What are the experiences and attitudes of Swiss university students regarding receiving human papillomavirus vaccination during primary care visits?In this survey study of 5524 Swiss university students, of whom 740 had received human papillomavirus vaccination from a general practitioner, in many cases, general practitioners had administered the vaccine on the student’s, rather than their own, initiative.These findings suggest that primary care provides an important opportunity to increase human papillomavirus vaccination rates in Switzerland, but the proactivity of general practitioners must be increased, especially with young men. This survey study examines the knowledge, experiences, and attitudes of Swiss university students in the context of receiving human papillomavirus vaccination during primary care visits. Human papillomavirus vaccination coverage rates lie below desired thresholds in Switzerland. Because general practitioners are the main contact for the relatively rare health issues of many Swiss young adults, primary care offers an important opportunity to provide catch-up human papillomavirus vaccination.To examine the knowledge, experiences, and attitudes of Swiss university students in the context of receiving human papillomavirus vaccination during primary care visits.This self-administered, cross-sectional, web-based survey study was conducted among students of 3 universities and 1 educational institution for health professions in the Swiss Canton of Zurich. Specific questions about human papillomavirus vaccination experience were directed to respondents who had received at least 1 dose administered by a general practitioner. Responses were collected during 12-week intervals between November 11, 2020, and April 7, 2021, and data were analyzed from August 3 to August 30, 2022.The primary outcome was whether human papillomavirus vaccination had been administered on the patient’s or the general practitioner’s initiative.The responses of 5524 participants  were analyzed. The survey completion rate was 90.9% (5524 of 6076 students who consented to participate). A total of 2029 respondents (1792 women [46.2%] and 237 men [14.6%]) reported having received at least 1 human papillomavirus vaccination dose, of whom 740 (36.5%) had received at least 1 dose administered by a general practitioner. Among these, 190 respondents (25.7%) reported that vaccine administration had occurred on their request rather than on their general practitioner’s initiative. Among all respondents, 4778 (86.5%) wanted to obtain more information about human papillomavirus vaccination at a general practitioner’s office, and 2569 (55.3%) rated acute consultations in general practice as inappropriate for addressing human papillomavirus vaccination.The findings of this survey study of Swiss university students suggest that primary care shows a high potential for increasing human papillomavirus vaccination coverage rates in Switzerland. However, there was room for improvement in the proactivity of general practitioners, especially with men, and in the attitudes of students toward the appropriateness of acute consultations in general practice for addressing human papillomavirus vaccination. A previous study11 suggested that among Swiss GPs, HPV vaccination is generally well received, and potentially eligible patients are seen regularly in clinical practice. However, a major obstacle is that young adults’ reasons for encounter in primary care in Switzerland are usually acute complaints and not vaccination-related topics.12 In such medical consultations, the vaccination status is rarely checked, and it may be difficult for GPs to transition from the current reason for the medical encounter to the topic of HPV vaccination.11 On the other hand, a growing body of literature has revealed an important lack of awareness and knowledge among university students, both in Switzerland14 and abroad.19 However, specific knowledge on the perceptions of young adults concerning counseling and administration experiences of HPV vaccination in primary care is lacking, but it would be essential to provide GPs with specific recommendations about how to best address catch-up HPV vaccination. The aim of this survey study was, therefore, to assess the knowledge, experience, and attitudes of Swiss university students regarding receiving HPV vaccination in the context of primary care visits.General practitioners (GPs) are the primary contact person for health issues of many Swiss young adults.20 and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline21 cross-sectional studies. To report results of this study, we further adhere to the American Association for Public Opinion Research (AAPOR) reporting guideline. Since the questionnaire was completely anonymous, this study did not fall under the scope of the Federal Act on Research Involving Human Beings,22 and the local ethics committee of the Canton of Zurich waived approval.We conducted a cross-sectional, internet-based survey developed with SurveyMonkey  at 30 faculties or departments of 3 universities and 1 educational institution for health professions in the Canton of Zurich . Respondents who indicated awareness of HPV were further asked to estimate the lifetime risk of contracting HPV and to indicate which gender they deemed to be most commonly affected by HPV infection.Second, the experience section started with asking respondents whether they had ever received at least 1 HPV vaccination dose  and, if applicable, about the settings where they had received HPV vaccination. If respondents indicated having received at least 1 vaccination dose administered by a GP, they were further asked about the context .Third, to assess attitudes toward HPV vaccination, we asked respondents whether they wanted more information on HPV at their GP’s office and to rate the appropriateness of counseling about HPV vaccination during GP encounters in the context of a check-up, of another vaccination, or of an acute illness on a 5-point Likert scale (from very inappropriate to very appropriate). We further asked whether respondents generally wanted more information about HPV vaccination and about their preferred sources of information.Fourth, the last page of the survey asked for demographic characteristics. See eTable 2 in We performed statistical analyses of the survey responses between August 3 and August 30, 2022. All respondents who reached and completed the last section of the questionnaire were included as participants; no further exclusion criteria were used. Descriptive summaries are presented as counts and percentages for categorical variables and as medians with IQRs for continuous variables. Tabulated results are stratified by reported gender.23Multivariable logistic regression was used to model the association of covariates collected in the survey with 1 binary outcome per section: awareness of HPV vaccination in the section on knowledge, history of at least 1 HPV vaccination dose in the section on experience, and desire for education on HPV by the GP in the section on attitudes. Respondents indicating other gender were excluded from these analyses because of their rare occurrence , to avoiOf the 6076 students who consented to participate, 5524 completed all sections of the survey  and were included as respondents in the final analyses   and HPV Among all respondents, 2029 (36.9%) indicated having received at least 1 HPV vaccination dose (1792 women [46.2%] and 237 men [14.6%]). In adjustment, a positive answer was associated with female gender , increasing age , enrollment in a health care–related program , and a standard health care insurance model  . OverallA desire for more or better information on the topic of HPV was expressed by 3925 respondents . Among these, most wanted more information at schools or university (2857 respondents [72.8%]), followed by information at physicians’ offices (2636 respondents [67.2%]) and by campaigns of the Federal Office of Public Health (2282 respondents [58.1%]). Of all respondents, 4778 (86.5%) wanted to be informed about HPV at their GP’s office, regardless of whether they were vaccinated against HPV. In multivariable adjustment, only having lived outside Switzerland at age 11 to 18 years showed a significant association with a positive answer  . Table 4To provide evidence on how GPs could best address the topic of HPV vaccination, in this survey study, we assessed the knowledge, experience, and attitudes of Swiss university students regarding HPV vaccination in the context of primary care. In this survey with 5524 responses, we found that GPs are important providers of HPV vaccination, but that their proactivity, especially with young men, may need improvement.6 and are in line with further estimates.25 The association of history of HPV vaccination with female gender may be linked to the fact that gynecologists are important providers of HPV vaccination in Switzerland,26 and the association with health care-related programs is consistent with the international literature.28 The association of both higher awareness of HPV and positive history of HPV vaccination with a standard health insurance model  is, however, surprising, since coverage of HPV vaccination by health insurance is independent of the model. We may speculate that individual health care–seeking behavior could act as a confounder, influencing both the choice of the insurance model and our HPV-related outcomes.Almost all participants reported having spent their youth in Switzerland, where HPV vaccination had been recommended for all genders for several years at the time of the survey. Accordingly, most of the study population would be expected to have been confronted with HPV vaccination at school, in pediatric care, or in gynecological care. The low HPV vaccination coverage rates we observed are similar to official national data6 Particularly noteworthy is the high proportion of respondents who reported not to know their vaccination status. Although this specific lack of awareness may reflect a general lack of awareness on issues related to HPV, a possible explanation lies in a decision about HPV vaccination made by the respondents’ parents during early adolescence.Our results underline the need for and importance of catch-up vaccinations, because the coverage rate in our sample suggests no relevant increase compared with earlier national data for adolescents.26 A plausible explanation is selection bias due to our survey being spread among a section of the population pursuing higher education and due to self-selection of participants who arguably have higher awareness for health prevention measures than the general population. Still, the GP seems to be a particularly important source of HPV vaccination for men. On the other hand, the proportion of women who reported that their GP had ever addressed HPV vaccination during a consultation was more than twice as high as that of men. This may result from an at least partial focus on women in HPV counseling rather than on all genders,11 together with the well-known female-gendered perception among the population,27 which we were able to reproduce in our study.GPs play an important role in the delivery of HPV vaccination. Approximately one-third of women and two-thirds of men knowingly vaccinated against HPV vaccination reported having received the vaccine from their GP and not from school health services, pediatric care, or gynecological care. The proportions found in this study are considerably higher than those reported in a national study conducted in 2015.Men reported more often that they had to ask their GP for HPV vaccination rather than their GP offering it on their own initiative. In addition, only 15.6% of all respondents reported that their GP had ever addressed the topic of HPV vaccination during encounters. These observations call for a change in practice.Our study suggests that many university students want more information about HPV at their GP’s office. Interestingly, adjusted analysis revealed no association with demographic factors except for having spent adolescence outside Switzerland. This observation may reflect different perceptions of the roles of GPs as HPV vaccination providers in different health care settings.11 Still, the considerable proportion of students with neutral or positive attitudes may encourage GPs to raise the issue of HPV vaccination at every opportunity. On the other hand, our findings highlight a need for education of young patients concerning the role of GPs as providers of preventive medicine in Switzerland.Only about half of the respondents did not rate encounters in the context of an acute illness as inappropriate occasions to counsel about HPV. This lack of acceptance may in part explain previous observations suggesting that Swiss GPs themselves only rarely take the opportunity to offer HPV vaccination during visits for acute complaints.25 and international33 data showing a large lack of knowledge in the target population, particularly among young men.When addressing HPV, we further conclude that GPs must not assume a high level of knowledge in the target population. We observed a substantial underestimation of the lifetime risk of HPV infection, which further enhances the issue of low awareness. In particular, awareness of HPV not only affecting women cannot be taken for granted by GPs. Although respondents in health care–related educational programs showed slightly higher knowledge, we noticed large gaps even in this group. Our results are in line with both national8 Although the benefit of HPV vaccination declines with increasing age of the patient,2 consultations for these routine vaccinations may still include checking the patient’s HPV vaccination status. An important opportunity, not only in the setting of primary care, might be the upcoming evidence and recommendations to adjust the HPV vaccination dosing schedule to a single-dose schedule.35 A single-dose schedule would allow vaccinating eligible patients directly on site without the need for further consultations, which would especially suit the relatively rare encounters of young adults with their GPs.The fact that GPs had administered HPV vaccination along with other vaccines in a minority of cases highlights a further missed opportunity. The Swiss vaccination schedule recommends a diphtheria, tetanus, and pertussis booster vaccination for young adults at the age of 25 years.25 were limited in size or recruited only in geographically confined regions. In various countries, administration of HPV vaccination relies on different health care practitioners in a similar way as in Switzerland, and the potential of providing catch-up vaccination to young adults has been emphasized in various contexts.39 Our findings are, therefore, likely to apply to other settings where GPs play an important role as the main health care providers of young adults.A major strength of our study is the high number of respondents. Prior national studies41 Arguably, the positive attitudes toward HPV vaccination may be overestimated by being associated with a general willingness to participate in an online survey on a health-related topic.This study also has limitations. Despite the high number of participants, our design does not allow accurate estimates that are generally representative of the general Swiss young adult population, especially since we restricted our sampling frame to students of higher education institutions in an urban area. Furthermore, we were not able to estimate the response rate, because we had no access to either the email lists or the login data of the intranet sites used for advertisement of the survey. In addition, potential bias may stem from self-selection of the survey respondents and recall bias, which are typical issues of web surveys.GPs play an important role as providers of catch-up HPV vaccination in Switzerland. However, their proactivity needs improvement, especially with men. Most university students want more information about HPV from their GP. However, they often do not consider acute consultations in primary care to be appropriate for counseling about HPV vaccination, suggesting that there is room for improvement on their views about GPs as providers of preventive medicine.


Rwanda was the first African country to implement national human papillomavirus (HPV) vaccination . In 2011, a school-based catch-up programme was initiated to vaccinate girls aged younger than 15 years but it also reached older girls in schools. We aimed to estimate the population-level effect of HPV vaccination on HPV prevalence.Cross-sectional surveys were done between July, 2013, and April, 2014 (baseline), and between March, 2019, and December, 2020 (repeat), in sexually active women aged 17–29 years at health centres in the Nyarugenge District of Kigali, Rwanda. HPV prevalence was assessed in cervical cell samples collected by a health-care worker in PreservCyt solution  and tested using a general primer (GP5+ or GP6+)-mediated PCR. Adjusted overall, total, and indirect (herd immunity) vaccine effectiveness was computed as the percentage of HPV detection among all women and among unvaccinated women.1501 participants completed the baseline survey and 1639 completed the repeat survey. HPV vaccine-type prevalence in participants aged 17–29 years decreased from 12% (173 of 1501) in the baseline survey to 5% (89 of 1639) in the repeat survey, with an adjusted overall vaccine effectiveness of 47% (95% CI 31 to 60) and an adjusted indirect vaccine effectiveness of 32% (9 to 49). Among participants aged 17–23 years, who were eligible for catch-up vaccination, the adjusted overall vaccine effectiveness was 52% (35 to 65) and the adjusted indirect vaccine effectiveness was 36% (8 to 55), with important heterogeneity according to education  and HIV status .In Rwanda, the prevalence of vaccine-targeted HPV types has been significantly decreased by the HPV vaccine programme, most notably in women who were attending school during the catch-up programme in 2011. HPV vaccine coverage and population-level impact is expected to increase in future cohorts who are eligible for routine HPV vaccination at age 12 years.Bill & Melinda Gates Foundation. In Rwanda, cervical cancer is the second most common cancer among women, with an age-standardised (on the world population) incidence rate of 28 cases per 100 000 population,The Ministry of Health of Rwanda and the International Agency for Research on Cancer (IARC) have collaborated for 10 years on a series of cross-sectional surveys to show the real-life effect of HPV vaccination at a population level. HPV prevalence was assessed in surveys involving urine samples among girls in schoolsEvidence before this studyThe favourable impact of human papillomavirus (HPV) vaccination on HPV burden and cervical cancer incidence at a population level has been repeatedly shown in high-income settings. We searched PubMed on Jan 1, 2023, using the terms “HPV”, “vaccine”, and “epidemiology”, with no language or date restrictions, to identify studies reporting the biological effect of HPV vaccination at a population level in low-income or middle-income countries. A series of cross-sectional surveys in Bhutan, a middle-income country where vaccination coverage reached the target recommended by WHO for cervical cancer elimination as a public health problem , showed that infections with vaccine-targeted HPV types can be almost eliminated among birth cohorts with a high vaccination coverage. In low-income settings, the only empirical assessment of HPV vaccination effect is from Rwanda, through a series of urine-based surveys among girls in schools. A report from 2020 in Rwanda found national coverage of HPV vaccination in birth cohorts who were offered the HPV vaccine in the catch-up programme to be significantly lower than that in birth cohorts who were offered routine vaccination at age 12 years. Based on this finding, it is reasonable to expect different levels of effect of HPV vaccination in different birth cohorts in Rwanda. However, to our knowledge, no empirical assessment of the effect of HPV vaccination at a population level has yet been reported in Rwanda, in Africa, or in any other low-income setting.Added value of this studyIn this study, we aimed to estimate the effect of HPV vaccination on HPV prevalence in Rwanda and on future cervical cancer incidence, based on empirical data collected in a series of cross-sectional surveys in the general population. The self-reported vaccine coverage among study participants eligible for catch-up HPV vaccination was shown to be significantly lower than the 90% target recommended by WHO. Furthermore, HPV vaccination coverage, and consequently the effect of HPV vaccine on HPV prevalence, was shown to differ with respect to level of education and HIV status.Implications of all the available evidenceQuantifying the effect of HPV vaccination and its heterogeneity across population subgroups in Rwanda is likely to have implications both locally and on a wider scale. Based on our findings, Rwandan public health authorities can reinforce their political and financial commitment towards cervical cancer elimination, improve vaccination coverage, and design adapted cervical cancer screening strategies. Public health authorities in other countries in sub-Saharan Africa and elsewhere can learn from the Rwandan example, both in terms of implementing HPV vaccination and of monitoring its impact on HPV prevalence and cervical cancer burden.Cross-sectional surveys were done between July, 2013, and April, 2014 (baseline), and between March, 2019, and December, 2020 (repeat), in sexually active women aged 17–29 years at health centres in the Nyarugenge District of Kigali, Rwanda. This age range was selected to focus on birth cohorts who were potentially covered by the national HPV vaccination programme in the repeat survey. The vaccination programme began in 2011 but, as girls up to age 15 years in school grades P6 (last year of primary school) and S3 (last year of lower secondary school) were included,Baseline survey procedures for study population recruitment, collection of cervical cells, DNA extraction, HPV testing, and genotyping have been previously reported.This study was approved by the Rwanda National Ethical Committee of the Ministry of Health of Rwanda  and the IARC Ethics Committee (13-06 and 13-07).In the repeat survey, we aimed to recruit around 1500 sexually active women aged 17–29 years and to match, as far as possible, the distribution by age and catchment areas studied in the baseline survey. Women were recruited in nine health centres in the baseline survey and 11 health centres in the repeat survey . Women aUsing a predefined questionnaire , up to tWe described selected characteristics of the women included in the baseline and repeat surveys. Type-specific HPV prevalence was assessed in both surveys by grouping HPV types as vaccine types or non-vaccine types. To assess for cross-protection attributable to vaccination, non-vaccine types were further stratified into other alpha-9 types, other alpha-7 types, and all other detectable non-alpha-7 and non-alpha-9 types.We estimated the effect of HPV vaccination at a population level in Rwanda using an adaptation of the method proposed by Halloran and colleaguesWe estimated vaccine effectiveness as complementary to HPV prevalence ratios (PRs). HPV PRs and corresponding 95% CIs were estimated using binomial regression models with a log link. PR estimates were adjusted for respondent's age group , HIV status , years of education completed (<6 or ≥6), and lifetime number of sexual partners , to account for any demographic or behavioural changes between the two surveys. The adjusted PRs were used to estimate adjusted HPV vaccine effectiveness (1 – PR) and their corresponding 95% CIs.vs age 24−29 years). We also estimated vaccine effectiveness stratified by years of education and HIV status. Statistical analyses were done using Stata SE (version 15.1). Adjusted PRs were assessed using the “glm, fam(bin) link(log)” procedure. Observations with missing data were omitted from the analyses and no imputation of the missing data was attempted. Of note, in our analysis, there was no allowance for multiple testing.Overall, total, and indirect vaccine effectiveness percentages were estimated for all women aged 17−29 years, and separately for those who were originally eligible for the vaccine in the national HPV vaccination programme  and repeat (with vaccination) surveys. These projections were drawn under the assumption that the overall adjusted vaccine effectiveness estimated from our surveys was representative of the whole country and of lifelong HPV vaccination protection. The projections were performed with R software (version 4.1.2) using the method proposed by Bonjour and colleagues,The funder of the study had no role in study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication.vs 54% [n=815]), more frequently literate (90% [n=1514] vs 88% [n=1323]), and more frequently reported being housewives (64% [n=1042] vs 45% [n=678]). The proportion of women who reported being HIV-positive was 12% in both surveys. However, the proportion of women with an uncertain HIV status was lower in the repeat survey than in the baseline survey  had a valid HPV test and completed the study questionnaire. In the repeat survey, 1689 women signed the informed consent form, 1685 had cervical cell collection, and 1639 (97%) had a valid HPV test and completed the study questionnaire . ApproxiOverall prevalence of HPV6, 11, 16, and 18 in women aged 17–29 years decreased from 12% (173 of 1501) in the baseline survey to 5% (89 of 1639) in the repeat survey , there was a significant reduction in HPV6, 11, 16, and 18 prevalence from 13% (95% CI 11 to 16) in the baseline survey to 4% (3 to 6) in the repeat survey, with an overall effectiveness of 68%  and HIV status (11% for HIV-negative vs 2% for HIV-positive), but vaccine coverage in this age group was insufficient to justify comparison of vaccine effectiveness by these strata. No HPV6, 11, 16, or 18 infections were detected among the few (n=41) vaccinated women aged 24–29 years.Vaccine coverage also varied among women aged 24–29 years by years of school completed  per 100 000 women in the baseline survey (without vaccination) to 1660 cases (1239–2161) per 100 000 women in the repeat survey (with vaccination), and the annual age-standardised incidence rate decreased from 28·0 cases (UI 20·9–36·4) per 100 000 women in the baseline survey (without vaccination) to 17·5 cases (13·0–22·7) per 100 000 women in the repeat survey  against vaccine-targeted HPV types  at a population level among women eligible for vaccination in the catch-up programme. Indirect effectiveness (herd immunity) contributed substantially to overall effectiveness. Total effectiveness of HPV vaccination against vaccine-targeted types  was somewhat lower than the efficacy estimated in clinical trials,The overall effectiveness against HPV vaccine types estimated in our survey among women offered the vaccine in the vaccination programme, who had vaccine coverage similar to that reported by Sayinzoga and colleagues,As in other similar studies,Of note, self-reported vaccine coverage and overall vaccine effectiveness against vaccine-targeted HPV types were highly heterogeneous across subgroups of participants who were younger than 24 years, while vaccine coverage was low and overall vaccine effectiveness was non-significant in women aged 24–29 years. Overall effectiveness was higher among women who had completed more years of school and similar to that found in urine-based surveys done in schools from the same area of Kigali .Our study has some limitations. Participants were recruited in the catchment area of health centres in one district of Kigali, the capital of Rwanda, and so the study population might not be fully representative of the general population of the country, which is still largely rural. Furthermore, participation rates could not be estimated due to the uncertainty regarding the number of women who had been reached by the information campaign, and because exhaustive lists of the population residing in the catchment areas of health centres are not available. Also, women self-reported their vaccination status, and there might have been some misreporting. To assess the sensitivity of our total and indirect vaccine effectiveness estimates to the uncertainty about reported vaccination status , we recalculated total and indirect vaccine effectiveness, first excluding from the analysis all women who were unsure about their vaccination status, and then considering these women as vaccinated. No substantial effect due to possible misclassification was observed. Finally, although it is possible that heterogeneity of vaccine effectiveness across Rwanda might not be entirely captured in our estimate, no other data are yet available; therefore, we have drawn our projections of lifetime cervical cancer risk under the provisional assumption that the overall adjusted vaccine effectiveness estimated from our surveys was representative of the whole country.In conclusion, this study builds upon our previous observation of a strong impact of HPV vaccination among school girls in Kigalihttps://gitlab.com/iarc-miarc/methis/methis.atlas.External researchers can make written requests to the International Agency for Research on Cancer for sharing of data and study protocol. Requests will be assessed on a case-by-case basis in consultation with the lead and co-investigators. All data sharing will abide by rules and policies defined by the involved parties. Data sharing mechanisms will ensure that the rights and privacy of individuals participating in research will be protected at all times. The model code used to project the estimated impact of HPV vaccination on cervical cancer burden in Rwanda is available at DAMH is minority shareholder of Self-screen, a spin-off company of VU University Medical Center ; Self-screen develops, manufactures, and licences high-risk HPV and methylation marker assays for cervical cancer screening and holds patents on these tests. All other authors declare no competing interests.


The persistence of HPV infection is a significant etiological factor in the development of cervical cancer. The present study investigated the prevalence and genotype distribution of human papillomavirus (HPV) in a cohort of 164,137 unvaccinated women from Wenzhou, aiming to provide guidance for clinics in the cervical cancer screening and HPV vaccination strategies.The present retrospective study included a total of 164,137 women, comprising 118,484 outpatients and 45,653 healthy female subjects recruited from 2015 to 2020. Cervical exfoliated cells were collected from these participants for subsequent DNA extraction. The extracted DNA samples were underwent analysis using a fluorescence in situ hybridization method, encompassing the detection of 27 HPV genotypes.The overall prevalence of HPV was 17.35%; this corresponded to a prevalence of 19.10% in the outpatient group and 12.82% in the healthy female group. Among the outpatient group, the five most prevalent HPV genotypes were identified as HPV 52, 58, 16, 53, and 61. In the healthy female group, the five most common HPV genotypes were found to be HPV 52, 53, 58, 61, and 81. Additionally, it was estimated that the highest rate of HPV infection occurred among individuals aged between 10 and 19 years old (44.65%) and those aged between 60 and 69 years old (27.35%).The prevalence of HPV in this region is substantial; therefore, it is imperative to implement scientifically sound and rational clinical interventions such as vaccination. Routine cervical screening should be performed to prevent the development of cervical intraepithelial neoplasia resulting from persistent infection with high-risk HPV, particularly in women with gynecological diseases and those over 60 years old.The online version contains supplementary material available at 10.1186/s13027-023-00553-4. Human papillomavirus (HPV) is one of the most common sexually transmitted infections that primarily targets the human epithelium . More thThe incidence of cervical cancer is significantly elevated in countries burdened with a high prevalence of HPV. Consequently, the implementation of HPV detection and vaccination programs has been widely recognized as the most efficacious approach to prevent cervical cancer . HoweverIn China, cervical cancer screening procedures are based on guidelines published by Colposcopy and Cervical Pathology (ASCCP) and Society of Gynecologic Oncology (SGO), which include co-testing with cytology and HPV detection . Recent From January 2015 to December 2020, we collected a total of 164,137 participants (age range 12–89 years) refraining from receiving HPV vaccination in this retrospective study. The participants were categorized into two distinct groups: (1) The outpatients group (OG) including 118,484 outpatients from the department of gynecology underwent HPV tests for various indications, including vaginitis, urethritis, irregular vaginal bleeding, cervicitis, undiagnosed abdominal pain, and genital warts, and women with known HPV infection were excluded from the group. (2) The healthy female group (HFG) consisted of 45,653 female subjects without reported gynecological symptoms who visited the physical examination center. The participants were recruited from the Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University.®HPV 27 genotyping Assay  using Luminex 200 System (Luminex Corporation in the USA), following the manufacturer’s instructions. This method uses multiplex PCR amplification with universal primers and flow fluorescence hybridization to simultaneously detect 27 types of HPV, including 10 LR-HPV genotypes , and 17 HR-HPV genotypes . The advantages of the flow fluorescence hybridization method used in the present study have been confirmed in previous studies [Cervical exfoliated cells were obtained from women using a cytobrush (Shanghai Tellgen Life Technologies Inc.) for genomic DNA extraction. DNA was extracted and purified using a commercial kit (Shanghai Tellgen Life Technologies Inc.) by the exchange resin adsorption method. The method was performed according to the manufacturer’s instructions. Subsequently, HPV DNA was detected and genotyped by flow-through hybridization and gene chip of TellgenplexPositive and negative controls were used during testing to verify the reliability of the results. The β-globin gene was utilized as the internal reference sequence, and a signal value < 1000 was considered an unqualified detection. According to the manufacturer’s verification report, when compared to the Sanger sequencing method as the reference method, this assay would have a sensitivity of 100%, specificity of 76.33%, and total coincidence rate of 96.08%.The positive specimens included in the study underwent HPV typing, and overall prevalence of HPV was calculated. Additionally, an analysis of the annual trend in overall prevalence was conducted, along with calculations for prevalence of both multiple and single infection, HR-HPV and LR-HPV infection, as well as proportions of infection within each age group. Furthermore, a comparison between the OG group and HFG group was performed to identify any differences. The genotyping of all HPV infections was statistically analyzed, and the above indicators were also analyzed.P < 0.01.Statistical analysis was performed using WPS Office  and GraphPad Prism 5 . The differences in the HPV positive rates and proportions of multiple-type HPV infections between the OG and HFG were assessed by the unpaired Student’s t-test. A statistically significant difference was considered when P < 0.01).A total of 164,137 women were involved in the present study, including 118,484 females in the OG and 45,653 females in the HFG . A total of 7403 positive HPV genotypes were noted in the HFG, with a per capita carrying rate of 0.16 .In total, HPV 52 (3.29%), 58 1.96%), 53 (1.87%), 16 (1.67%), and 61 (1.34%) were the five most prevalent HPV genotypes. The five most common genotypes were HPV 52, 58, 16, 53, and 61 in the OG, and the five most common genotypes were HPV 52, 53, 58, 61, and 81 in the HFG .HR-HPV was detected in 26,568 individuals, with a total infection rate of 16.19%  , followed by HPV 58 , HPV 53 , HPV 16 , and HPV 39 .P > 0.01). Among women with multiple HPV infections, the multiple infections with the HR-HPV rate accounted for 93.39% (4987/5340) of the population in the OG and for 92% (1104/1200) of the population in the HFG (P > 0.01).The frequency and number of HPV infections are shown in Table P < 0.01).Multiple and single HPV genotypes accounted for 40.87%  and 59.13%  of all positive types, respectively. Single infections and multiple infections were identified across all genotypes  exhibited an age-dependent increase. However, individual genotypes displayed distinct age-related trends  and the Society of Gynecologic Oncology (SGO) recommending the discontinuation of cervical screening after the age of 65. Several studies have also demonstrated a significant decline in HR-HPV infection rates among individuals aged above 45 , 31. HowIn this study, a total of 164 137 women underwent HPV testing and were stratified accordingly. The prevalence of HPV was compared between carriers of gynecological diseases and healthy individuals, while also analyzing the infection rates across different types and age groups. This comprehensive dataset on HPV infection among women in our region provides valuable insights for HPV screening and vaccination strategies. However, we did not conduct a detailed categorization of patients based on specific clinical disease types to enable a comparison of HPV infection rates within these categories, which would have facilitated the exploration of the association between HPV infection and gynecological diseases. The present study revealed a declining trend of HPV 16 prevalence with increasing age, while HPV 52 demonstrated a bimodal distribution pattern characterized by peaks at ages 30–39 and 60–69 years. In future investigations, data needs to be gathered in order to explore and elucidate the association between HPV infection and gynecological diseases, as well as the interplay among HPV genotypes, age demographics, and immune responses.The present study revealed the temporal trends and age-specific genotype distribution of HPV in Wenzhou. Despite advancements in social and economic development, the prevalence of HPV remains high. We strongly advocate for the prompt and comprehensive implementation of targeted measures, such as vaccination. Notably, the OG group exhibited a significantly higher prevalence of HPV compared to the HFG, underscoring the necessity for routine cervical cancer screening among patients with gynecological diseases. Furthermore, there is an escalating prevalence of HR-HPV infections among women aged over 40 years old that peaks after reaching 60 years old. Consequently, this study strongly advocates for regular cervical screening in women above the age of 60 to mitigate the risk of developing cervical intraepithelial neoplasia subsequent to persistent HPV infection.Additional file 1: Figure S1. The proportion of each HPV type corresponding to a positive detection during a period of 5 years. HPV Human papillomavirus. Table S1. Age-specific genotypes of HPV infection. HPV Human papillomavirus.


Background: Human papillomavirus (HPV) is responsible for most cervical cancer cases globally, with women living with HIV having a higher risk of persistent HPV infection and HPV-associated disease. The HPV vaccine is a promising tool to reduce cervical cancer rates, but its uptake among women living with HIV in Nigeria is unknown. Methods: A facility-based, cross-sectional survey was conducted with 1371 women living with HIV to assess their knowledge of HPV, cervical cancer, and the HPV vaccine as well as their willingness to pay for the vaccine at the HIV treatment clinic at the Nigerian Institute of Medical Research, Lagos. To identify factors associated with the willingness to pay for the HPV vaccine, multivariable logistic regression models were developed. Results: This study found that 79.1% of participants had not heard of the vaccine, and only 29.0% knew its efficacy in preventing cervical cancer. In addition, 68.3% of participants were unwilling to pay for the vaccine, and the average amount they were willing to pay was low. Knowledge of HPV, the HPV vaccine, and cervical cancer and income were factors associated with the willingness to pay for the vaccine. Health workers were the primary source of information. Conclusions: This study highlights the lack of knowledge and low willingness to pay for the HPV vaccine among women living with HIV in Nigeria and emphasizes the importance of improving education and awareness. Factors associated with the willingness to pay, such as income and knowledge, were identified. Practical strategies, such as community outreach and school-based education programs, could be developed to increase vaccine uptake. Further research is needed to explore additional factors influencing the willingness to pay. With more than 600,000 newly reported cases and about 300,000 fatalities from cervical cancer in 2020, it significantly threatens public health worldwide ,2. Low- According to the World Health Organization, vaccinating girls aged 9–14 against HPV can prevent at least one third of all HPV-related cancers in Africa ,9. Many Despite the success of cervical cancer screening programs in developed countries, screening for cervical cancer remains unpopular in Nigeria ,15,16 asConsidering all-female populations is crucial in achieving the global goal of cervical cancer elimination. WLHIV are particularly important, as they have higher rates of persistent HPV infection and HPV-associated disease. Furthermore, countries such as Nigeria, with increased rates of HIV, also tend to have low rates of cervical cancer screening, making simple and affordable vaccine schedules critical . StudiesIntroducing HPV vaccines in developing countries has been a significant challenge due to high prices. The Vaccine Alliance (Gavi) and its partners aim to provide the poorest countries with access to a sustainable supply of new and underused vaccines, including HPV vaccines, for as low as USD 4.50 per dose NGN 2072.25) ,20. Gavi72.25 ,20Research has indicated that impediments to the adoption of HPV immunization include the cost; parental inclination to finance the vaccination for their female offspring; insufficient awareness, particularly among caregivers of the intended demographic and particularly in lower-middle-income nations such as Nigeria; negative beliefs; and opposing attitudes ,24. In NThis research used a cross-sectional survey at the HIV treatment clinic at the Nigerian Institute of Medical Research (NIMR), Lagos State. The institute is a preeminent institution dedicated to researching diseases with significant public health implications in Nigeria. The institute presently offers a comprehensive range of HIV care, treatment, and support services to a population exceeding 20,000 individuals, with women constituting 62.9% of the total.Study population: The study population included women of known HIV status aged 18 years and above that were receiving treatment and were eligible for cervical cancer screening at the NIMR clinic, Lagos State. Women who were unable to provide informed consent were excluded from the study.2P (1 − P)/d2, where Zα is the Z statistic for a 95% confidence level, N is the sample size, P is the prevalence of WLWH willing to pay for the HPV vaccine, and d is the precision. The population proportion of WLWH in Nigeria that were willing to pay for the HPV vaccine was 50%, with a 95% confidence level and a 5% margin of error; the minimum required sample size that was calculated was approximately 385 participants. However, with an increase in the precision estimate and accounting for potential non-responses or missing data, the sample size was increased to 1371 participants using a margin of error of approximately 2.5% with a 95% confidence level.Sampling method and sample size determination: The sampling method for this study was convenience sampling, a type of non-probability sampling technique. The sample size was calculated according to the formula N = Zαx’ on the maximum amount you will pay (in Naira) to have yourself and/or your daughter vaccinated against HPV.” Individuals who responded negatively or reported a payment card value of zero were categorized as “vaccine rejecters,” whereas those who responded affirmatively and said a positive payment card value were classified as “vaccine acceptors.” The payment card provided a range of WTP values from zero to NGN 27,623.40, equivalent to USD 60. The highest price tendered corresponded to the overall market value of the vaccine in Nigeria. The perceived monetary benefit of the vaccine was deemed as the upper limit of their willingness to pay. The participants’ answers to the willingness to pay inquiries were classified into two groups: those who accepted the vaccine and those who declined it. The variable that became the dependent variable in the multivariate logistic regression was the response to the willingness to pay question.Data collection tool: The questionnaire was pretested for reliability and validity using a pilot study with a small sample of participants before its administration in the main study. The study used an interviewer-administered questionnaire to gather data on various demographic variables of the participants, including their age, level of education, primary occupation, and average monthly per capita income. In addition, the study questionnaire collected data on HPV, cervical cancer, and HPV vaccination knowledge. For the evaluation of participants’ level of comprehension regarding the ailment and HPV vaccination , questions were included regarding the etiology of cervical cancer. The present investigation operationalized the willingness to pay for the HPV vaccine as the inclination of unvaccinated females to obtain the HPV vaccine after being informed of its cost. The measurement of vaccine rejection was based on the response elicited by the following inquiry: “If the vaccine is not free, and you have to pay ‘out of pocket’ by yourself, will you vaccinate yourself and/or your daughter against HPV?” A follow-up question was used to assess the willingness to pay (WTP) of “vaccine acceptors.” The question read, “From the scale below, mark ‘Data collection procedure: The data collection was conducted between June 2022 and November 2022. It involved face-to-face interviews with eligible participants. All research assistants were trained before the commencement of the study on the research tools, interviewing skills, data management, and clarifications of ethical issues in research. The research assistants administered the questionnaires in Pidgin English or the local language for participants who could neither read nor write. The questionnaires were administered privately, and clarification and assistance were provided where necessary. The interviews took approximately 20 min to complete.Statistical analysis: The data collected in the survey were analyzed using the SPSS version 27.0  statistical package. Descriptive statistics, including frequencies and percentages, were used to summarize the socio-demographic and health characteristics of the study’s participants. The means and standard deviations were used to summarize continuous variables such as age and income. The primary outcome variable was the willingness to pay for the HPV vaccine, which was measured as a binary variable (yes/no). To test the assumptions of a logistic regression, we checked for multicollinearity, linearity, and the normality of the residuals.p-value of less than 0.05 was considered statistically significant. We also conducted sensitivity analyses to assess the robustness of the findings using different assumptions and models. Subgroup analyses examined the associations between the independent variables and the willingness to pay for the HPV vaccine by age group, income level, and educational level.We assessed the presence of multicollinearity using the variance inflation factor (VIF), with a VIF value of 10 indicating high multicollinearity. We found that all independent variables had VIF values below the threshold, indicating no significant multicollinearity. We also examined the linearity assumption by plotting the residuals against the predicted values and examined the normality assumption by generating a standard probability plot of residuals. The residual plots showed no evidence of nonlinearity or non-normality, confirming that the assumptions of the logistic regression were met. We also conducted sensitivity and subgroup analyses to assess the robustness of the results using different beliefs and models. Finally, we used a logistic regression analysis to examine the factors associated with the willingness to pay for the HPV vaccine. The independent variables included in the regression model were socio-demographic variables, HIV-related health status variables, and knowledge about HPV and the HPV vaccine. The odds ratios (ORs) and 95% confidence intervals (CIs) were used to estimate the strengths and directions of the associations between the independent and outcome variables. A This study was conducted following the ethical principles of the Declaration of Helsinki. Ethics approval was obtained from the Institutional Review Board of the Nigerian Institute of Medical Research, Lagos State (IRB-21-047). Before administering the questionnaire, the participants were given information sheets outlining the study’s objective and scope, which were duly explained to the participants in English or the local dialect (Yoruba/Pidgin). The participants were informed that participation in the study was voluntary and that they were free to withdraw from the study at any point without any consequences. The confidentiality and anonymity of the participants were ensured, and all data were kept confidential and were used only for research purposes. The participants were assured that participation or non-participation would not affect their access to healthcare services. In addition, participants who required psychological support after the study were referred to the appropriate healthcare professionals.However, after controlling for potential confounders and inter-relationships between factors, it was shown that participants who had attended tertiary education  and those that were earning more than NGN 100,000.00 (USD 217)  were willing to pay for HPV vaccination. Furthermore, knowledge of HPV  and cervical cancer  were statistically significantly associated with the participants’ willingness to get vaccinated. The knowledge of the HPV vaccine was initially significant  but was not statistically significant after controlling for other factors .This study investigated the willingness to pay for HPV vaccination among WLWH in Nigeria. Cervical cancer remains a significant public health concern in Nigeria. However, it is clear that HPV awareness is low, and specific knowledge was generally poor among WLWH in Nigeria.The results of this study indicate a significant lack of knowledge related to HPV, cervical cancer, and the HPV vaccine among the participants, indicating a need for greater public awareness and education about these critical health issues. This outcome is similar to that of a study conducted among WLWH in Lagos, Nigeria, where 67.7% of the participants had never heard of HPV infection and only 22.3% knew about the HPV vaccine . MoreoveThe source of information about HPV and cervical cancer was primarily health workers, indicating the need for healthcare providers to play a more significant role in disseminating information about these health issues to the public. These findings are consistent with previous studies that have reported the critical role of health workers in improving the knowledge and awareness of HPV and cervical cancer ,30.This study revealed that most participants were unwilling to pay for the HPV vaccine, indicating that the cost is a substantial barrier, particularly for those with lower incomes. Only 3% of the participants had already received the HPV vaccine. The scenario above resembles a research endeavor in Vietnam, where individuals in the poor/near-poor household category have not received HPV vaccinations . MultiplThis study also assessed the willingness of WLWH to pay for HPV vaccination for their daughters and females in their communities. The results showed that 55.6% of the participants were willing to vaccinate their daughters, while 66.8% were not willing to pay for the vaccine, indicating that the cost was a significant factor in their decision making. However, if the vaccine was free, 79.1% of the participants expressed their willingness to vaccinate their daughters and other females in their communities, suggesting potential demand for the vaccine. Another study found that 72.0% of parents were willing to vaccinate their daughters if the vaccine was free . StudiesThis study found that participants were willing to pay a meaningful amount of USD 7.46 ± USD 9.17 (NGN 3221.15 ± NGN 3963.95), which was significantly lower than the market cost. Therefore, reducing the vaccine cost could increase the willingness to pay and vaccine uptake, and a co-payment for HPV vaccination could be a viable option to augment the cost of vaccination in a government-funded vaccination scenario. This finding is consistent with previous studies conducted in Kenya and India, which identified costs as a significant barriers to HPV vaccination uptake and suggested strategies to reduce costs, such as government-sponsored programs and subsidies .This study aimed to identify factors associated with the willingness to pay for the HPV vaccine. While the education level and income were not strongly associated with the willingness to pay for the HPV vaccine, this study found that participants who had attended tertiary education were more willing to pay for the vaccine than those who had not. This study suggests that higher education levels may contribute to determining an individual’s willingness to pay for the HPV vaccine. This study’s finding is consistent with previous research suggesting that education can influence health-related decision making ,41. AnotA study conducted in Nigeria found that the cost and a lack of knowledge about cervical cancer and its prevention were significant barriers to vaccine uptake and willingness to pay . This stFurthermore, this study highlights that the knowledge of the HPV vaccine’s effectiveness in preventing cervical cancer is the most significant factor related to the willingness to pay for the vaccine. This finding suggests that increasing public awareness about the vaccine’s effectiveness in preventing cervical cancer could increase vaccine uptake.Overall, the findings of this study and similar studies conducted in other countries emphasize the importance of addressing knowledge gaps, increasing awareness about the vaccine’s benefits, and managing cost barriers to improve vaccine uptake and the willingness to pay. In addition, targeted educational interventions and strategies to improve access to the vaccine and the affordability of the vaccine could help increase vaccine uptake and ultimately reduce the burden of cervical cancer.This study has several limitations. First, the study was conducted at a single HIV treatment clinic in Nigeria and may not be generalizable to other populations or settings. Second, the study relied on self-reported data, which may be subject to social desirability or recall bias. Third, the study did not assess the knowledge and willingness to pay for the vaccine among women who were not receiving HIV treatment, and this may have biased the results. Fourth, the study did not explore other potential barriers to vaccine uptake, such as cultural or religious beliefs. Lastly, this study did not collect data on the history of violence or sexual abuse among the study participants, which could be a potential confounding factor for the willingness to pay for the HPV vaccine. Therefore, we cannot rule out the possibility that past experiences of violence or sexual abuse may have influenced the results of our analysis.In terms of prospects, this study highlights the need for effective strategies to increase awareness and access to the HPV vaccine among women living with HIV in Nigeria. Community outreach programs, school-based education programs, and targeted campaigns for women and parents could be effective strategies to increase vaccine uptake. Additionally, further research is necessary to explore other factors that may influence the willingness to pay for the HPV vaccine in Nigeria and to identify potential barriers to vaccine uptake that were not explored in this study. Future studies should consider collecting such data to better understand the relationship between past experiences of violence or sexual abuse and the willingness to pay for the HPV vaccine among women living with HIV.This study highlights the low levels of knowledge about HPV, cervical cancer, and the HPV vaccine among WLWH in Nigeria, resulting in 66.8% of participants being unwilling to pay for the vaccine. The study emphasizes the importance of increasing education and awareness about the vaccine’s significance in preventing cervical cancer, with health workers playing a crucial role in providing information. Factors associated with the willingness to pay, such as income, knowledge of HPV and the vaccine, awareness of cervical cancer, and the health belief model of a perceived screening benefit, were also identified. The study’s findings could aid in developing effective strategies to increase vaccine uptake in Nigeria, such as community outreach and school-based education programs. Further research is necessary to explore additional factors influencing the willingness to pay for the vaccine. This study recommends that the Nigerian government and healthcare providers prioritize increasing awareness and education about the HPV vaccine and cervical cancer prevention among WLWH.


Many previous studies have focused on the prevalence of high-risk HPV16 and HPV18 strains, highly associated with cervical and oral cancers covered by the original HPV vaccine. However, little research is currently available regarding the oral prevalence of other high-risk HPV strains, such as HPV31 and HPV33, which are part of the recently revised nine-strain HPV vaccine. This study conducted one of the first oral prevalence studies of these high-risk HPV strains among a multi-ethnic patient population at a public dental school in Nevada. The results of this investigation revealed a significant percentage of children and adults in this study harbored one or more of these high-risk strains, which were mostly found among patients within the recommended vaccination or catch-up age range (9–45 years).N = 86 samples from the saliva biorepository met the quality and concentration standards and were screened for high-risk HPV. qPCR screening of adult samples revealed n = 10/45 or 22% were HPV31- or HPV33-positive. In addition, a total of n = 9/41 or 21.9% of pediatric samples were either HPV31- or HPV33-positive (or both). No samples harbored HPV35. Most samples were derived from patients within the recommended vaccination or catch-up age range (age 9–45 years). These results demonstrated that a significant percentage of patients harbor additional high-risk HPV strains within the oral cavity, including HPV31 and HPV33. These data support oral healthcare provider recommendations for the newer nine-valent vaccine, which includes both HPV31 and HPV33.Many human papillomavirus (HPV) strains induce cancer in the cervix and the oral cavity. Although high-risk strains including HPV16 and HPV18 are commonly known, additional high-risk strains including HPV31, HPV33, and HPV35 may also induce carcinogenesis, and much less is known about their prevalence. Using an approved protocol, samples from a salivary biorepository were screened to find pediatric and adult samples from a multi-ethnic, university-based patient clinic population. A total of  Human papillomavirus (HPV) is a non-enveloped, double-stranded DNA virus that is epitheliotropic in nature and is known to cause disease in a variety of tissues ,2. ThereHPV infections can spread through skin-to-skin contact through both sexual and non-sexual transmission pathways ,8. EpideThe main clinical distinction between the many human papillomavirus (HPV) strains lies in their ability to mediate cellular transformation into cancer within various tissues, which are broadly categorized into low-risk (LR) or high-risk (HR) depending upon their most frequently associated clinical outcomes ,16. The Although the high-risk strains HPV16 and HPV18 are the most frequently identified, additional high-risk strains found in the cervix and oral cavity may induce carcinogenesis, including HPV31, HPV33, and HPV35, although much less is known about their prevalence ,22,23. BBased upon lack of evidence regarding these high-risk strains, the primary objective of this project is to evaluate the prevalence of these strains among pediatric and adult patients through screening of clinical saliva samples. The working hypothesis for this project was that additional high-risk strains of HPV, such as HPV31, 33, and 35, would be identified if the appropriate screening for these additional HPV strains was conducted.The review of the protocol for this study was completed by the Office for the Protection of Research Subjects (OPRS) and the Institutional Review Board at the University of Nevada, Las Vegas (UNLV). Protocol #1717625-1, titled “Retrospective analysis of microbial prevalence from DNA isolated from saliva samples originally obtained from the University of Nevada, Las Vegas (UNLV) School of Dental Medicine (SDM) pediatric and clinical population”, was approved by the UNLV-IRB and OPRS on 3 March 2021.The original collection protocol was approved by the UNLV-IRB under protocol OPRS#1305-4466M, “The Prevalence of Oral Microbes in Saliva from the UNLV School of Dental Medicine Pediatric and Adult Clinical Population”. Inclusion criteria included patients between the ages of 5 to 45 years of age that agreed to provide informed consent (adult over 18 years of age) or pediatric assent with Informed consent . Exclusion criteria included any patients (or parents/guardians that refused to provide informed consent or pediatric assent) and any samples from patients outside the UNLV School of Dental Medicine.Original sample collection from UNLV–SDM clinic patients involved only voluntary study participants. Following voluntary agreement to study participation and the provision of informed consent and/or pediatric assent, clinic patients were provided a sterile 50 mL saliva collection tube. Up to 5.0 mL of unstimulated saliva was collected from each study participant. To prevent the collection of any personal or patient information, all samples were assigned a non-duplicated, randomly-generated number for labeling purposes. Only basic demographic characteristics, such as patient age at the time of collection, self-reported ethnicity or race, and sex were noted at the time of sample collection. All samples and other materials were stored in a biomedical laboratory for subsequent analysis and processing. A total of N = 253 samples from the biomedical sample repository were identified for potential inclusion in the current retrospective analysis. DNA was isolated from each sample using the phenol:chloroform extraction method. In brief, samples were thawed and vortexed, then 500 µL was transferred to a sterile microcentrifuge tube and mixed with 500 µL of TRIzol DNA isolation reagent from Invitrogen . To each sample, 200 µL of molecular-grade chloroform from Invitrogen  was added prior to incubation on ice for 15 min. Each sample was subsequently centrifuged using an Eppendorf Model 5425  refrigerated microcentrifuge for fifteen minutes at 12,000 × relative centrifugal force (RCF) at 4 °C. The upper aqueous phase (approximately 400–500 µL) was transferred to a new, sterile microcentrifuge tube and mixed with molecular-grade isopropanol from Invitrogen  to precipitate the DNA. Each sample was then centrifuged using the settings described above. Following removal of the isopropanol, the pellet containing sample DNA was washed using molecular-grade ethanol from Invitrogen  prior to centrifugation for ten additional minutes. After removal of the ethanol supernatant, DNA from each sample was resuspended in 100 µL of nuclease-free water obtained from Thermo Fisher Scientific . Analysis of quality and quantity of DNA was facilitated with a NanoDrop 2000 spectrophotometer obtained from Thermo Fisher Scientific  using absorbances of A260 and A280 nm, as specified by the manufacturer protocol. All samples that met minimum quantity standards (>10 ng/µL) as well as quality standards (A260:A280 ratio > 1.65) were then utilized in the current study for molecular HPV screening using qPCR.HPV31 forward: ATTCCACAACATAGGAGGAAGGTG;HPV31 reverse: CACTTGGGTTTCAGTACGAGGTCT;HPV33 forward: ATATTTCGGGGTCGTTGGGCA;HPV33 reverse: ACGTCACAGTGCAGTTTCTCTACGT;HPV35 forward: TCGGTGTATGTCTGTTGGAAAC;HPV35 reverse: CATAGTCTTGCAATGTAGTTATTTCTCCA.The samples that met the minimum criteria for DNA quantity and DNA purity (N = 86) were screened for high-risk HPV strains 31, 33, and 35 using quantitative polymerase chain reaction (qPCR). Each reaction consisted of 15 µL Fast SYBR Green Master Mix from Applied Biosystems , 1.5 µL of forward primer, 1.5 µL of reverse primer, 2.0 µL of sample DNA, and 5.0 µL of nuclease-free water. Reactions were performed using the QuantStudio 3 from Thermo Fisher Scientific  and the following validated primers:t-tests, using an alpha level of 0.05 for statistical significance.Demographic variables for the study sample were compiled and presented as simple, descriptive statistics. Analysis of differences between the study sample and the overall clinic population with respect to categorical variables, such as sex and race or ethnicity, were done using chi-square statistics which is appropriate for non-parametric data analysis. Analysis of qPCR screening results was also presented as simple descriptive statistics, such as percentages, and the differences between HPV-positive and HPV-negative samples were also analyzed using chi-square statistics and the GraphPad Prism software, Version 8 . Comparisons for parametric data, such as age, were completed using two-tailed Student’s N = 86 samples from an existing biorepository met the minimum DNA quality and quantity standards for inclusion in this retrospective study, which were nearly equally divided between adults  patients (n = 25/45), which closely approximates the percentage of females in the overall clinic population (49.1%), p = 0.1614 (n = 25/45), which was slightly lower but not significantly different from the percentages observed within the overall main clinic population (65.4%), p = 0.0592. Finally, the average age of the adult samples was found to be 41.5 years (range: 18 to 73 years), which closely approximates the average age of the main patient clinic population of 42.3 years (range: 18 to 89 years), p = 0.7738.A total of patients . Analysi= 0.1614 . In addin = 23/41), which was similar to the proportion of females observed from the pediatric clinic patient population (52.8%), p = 0.5478 (n = 34/41), which was not deemed to be statistically significant from the observed proportion of minority (non-White) patients from the overall the pediatric clinic population (75.34%), p = 0.0647. In addition, the average age of samples within this study was 12.7 years, ranging between 5 and 17 years, which was slightly higher than the average age of the overall clinical population of pediatric patients of 10.4 years, ranging between 0 and 17 years, p = 0.2531.Analysis of the pediatric patients in the study sample revealed approximately half were derived from females  and females (n = 5/10 or 50%), which closely matched the distribution of HPV-negative samples from males and females, p = 0.5478  was nearly equal and not significantly different , p = 0.5445.More detailed analysis of the adult samples revealed an equal distribution of HPV-positive samples between males  and females (n = 6/9 or 66.7%), which was significantly different from the distribution of HPV-negative samples from males and females, p = 0.005 (n = 7/9 or 77.8%), which did not differ significantly from the proportion of HPV-negative samples from minority patients (n = 27/32 or 84.4%), p = 0.1017. Finally, the proportion of HPV-positive samples and HPV-negative samples from patients within the HPV vaccination age range (11 to 17 years) was significantly different , p = 0.0001.More detailed analysis of the pediatric samples revealed an unequal distribution of HPV-positive samples between males , although no samples tested positive for HPV35. These data represent the first clinical descriptions of non-HPV16 and non-HPV18 high-risk HPV prevalence within this patient population ,28,29,30However, some notable differences were found regarding the prevalence of these high-risk HPV strains compared with previous studies of HPV strains HPV16 and HPV18. For example, this study found nearly one-quarter of adults (22.2%) harbored either HPV31, HPV33, or both. This is somewhat lower than the most recent study of HPV16 and HPV18 prevalence among adults within this patient population, which found an overall prevalence of 30.2% . HoweverIn addition, these data also demonstrated that HPV31 and HPV35 were found in approximately one-fifth of pediatric patient samples (21.9%), which corresponds to similar prevalence levels of HPV16 and HPV18 found within these patients as recently as last year (19.5%) . AlthougDespite the significance of epidemiological data regarding high-risk HPV prevalence, as more studies are now screening for HPV strains other than HPV16 and HPV18, there are some limitations associated with this type of study that should also be considered ,37. SpecHowever, due to the fact that high-risk oral HPV strains may have important functions in both the development and progression of oral cancers, any information regarding the prevalence of these non-HPV16 and non-HPV18 strains becomes critical for oral health researchers, clinicians, and epidemiologists to evaluate and consider ,44. MoreThe importance of these findings, including the increased prevalence of high-risk strains HPV31 and HPV33 detected in this study combined with previous data about the increasing prevalence of HPV16 and HPV18 within this patient population, may suggest a more robust and focused effort on both HPV vaccination and awareness of oral HPV infection ,28,29,30


Breast Cancer (BC) stands out as the widely prevalent malignancy among all the types of cancer affecting women worldwide. There is significant evidence that the pathogenicity of BC may be altered by Human Papillomavirus (HPV) infection; however, conclusive data are not yet available.2I statistic were used to calculate the heterogeneity of the prevalence among these studies using subgroup analysis. Variations in the HPV prevalence estimates in different subgroups were evaluated by subgroup meta-analysis.By searching five databases, including EMBASE, IBECS, PubMed, Scopus, Science Direct, Google Scholar, and Web of Science, a thorough systematic analysis was conducted on the prevalence of HPV in BC patients from 1990 to June 30, 2022. After applying extensive eligibility criteria, we selected 74 publications for further analysis based on the prevalence of HPV infections in breast tissues. All of the data were analyzed using a random-effects meta-analysis, Cochran Q test and I2 = 97% and p< 0.01). Consequently, 45 studies with available controls were further studied, and the prevalence of HPV in case-control studies was 26.2% with overall odds 5.55 . Further subgroup analysis of HPV revealed HPV-16 had a maximum prevalence of 9.6% . Among different geographical regions, Europe reported the maximum prevalence of HPV, i.e., 39.2% . Overall distribution showed HPV-18 was a frequent HPV subtype reported in Australia.In total, 3156 studies were initially screened, resulting in 93 full-text studies reviewed, with 74 meeting inclusion criteria. Among a total of 7156 BC biopsies, the pool prevalence of HPV was 25.6% (95% CI= 0.24-0.33, τ2 = 0.0369 with significant heterogeneity between estimates (Current study provides a global estimate of HPV prevalence in BC patients and demonstrates a significant association between this virus and BC etiology. Nevertheless, we recommend further investigation into the underlying mechanism is essential to validate this hypothesis. BesiHPV is a non-enveloped double-stranded DNA virus whose genome is divided into three regions: the long control region (LCR), the early region , and the late region (encodes L1 and L2) –17. E6 aThe transmission of HPV can happen in either sexual or nonsexual interactions. Direct skin-to-skin contact during sexual activity with a person infected with the virus is the most prevalent way for genital HPV to spread . It is sIn BC patients, the rate of HPV infection is anywhere between 0% to 86.2% ; howeverThough the involvement of HPV in breast carcinogenesis is still debatable, understanding it is essential in devising effective new preventative and treatment measures for women with BC. Consequently, the present systematic review and meta-analysis aim to address this information gap by providing an up-to-date estimate of the overall prevalence of HPV and its subtypes in BC patients worldwide.22.1We systematically analyzed publications on HPV prevalence in BC patients published between 1990 and June 30, 2022. We used five databases: EMBASE, IBECS, PubMed, Scopus, Science Direct, Google Scholar, and Web of Science. Different keywords or MeSH terms were used to find relevant data, with the articles limited written in English  studies published in a language other than English, (ii) studies composed of letters, commentaries, reviews, series, editorial, and commission, (iii) duplicate studies, and (iv) non-relevant studies that did not report any correlation between HPV and BC.2.3Following selecting relevant publications, three reviewers  independently reviewed the titles and abstracts of articles to be read in full text. Within three decades, 3156 studies were researched using electronic databases. After a thorough evaluation, 74 pertinent papers were included. Information about the author(s), year of publication, area, sample size, prevalence of HPV in BC, HPV subtypes, coinfection frequency, and detection technique was acquired for each. Results were classified following the Preferred Reporting Items for Systematic and Meta-analyses (PRISMA) guideline, as shown in 2.4Additionally, using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies, three reviewers  independently assessed the methodological quality of each included study . Disagre2.5I2 statistic, and we presented the results graphically using forest plots . Therefore, the I2 statistic, which ranges from 0 to 100%, reveals that heterogeneity, rather than chance, is the primary difference across research in systematic reviews and meta-analyses. 2I values of 25%, 50%, and 70% indicate low, medium, and high trial heterogeneity. However, subgroup meta-analysis were used to identify the potential sources of statistical heterogeneity.After extracting the data using Microsoft Excel, we conducted a statistical analysis using R version (4.2.3) for meta-analysis using different packages. HPV infection prevalence was determined using the binomial distribution, 3In this systematic review and meta-analysis, we found 3156 studies after a baseline online search between 1992 and June 30, 2022, whereas 06 were discovered after manually searching reference lists, as shown in In addition, the overall prevalence of HPV and the subtypes in individuals diagnosed with BC was calculated for each decade between 1990 and 2022 across all 74 studies. From 1992 to 2000, only three studies reported HPV in breast tissues, primarily subtype HPV-16 and 33, as depicted in 2 = 0.0369, p = 0)   Figure 6I2 = 0%, τ2 = 0.6111, p< 0.01). HPV-18 was reported in BC tissues in 20 studies with a prevalence of 6.6% . HPV-31 has been reported in 5 studies with an overall prevalence of 2% . HPV-33 was reported in 6 studies with an overall prevalence of 4.7%  . HPV 52 was reported in only 3 studies with an overall prevalence of 2.3% . In addition, HPV 58 was reported in only three studies with an overall prevalence of 8.2%  . In Europe, nine studies reported positive HPV cases with an overall prevalence of 39.1% . In America, six studies reported positive HPV cases with an overall prevalence of 30.3% . In Australia, two studies reported positive HPV cases with an overall prevalence of 29.2% . Furthermore, in Africa, three studies reported positive HPV cases with an overall prevalence of 31.8%   with a pooled prevalence of 22.7% . This finding underscores the urgency of identifying novel risk factors for BC development.The causal role of HPV in breast cancer has been a subject of debate for a long time, but recent studies have provided convincing evidence of a positive association between HPV infection and breast cancer development. However, there are still many unresolved questions and challenges in this area of research. Most studies detected HPV using conventional or nested PCR using commercial primers for the L1 gene (capsid protein). After positive results and using primers for E6 and E7 genes or sequencing, they reported probable causes of false positive and false negative results and limitation factors related to the diagnostic techniques used in those studies, like DNA/RNA quality and viral load . Approxi2 = I38%, τ2 = 1.4878, p< 0.01). The 2I value across subgroups was below 50%, indicating acceptable heterogeneity and emphasizing the importance of control selection. Multiple meta-analyses have reported similar results, showing a significant association of HPV with BC. For instance, a meta-analysis of 37 case-control studies containing 3,607 BC cases and 1,728 controls reported overall odds of 6.22   . Another 0.0002) . However 0.0002) .This review and meta-analysis encompass 3156 articles published over the last three decades. We assessed 74 publications to determine the prevalence of HPV in BC tissues after a rigorous evaluation of 1223 studies, of which 1130 were deemed inadequate. Our findings have been supported by Simoes et al.  meta-anap<0.05). Our study corroborates the existing literature and suggests that HPV infection may have a causal or contributory effect on BC initiation and progression. The prevalence of HR HPVs in BC tissue is six times higher than in normal and benign breast tissue controls . The second most common type found in BC tissues, as reported in 21 studies, was HPV-18 with a prevalence of 6.6% .There was a substantial variation in the prevalence of HPV strains observed across various populations . HR HPV controls . MoreoveIn this study, we aimed to investigate the prevalence and distribution of different HPV subtypes in BC tissues from various geographical regions. We found that HPV-16 was the most frequent subtype in Asia, America, Europe, and Africa, while HPV-18 was more prevalent in Australia. A total of 45 studies were examined, with the majority (n=25) published in Asia, indicating a prevalence of (22.7%) overall. We also observed regional variations in the prevalence of HPV among BC patients, with Europe having the highest rate (39.1%), followed by Africa (31.8%), Australia (30.5%), and America (30.3%). Our results suggest that the prevalence of HPV in BC patients varies by location, which may have implications for developing regionally specific methods for preventing and treating BC caused by HPV.The regional variation of HPV infection and its association with breast cancer may be attributed to multiple factors, such as sexual behavior, hygiene, screening, vaccination, and socioeconomic status. For instance, Asia has a high prevalence of HPV in breast cancer (22.7%) due to its large population of women with multiple sexual partners, low condom use, and limited access to cervical cancer screening and HPV vaccination –127. ConThe link between HPV and BC has not been conclusively established, which raises questions about the potential underlying mechanism. The simple detection of HPV is insufficient evidence to prove the virus’s role as a causal agent in the development of BC pathophysiology, and this fact has to be addressed. On the other hand, it is predicted that HPV infection will commence the progression of BC, ultimately resulting in accumulative changes over time similar to the process of cervical carcinogenesis . Many hyThis systematic review aimed to determine the global prevalence of HPV in BC tissues. In addition, we conducted a meta-analysis of case-control studies, which provided more reliable and informative results than studies that included only positive cases. This study provides a more comprehensive picture of the prevalence patterns of HPV infection by incorporating primary studies from different geographical regions around the globe. It also identifies the most vulnerable communities for targeted interventions.4.1One of the limitations of our study was the inability to determine the association between HPV and BC mortality, as none of the primary studies in our systematic review/meta-analysis addressed this issue. Moreover, we could not examine the effect of coinfections on BC aggressiveness due to insufficient data. To establish the causal role of HPV in BC, it is essential to detect both integrated and free virus DNA, which will improve the methodological quality of HPV detection.5To estimate the global prevalence of HPV in BC tissues, we performed a meta-analysis of data from multiple studies conducted within the last 30 years. Our findings indicate that HPV infection is a risk factor for developing BC. In addition, we discovered that the prevalence of HPV infection in BC patients is substantially higher than in the general population. Incorporating HPV testing of breast ductal lavage, nasopharyngeal discharge, and breast milk into the cervical screening program is essential for determining breast cancer risk and facilitating early detection. In addition, HPV vaccination may reduce the incidence of breast cancer. However, no research has investigated the link between HPV vaccination and cancer occurrence. Given the heterogeneity and high likelihood of HPV infection in BC lesions, additional rigorous studies employing standardized testing methods are necessary to clarify the role of HPV in BC.The original contributions presented in the study are included in the article/UA, NA, and AK were involved in the conceptualization, formal analysis, data collection, visualization, and writing the first draft of the manuscript. SA, SKa, UA, SKh, and XG did the data validation, statistical analysis, data interpretation, and figure editing. UA, XG, ZY, and JL were involved in conceptualizing, designing, and supervising the study and did the final revision of the manuscript. All authors listed have made a substantial, direct, and intellectual contribution to the work and approved the final version of the manuscript.