how much broadcasters receive in tips and ranks them based on the amount of tips they receive. Although this list provides rank-score RPI, we constructed actual-score RPI by dividing the total amount of tips that a broadcaster received on a given day by the average value of tips received by all broadcasters in the same category. To measure broadcaster effort, we used the total streaming minutes of a broadcaster on a given day as a proxy. via texts, allowing a broadcaster to better understand the viewers’ requirements. Regardless of whether viewers send favorable or critical comments to the broadcaster, commenting behavior signifies that the viewer has entered the showroom and is following the broadcaster.We measured viewer participation by counting the number of viewers who sent real-time comments to the broadcaster during live streams on a given day. Multiple comments from a viewer during the live streams hosted by a broadcaster were treated as a single comment. The live streaming business is inherently real-time. Viewers can connect with the broadcaster We delivered the questionnaires to the six raters through Wenjuanxing, a professional online questionnaire platform in China. The questionnaires included photographs of selected broadcasters and related questions asking them to evaluate the broadcasters’ appearance in four dimensions. We developed the questionnaires using the following steps. First, we looked for suitable photographs of sample broadcasters on the YY website. The photographs we chose had to satisfy several criteria: clear facial features, a natural expression, high resolution, and a conventional pose. Second, the 293 broadcasters who we selected were divided into three groups based on content type to enable the raters to compare broadcasters who generated similar content. Hence, every rater received three questionnaires. Raters had 2 days to complete the questionnaires by scoring the four dimensions of each broadcaster’s appearance – competence, trustworthiness, likability, and attractiveness – using a five-point Likert-type scale ranging from 1 (low) to 5 (high). We then summed the rater’s scores for each appearance dimension to construct the relevant appearance variables.r = 0.087, p < 0.01), viewer participation , and live streaming performance , broadcaster effort is positively correlated with live streaming performance , and viewer participation is also significantly positively correlated with live streaming performance . These preliminary results provided a basis for further examination of our predictions.H1 states that RPI improves live streaming performance by increasing broadcaster effort , while H2 states that RPI improves live streaming performance by increasing viewer participation . In recent years, many scholars have questioned the statistical validity of the hierarchical regression method . Thus, t1 = 455.029, t = 17.916, p < 0.01), which in turn improved live streaming performance , which in turn improved live streaming performance . The results presented in As can be seen from p < 0.01) when moderated by competence, 1.55 (p < 0.01) when moderated by trustworthiness, 1.25 (p < 0.01) when moderated by likeability, and 1.45 (p < 0.01) when moderated by attractiveness  was moderated by the broadcaster’s appearance, and thus model 14 in the PROCESS SPSS Macro was used to examine the moderated mediation model. The number of bootstrap samples was set to 5,000 and the CI was set to 95% to test the moderated mediation hypotheses. We conducted four moderated mediation tests using the broadcaster’s appearance of competence, trustworthiness, likability, and attractiveness as moderators. The results are presented in To further examine the moderating influence of broadcaster appearance, we separated each appearance dimension into low (mean-1 standard deviation (SD)) and high (mean + 1 SD) groups and conducted simple slope analyses. As can be seen from p < 0.01; trustworthiness: B = 0.66, p < 0.01; likeability: B = 1.53, p < 0.01; attractiveness: B = 1.74, p < 0.01). Thus, H4a–H4d are supported.We used the PROCESS SPSS Macro (model 7) to test H4a–H4d, which state that the informational effect of RPI will be more pronounced when broadcasters appear more competent, trustworthy, likable, or attractive, respectively. Similar to the strategy and parameters described above, we implemented a series of moderated mediation models in which one of the dimensions of broadcaster appearance served as the moderator. The results are presented in Several conclusions can be drawn from the above results. First, we confirmed the effort-inducing effect of RPI in a live streaming environment. This finding is consistent with those of previous studies in other contexts such as production tasks . Second,Our study contributes to the literature in a number of ways. First, it enriches the RPI literature by revealing the effort-eliciting and informational effects of RPI in the live-streaming market. Most previous studies on the influence of RPI on task performance have focused on the function of RPI in inducing effort , whereasThe second contribution of our study is that it complements the existing live streaming literature by providing large-sample archival evidence of the behavioral effects of RPI in the live streaming industry. Although live streaming businesses have attracted growing attention from different academic fields in recent years, this stream of research is still in its infancy . Extant Finally, the results of this study complement the behavioral labor economics literature by investigating the effects of the beauty premium in relation to the live streaming business . Using sThe findings of this study will be of interest to both broadcasters and live streaming platforms. First, our findings suggest that RPI is conducive to enhancing viewer tips by either increasing the broadcaster’s level of effort or encouraging viewer participation. Given that viewer tips are an important source of revenue for both broadcasters and live streaming platforms, and that broadcasters play a significant role in determining viewer behavior, it is crucial for live streaming platforms to develop an effective performance information sharing system through which broadcasters’ performance information can be made available to both broadcasters and viewers. For instance, the live streaming platform could prominently display the broadcaster performance ratings list on its website or app, or periodically transmit the broadcasters’ performance ratings to participants. However, given that previous studies have identified some potential disadvantages of publicly available RPI when it is provided too frequently or too precisely , live stSecond, live streaming companies should develop strategies to amplify the positive effects of RPI. Our findings suggest that RPI has both an effort-eliciting effect and an informational effect. Therefore, the desirable effects of RPI on live streaming performance could be enhanced if live streaming platforms introduced policies aimed at increasing broadcaster effort and/or viewer participation. In terms of strategies aimed at increasing broadcaster effort, live streaming companies could increase the broadcasters’ share of gift revenue, thereby providing broadcasters with a greater incentive to live stream . IntroduFinally, our findings concerning the moderating effects of the various dimensions of broadcaster appearance reveal that both effort-eliciting and informational effects are more pronounced when the broadcaster is perceived as more competent, trustworthy, likable, or attractive. Therefore, broadcasters should dress formally and wear appropriate makeup in an effort to portray a favorable exterior image, thereby satisfying viewer expectations . MeanwhiThis study has some limitations that should be addressed in future research. First, although the strategy of selecting broadcasters at random reduced the likelihood of self-selection bias to some extent, our findings might still be skewed because a degree of subjectivity related to personal preference was involved in the selection process. In addition, given that endogeneity is not properly accounted for in the study design, the findings might have been influenced by this methodological problem. Future research should use an experimental design that eliminates these issues by strictly randomizing the broadcaster selection process.The second potential problem relates to the measurement of the live streaming performance. Because gifting is one of the main factors determining the revenue of both broadcasters and platforms, we simply used viewer tips as a proxy for live streaming performance, ignoring all other performance metrics. However, we acknowledge that various non-pecuniary performance measures are also important in the context of live streaming, such as the duration of a viewer’s stay in the showroom and how many “likes” the broadcaster receives. Future research should explore whether, and if so, how non-pecuniary performance information affects the behavior of broadcasters. Related to this, an interesting topic for future research is to examine how non-pecuniary performance information such as “likes,” relative to viewer tips, affects broadcaster’s behavior during live streams. Future research could also examine the joint effects of viewers’ tips and “likes” on broadcaster behavior. In addition, compared to traditional consumption processes, viewer behavior  during live streams is more observable and accessible, providing an ideal opportunity for future research to examine the relationship between consumers’ cognitive decision-making algorithms and their visual-based choices in live streaming scenarios using machine-learning technology .Finally, we restricted the category of broadcasters to the pan-entertainment industry because entertainment accounts for a significant proportion of all live streaming services . HoweverResearchers in various disciplines are devoting considerable attention to the live streaming industry in light of the tremendous development of live streaming businesses. Unlike other industries, the live streaming industry makes RPI regarding broadcasters readily available to all participants, although we know little about the behavioral effects of RPI in this context. Thus, in an attempt to fill this gap, this study examined the effects of broadcasters’ RPI on live streaming performance. Using data from 42,166 live streams by 293 broadcasters and drawing on economic and social comparison theory, as well as insights regarding herd behavior and the beauty premium, we developed and tested models focusing on both the effort-eliciting and informational effects of RPI, as well as the moderating effects of broadcaster appearance. The results of this study indicate that RPI can either increase a broadcaster’s level of effort or encourage viewer participation, thereby improving subsequent live streaming performance, and that these effects are more pronounced when broadcasters appear more competent, trustworthy, likable, or attractive. On the basis of these findings, this study contributes to the RPI and live streaming literature by demonstrating that providing RPI regarding broadcasters can result in effort-eliciting and informational benefits in the live streaming industry. Furthermore, the findings of this study contribute to the behavioral labor economics literature by identifying the effects of the beauty premium in the context of the live streaming industry.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Xiamen University. The patients/participants provided their written informed consent to participate in this study.YC, XH, and SZ contributed to conception, design of the study, organized the database, and performed the statistical analysis. XH and SZ wrote the first draft of the manuscript. All authors wrote sections of the manuscript. All authors contributed to the article and approved the submitted version.YC would like to acknowledge the financial support received from National Natural Science Foundation of China (Grant# 72172132).SZ was employed by the company Ernst & Young (China) Hua Ming LLP Hangzhou Branch, Hangzhou, China.The remaining 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.


TGFB1 variants  in HPV infection susceptibility and cervical lesions development, and their impact on TGFB1 cervical and plasma levels. TGFB1 genotypes were assessed with PCR-RFLP and haplotypes were inferred for 190 HPV-uninfected and 161 HPV-infected women. TGFB1 levels were determined with immunofluorimetric assay. Case-control analyses were performed with logistic regression adjusted for possible confounders. Women carrying –1347TT or –1347CT+TT as well as those with 29CT, 29CC, or 29CT+CC were more likely to have HPV than –1347CC and 29TT carriers, respectively. Regarding haplotypes, the most frequent were *4 (GCTG) and *3 (GTCG). Women *4/*4 were less likely to have HPV than those with no *4 copy. Comparing the inheritance of *3 and *4, carriers of *3/*4 or *3/*3 were more susceptible to HPV than *4/*4. The TGFB1 plasma and cervical levels were higher in the infected patients. Plasma levels were also higher in infected women with low-grade lesions. HPV-infected patients carrying *3/Other and *3/Other+*3/*3 presented lower TGFB1 plasma levels than those with no copy of *3. TGFB1 variants could contribute to the comprehension of the TGFB1 role in HPV-caused cervical disease.This study aimed to verify the role of  Human papillomaviruses (HPVs) are small, non-enveloped double-stranded DNA viruses with an icosahedral capsid capable of infecting skin and mucosa epithelial cells, belonging to the Papillomaviridae family . CommonlMore than 200 HPV types have been identified and are classified into low-risk (LR) and high-risk (HR) HPVs depending on their oncogenic ability ,4. PersiHPV-driven cancer is a small probability event because most infections are transient and can be cleared spontaneously by the host immune system . TherefoIn this context, we highlight the transforming growth factor-beta 1 (TGFB1), a pleiotropic cytokine that plays an important role in several biological processes, including cell replication, differentiation, apoptosis, angiogenesis, and immune system regulation ,11. Its TGFB1 gene is located in the 19q13.2 chromosomal region, comprises seven exons separated by six very large introns [TGFB1 promoter region, and rs1800470, on codon 10 , and rs1800471, on codon 25 , both on the signal peptide sequence.The  introns . Among tGenetic variations may alter gene expression, messenger RNA (mRNA) stability, alternative splicing, microRNA target sequence, protein exportation to the endoplasmic reticulum via signal peptides, or alter protein function when an amino acid is changed .TGFB1  and their haplotype structures in HPV-uninfected and infected patients, and in patients who developed or did not suffer premalignant lesions caused by HPV. This study also seeks to verify the impact of the haplotype structures on plasma and cervical TGFB1 levels.Much has been discovered about the role of TGFB1 in HPV infection, such as the immunosuppression caused by TGFB1 favoring infection or the cytokine increasing by the action of viral oncoproteins. However, many pieces are lacking for complete elucidation of the mechanisms involving TGFB1 participation in the infection, intraepithelial lesion development, and cervical cancer establishment. Therefore, looking for one of these pieces, this work analyzes four genetic variations of Participants in the current study were women (n = 351) who underwent outpatient cytology testing between 2013 and 2015 at an ambulatory colposcopy facility of the Intermunicipal Consortium of Health of the Middle Paranapanema, at the University Hospital and Clinic Center of the State University of Londrina, and Basic Healthcare Units in Londrina-PR, Brazil. Cytobrushes were stored in 2 mL of TE buffer  pH 8.0). Peripheral blood was drawn into sterile syringes containing EDTA. All samples were kept at 4 °C. Individuals were divided into groups based on the cervical cytology-determined lesion grade and the presence or absence of HPV DNA. Each participant completed a structured questionnaire and signed an informed consent form.Peripheral blood, 200 μL, was intended for DNA extraction and the remainder had the plasma separated and stored at −20 °C until TGFB1 dosage. Suspension of cervical cells in TE buffer was centrifuged and used for DNA extraction, while the supernatant was stored at −20 °C until TGFB1 dosage.TM, Carlsbad, CA, USA) according to the manufacturer’s instructions, and stored at −20 °C. DNA was also extracted from peripheral blood using a Biopur Mini Spin Plus Kit . DNA concentration was measured on a NanoDrop 2000c spectrophotometer , and purity was assessed by the A260/A280 ratio.Genomic DNA was obtained from cervical cytobrushes using DNAzol (InvitrogenHPV was detected using MY09 (5′-CGTCCMAARGGAWACTGATC-3′) and MY11 (5′-GCMCAGGGWCATAA-YAATGG-3′) primers. They were designed to amplify a conserved region (450 base-pairs (bp)) in the HPV L1 gene region (GenBank Accession number: AJ236888) . Human bAll PCR products were electrophoresed on 10% polyacrylamide and stained with silver nitrate .Based on the Bethesda System (2014), cytologic samples were graded at the Public Health System Laboratory. Patient samples were classified as low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL). Otherwise, a designation of no lesions (NL) was given if cytology samples were normal, i.e., not indicated as having low- or high-grade squamous intraepithelial lesions, cervical carcinoma, atypical squamous cells of undetermined significance, or other atypical squamous cells that could not be excluded as high-grade squamous intraepithelial lesions .®  provided all of the restriction enzymes. Briefly, two primer pairs were created using the TGFB1 gene reference sequence (NCBI gene bank accession number NG 013364.1), one of which included the two promoter region variants (c.-1638G>A and c.-1347C>T) and the other of which included the signal peptide variants (c.29C>T and c.74G>C) [HpyCH4IV was used, yielding 402 and 195 bp fragments for the G allele  with changes , geneticc.74G>C) . The PCRG allele , and theorphisms . The mann enzyme . The BglC allele . The man® (Applied Biosystems) using the BigDye® Terminator v3.1 Cycle Sequencing kit  and PCR-RFLP analysis on at least 5% of the entire sample was repeated, yielding 100% agreement between the results.To verify the precision of the genotyping procedure, one person per genotype across all genetic variations examined was sequenced in a 3500 Genetic AnalyzerUsing PHASE software version 2.1.1, recombination sites between TGFB1 SNV alleles were inferred ,20. HaplBlood samples were centrifuged at 3000 rpm for 15 min and plasma was stored at −20 °C. Cervical mucus samples collected with cytobrushes were suspended in TE buffer, centrifuged at 3000 rpm for 15 min, and the supernatants were stored at −20 °C.TGFB1 levels were determined using microspheres immunofluorimetric assay  for the Luminex platform , according to the manufacturer’s instructions. Results were expressed as pg/mg of total protein, and cervical TGFB1 levels were normalized by the total protein in the supernatant. The plasma concentrations were reported as pg/mL.TGFB1 variants  between case groups and controls regarding HPV status and SIL diagnosis. To avoid type error I from multiple comparisons, Bonferroni’s correction was applied as a post-hoc test. The χ2 test was also used to evaluate Hardy–Weinberg equilibrium. Differences between groups for continuous variables were assessed by the Mann–Whitney test or Kruskal–Wallis test with Dunn–Bonferroni’s post-hoc test. Categorical data were expressed as absolute number (n) and percentage (%) and continuous data as median and interquartile range (IQR). Binary or multinomial logistic regression were carried out to independent association prediction between SNVs as explanatory variables and HPV status or SIL diagnosis as outcome variables. Possible confounders using the forced entry method adjusted logistic regression results. Confounders were chosen by the automated backward method with the elimination criterion based on the likelihood ratio statistic. Adjusted odds ratios (ORs) and 95% confidence intervals (CI) were estimated. All tests were two-tailed, with a p-value (p) < 0.05 as statistically significant. Statistical analyses were carried out using SPSS Statistics 25.0 software .Pearson’s chi-square (χ2) test or Fisher’s exact test was used to assess differences in the frequency distributions of clinical and sociodemographic categorical data as well as First, 351 women were included in the study and categorized as HPV-infected (45.9%) and HPV-uninfected (HPV control group—54.1%). The HPV-infected women were divided into three groups based on cytological abnormalities detected and classified according to the Bethesda System classification as follows: no cervical lesion , LSIL (14.7%), and HSIL (34.0%) groups. For lesion analyses, five patients were excluded, one woman without a cervical cytology result and four women diagnosed with cervical cancer .95% = 1.35–3.90). Regarding lesion grades groups (infected women), differences in age range distribution were not observed. However, these women with three or more pregnancies were more likely to have LSIL  and HSIL  than those with up to two pregnancies. Furthermore, women who had had less than three lifelong sexual partners were less likely to have HSIL  compared to those who had had three or more partners.Patients’ features such as age, age at menarche, age at first sexual intercourse, pregnancies, oral contraceptive usage, marital status, sexual partners during the lifetime, and smoking status are summarized in TGFB1 SNVs c.–1638G>A, c.–1347C>T, c.29C>T, and c.74G>C. Only one sample (HPV-infected) could not be genotyped for c.–1347C>T SNV and was excluded from further analyses involving this genetic variation. For each SNV, all groups were tested for Hardy–Weinberg Equilibrium and no deviation from expected genotype frequencies was found (p > 0.05). Additionally, higher linkage disequilibrium was observed between c.–1347C>T and c.29C>T  (Alleles and genotype distribution are given in  = 0.63) .p = 0.028) and c.29C>T (p = 0.006) allele distribution, and c.29C>T genotype distribution (p = 0.023) between the infection groups but not the lesion grades groups. The –1347T and 29C alleles and the 29CC genotype were more frequent in HPV-infected than in uninfected women .Differences in allele and genotype distributions between groups were assessed by the χ2 test. Differences were noted regarding the c.–1347C>T  is formed by c.–1638G, c.–1347C, c.29C, and c.74G alleles . Differences between groups were found in the frequencies of *4 (GCTG) when infected and uninfected women were compared (p = 0.003) , *3 , *5B , and *2 . SNV alleles were represented in haplotype structures according to their position in the TGFB1 gene, following the order c.–1638G>A, c.–1347C>T, c.29C>T, and c.74G>C.Combinations of investigated variants resulted in eight inferred haplotype structures, two of them possibly recombinant . Accordi= 0.003) . For furBinary and multinomial logistic regression adjusted for “age range, age at first sexual intercourse, marital status, and sexual partners during lifetime” or “pregnancies, oral contraceptive usage, marital status, sexual partners during the lifetime, and smoking status” was conducted to assess the influence of SNVs on the susceptibility to HPV infection and development of low and high-grade lesions, respectively .*4 haplotype regarding HPV infection. Both women carrying c.–1347TT and women with –1347CT or TT were more likely to have HPV than –1347CC ones, with respective odds ratios and confidence intervals (95%) of 2.16 (1.10–4.25) and 1.62 (1.03–2.54). Susceptibility to infection was also greater among women carrying 29CT, 29CC, or 29CT + CC when compared to 29TT, with odds ratios and confidence intervals (95%) of 1.77 (1.06–2.97), 2.31 (1.23–4.34), and 1.92 (1.18–3.12), respectively. Regarding haplotypes, women with two copies (homozygotes) of *4 (GCTG) were less likely to have HPV compared to women with no copy of *4 . Furthermore, *3 (GTCG) in comparison to *4 (the two more frequent haplotypes) evidenced higher susceptibility to HPV infection in women carrying *3/*4 or *3/*3 than *4/*4 .Relevant influences were only observed for c.–1347C>T, c.29C>T, and TGFB1 genetic variations on susceptibility to HPV infection, their impact on plasma and cervical TGFB1 levels was evaluated.After having observed the influence of p < 0.001 and p = 0.008, respectively). However, among the lesion groups, there was a difference only in plasma levels (p = 0.007), whose group of women with LSIL presented higher TGFB1 levels than the NL group (6653.45 (IQR 5098.44) and 3689.42 (IQR 3383.84) pg/mL, respectively, p = 0.010)  pg/mL and 53.17 (IQR 56.46) pg/mg of total protein, respectively) than in uninfected (2964.80 (IQR 3091.45) pg/mL and 32.57 (IQR 54.49) pg/mg of total protein, respectively) (= 0.010) . Thus, T= 0.010) .*3 (GTCG) haplotype. Comparing patients *3 no carriers, homozygotes (*3/*3), and heterozygotes (*3/Other), heterozygotes presented a lower amount of TGFB1 than those with *3 no copy (3067.13 (IQR 4200.20) pg/mL and 4836.23 (IQR 4313.38) pg/mL, respectively, p = 0.03). There was also a lower TGFB1 level in *3 carriers (homozygotes + heterozygotes) when compared with *3 no carriers (3993.99 (4173.05) and 4836.23 (4313.38), respectively, p = 0.04). For TGFB1 cervical levels, there was no difference neither in uninfected nor in HPV-infected women concerning the haplotype inheritance  and hence transcriptional activity.The c.–1347C>T variation is located in the first negative regulatory region and T allele carriers have almost double plasma levels in comparison to C allele carriers. Furthermore, as reviewed by Cebinelli and colleagues (2016) , severalThe c.29C>T and c.74G>C SNVs are located in the signal peptide sequence and cause amino acid substitutions, proline to leucine, and arginine to proline exchanges at positions 10 and 25, respectively. Modifications in the signal peptide amino acid composition could affect its polarity and result in different rates of protein export . AllelesConcerning the frequency of the investigated variants, the HPV-uninfected group  presented the minor allele frequencies very similar to the Southern European population as reported in the Genome Aggregation Database (gnomAD), using the dataset gnomAD v2.1.1 (Controls) ,36. AparTGFB1, c.29C>T and c.74G>C. They found a higher frequency of 29CC and 74GC genotypes in the infected patients than in the uninfected, with the 29CC/74GC combined genotypes increasing the infection susceptibility. In the current study, 29CC, CT, and CT+CC were independently associated with greater susceptibility to HPV infection than 29TT carriers were. Similarly, Guan and colleagues (2010) [Previously in HPV infection, Trugilo and colleagues (2018)  evaluates (2010)  reporteds (2010) ,41,42.The –1347T allele was associated with infection, as well as –1347TT and CT+TT were in the adjusted analysis. Differently, Guan and colleagues (2010) , in the TGFB1 SNVs were analyzed and eight haplotype structures were inferred from the current study population. The frequency of haplotypes in the HPV-uninfected group (control) was similar to that found by Vitiello and colleagues (2018) [TGFB1 haplotypes in this population.However, the phenotype could be better explained in a natural context by a set of genetic variations, such as the haplotypes, rather than variations studied in isolation. Here, four s (2018)  in their*4 (GCTG) was most frequent among uninfected women, being independently associated with protection against HPV infection, as were the single alleles –1347C and 29T harbored by it. The protective effect remained when *4 was compared with *3 (GTCG). Thus, could any haplotype influence protein levels in such a population?Of all the eight haplotype structures, TGFB1 gene expression [+ T cells (TCD4+) of cervical tissue also produce TGFB1. Bonin and colleagues (2019) observed that double labeling (CD4+/TGFB) by immunohistochemistry was higher in cervical tissue with a high viral load than in uninfected tissue. At the same time, they saw that double labeling CD25+/FOXP3+ was also higher in the infected cervix [+ CD25+ FOXP3+ T regulatory (Treg) cells may play an important role in an immune-tolerant microenvironment and the failure of HPV elimination. Not only were CD25+/FOXP3+ Tregs producing TGFB, but also TGFB itself induces the conversion of FOXP3- T cells into FOXP3+ T cells [Firstly, plasma and cervical levels of TGFB1 were measured . Increaspression ,46; (2) pression ,48. In ad cervix . Evidenc T cells . It is w T cells . Thus, TTGFB1 haplotypes and protein levels was assessed in uninfected and infected women. No differences in the TGFB1 plasma and cervical levels were found in uninfected ones according to the haplotype inheritance. Otherwise, *3/Other patients and *3 carriers (*3/*3 + *3/Other) presented lower TGFB1 plasma levels than patients *3 no carriers (Other/Other) in the infected group. Surprisingly, *3 haplotype harbors the –1638G, –1347T, 29C, and 74G alleles that were associated with higher TGFB1 production compared to their respective alternative alleles [TGFB1 expression, and thus, if the affinity for them is weakened, TGFB1 production could be reduced.Looking for an answer to the question above, the association between  alleles ,32,33,34TGFB1 haplotype was associated with HPV infection: *4/*4 conferring protection against HPV infection as well as *3/*4 and *3/*3 increasing susceptibility to HPV compared to *4/*4 patients. Moreover, infected carriers of *3 presented lower TGFB1 plasma levels than infected patients with no copy of *3. Although further studies are warranted to confirm the results, the current study suggests the c.–1638G>A, c.–1347C>T, c.29T>C, and c.74G>C TGFB1 variants as possible elements that can contribute to the understanding of the mechanisms that involve HPV infection and the pathogenesis of cervical lesions.Although the small number of patients with LSIL and the exclusion of patients with cervical cancer may have limited the sensitivity of the cervical lesion grade analyses in this research, the strengths lie in the analysis of haplotypes and the adjustment for potential confounding factors. To our knowledge, this is the first time that