Short-term fluctuations in the detection of cervical human papillomavirus DNA

HPV vaccination among seropositive, DNA negative cohorts: a systematic review & meta-analysis

Objective

Vaccine efficacy among previously exposed, but currently uninfected women, i.e., those who have serological evidence of a prior human papillomavirus (HPV) infection without corresponding detectable HPV DNA, remains incompletely defined. This meta-analysis assessed the serotype-specific efficacy of prophylactic HPV vaccination against HPV16/18 persistent infection (PI) and cervical intraepithelial neoplasia (CIN) among seropositive, DNA negative (SPDN) women enrolled to randomized controlled trials (RCTs) of HPV L1-based vaccines.

Methods

Searches were conducted on 08/16/20 on MEDLINE, Embase, Scopus and CENTRAL. RCTs of L1-based prophylactic bivalent or quadrivalent HPV vaccines, reporting serotype-specific clinical efficacy endpoints in the HPV16/18 seropositive, DNA-negative populations were included. Relative risks (RRs) of 6-month PI (6mPI), 12-month PI (12mPI), CIN1+ and CIN2+ were pooled using a random-effects model.

Results

A total of 1,727 citations were reviewed. 8 studies, with a total of 9,569 SPDN participants, met all eligibility criteria. The RR of 6mPI (RR=0.22; 95% confidence interval [CI]=0.08–0.61; p=0.018), 12mPI (RR=0.20; 95% CI=0.05–0.80; p=0.035), CIN1+ (RR=0.13; 95% CI=0.05–0.30; p=0.003) and CIN2+ (RR=0.15; 95% CI=0.04–0.59; p=0.022) was significantly reduced in the vaccinated compared to the unvaccinated group.

Conclusion

Our findings suggest high serotype-specific efficacy for HPV vaccination among cohorts of women with evidence of prior HPV16/18 infections, including 87% efficacy (95% CI=70%–95%; p=0.003) against HPV16/18 cervical dysplasia. HPV vaccination is highly effective among uninfected women, regardless of prior exposure history.

Trial Registration

PROSPERO Identifier: CRD42020206888

Human Papillomavirus Genotypes Predict Progression of Anal Low-Grade Squamous Intraepithelial Lesions

Background

High-risk human papillomavirus (hrHPV)-induced anal low-grade squamous intraepithelial lesions (LSILs) have the potential to progress to high-grade squamous intraepithelial lesions (HSILs). We investigated whether anal hrHPV infections, particularly types 16 and 18, predict LSIL-to-HSIL progression.

Methods

One hundred forty-six human immunodeficiency virus (HIV)-infected and 22 HIV-uninfected patients with anal LSILs underwent cytology, HPV genotyping (16, 18, and pooled 12 hrHPV types), and high-resolution anoscopy-guided biopsy at baseline and surveillance. The associations between the rate of LSIL-to-HSIL progression and HPV types as well as longitudinal HPV-16/18 status were assessed by fitting separate Cox regression models.

Results

At baseline, 91% of patients harbored hrHPV: HPV-16/18 (44%) and non-16/18 (86%). Upon follow-up (median, 20 [range, 6-36] months), 41% developed HSIL (84% at the same anatomic location as the initial LSIL and 16% at a different location). Baseline HPV-16/18-positive patients had greater probability of progression than patients with non-16/18 types or negative (67%, 25%, and 7%, respectively; P < .001). Persistent HPV-16/18 conferred the highest probability of progression (70%), followed by intermittent HPV-16/18 positivity (52%). In unadjusted and adjusted analyses, baseline and persistent HPV-16/18 were significantly associated with LSIL-to-HSIL progression.

Conclusions

Anal LSIL patients who are positive for hrHPV, especially HPV-16/18, have an increased risk of developing HSIL. Type-specific HPV testing could serve as a risk stratification tool, providing prognostic information.

CHAPTER 7 Methods for detection of HPV infection and its clinical utility

HPVs cannot be cultured and the detection of virus relies on a variety of techniques used in immunology, serology, and molecular biology. Currently the only FDA-approved commercially available method for the detection of HPV DNA is the Hybrid Capture assay, version hc2 (Digene, Gaithersburg, MD, USA) which is able to detect 13 high-risk types of HPV. The advantage of PCR-based methods of HPV DNA detection is that they allow for the identification of different types of HPV. This article discusses the advantages and disadvantages of the different methods of HPV DNA detection. HPV DNA testing can be used in a variety of clinical scenarios that include a primary screening test, particularly in women older than 30 years;as an adjunctive test to cytology;to triage women who have an equivocal cytologic finding, e.g., ASC-US, or for follow up post-treatment. In addition, HPV DNA testing can be performed on samples obtained by women themselves (so-called self-sampling), which may be useful in women who are resistant to undergoing gynecologic examinations.

Persistent HPV infection in postmenopausal age women

OBJECTIVE

Persistence of human papillomavirus (HPV) is associated with an increased risk of developing cervical SIL and cancer in young women. Because this association in older, postmenopausal age women has received little attention, we evaluated persistence of HPV among women in this age group.

METHODS

Women (n=105) ages 45-64 were examined annually for 7 years to evaluate HPV in cervical cytologic specimens. PCR, dot blot hybridization and DNA sequencing were used to detect HPV types.

RESULTS

The cumulative prevalence of HPV was 34%, and 24% had HPV high-risk oncogenic types which are associated with genital cancers. The most common oncogenic types were HPV-16 (72%) and HPV-31 (16%). The persistence rate of HPV infection was 16%. No specific risk factors were associated with repeat viral positivity.

CONCLUSION

Postmenopausal women are infected with persistent oncogenic HPV at a substantial rate, supporting the need for continued screening in postmenopausal women to detect preneoplastic genital lesions.

Daily self-sampling for high-risk human papillomavirus (HR-HPV) testing

BACKGROUND

Self-sampling for HPV as part of primary screening is a well-tolerated method for women not attending organized Pap smear screening and could increase coverage of cervical cancer screening.

OBJECTIVE

To investigate if the prevalence of HR-HPV varies from day to day in infected women and if one single sample is reliable for detecting an ongoing infection.

STUDY DESIGN

This is a prospective cohort study on 12 premenopausal and 13 postmenopausal women performing daily self-sampling for HR-HPV testing. They were all HR-HPV-positive 1-3 months ago. Postmenopausal women were sampled for 28 days and premenopausal women sampled during bleeding-free days in one menstrual cycle. A possible difference in viral load between the estrogen-dominated proliferative phase and the progesterone-dominated secretory phase was analyzed.

RESULTS AND CONCLUSIONS

Consistent results throughout the sampling period were observed for 19 women, with either a daily presence of HPV (14 women) or no HPV at all during the sampling period (5 women). Of 607 samples from 25 women, 596 were consistently positive or negative for HPV during the sampling period and 11 were inconsistent (2%). There was no difference in HPV copy number between the estrogen dominated proliferative or progesterone dominated secretory menstrual cycle phases. The major finding was a high degree of consistency concerning HR-HPV positivity and negativity of HR-HPV in vaginal fluid during a sustained period of daily self-sampling. It does not appear to matter whether the sample is collected in the proliferative or secretory phase.

Menstrual cycle and detectable human papillomavirus in reproductive-age women: a time series study

BACKGROUND

Current evidence on the relationship between human papillomavirus (HPV) DNA detection and menstrual cycle has been inconsistent.

METHODS

We included 21 nonoral contraceptive pill (non-OCP) users who self-collected vaginal samples twice per week for 16 weeks. We explored whether variable detection of HPV DNA exhibited cyclic or other structured temporal patterns. We also evaluated relationships between serial HPV prevalence, sexual behavior, and suspected bacterial vaginosis (BV) as defined by Nugent Gram stain score ≥7.

RESULTS

During follow-up, any-type HPV prevalence varied between 61.1% and 85.0%. Although not statistically significant, we observed a maximum autocorrelation in serial HPV prevalence lagging 14 days (correlation coefficient [ρ], -0.24). Any-type HPV detection had a periodic behavior, generally repeating every 28.0 days (bootstrapped interquartile range, 22.4-28.0) and peaking around the ovulation time (adjusted odds ratio, 1.96; 95% confidence interval [CI], 1.06-3.62) as compared to menstruation. We also showed that an increase in any-type HPV prevalence preceded the beginning of a menstrual cycle by 9-12 days. There was no evidence of relationships between HPV prevalence and sexual activity or Nugent score.

CONCLUSIONS

Serially detected any-type HPV DNA showed a periodic behavior and was likely to peak in the periovulatory phase among non-OCP users.

Cervical human papillomavirus detection is not affected by menstrual phase

OBJECTIVES

In many settings, human papillomavirus (HPV) DNA testing already plays an important role in cervical cancer screening. It is unclear whether hormonal fluctuations associated with menstrual phase or oral contraceptive (OC) use have any effect on HPV detection. We evaluated the effects of OC use and timing of cervical sampling in relation to women's last menstrual period (LMP) on HPV detection, and viral load in the Brazilian Ludwig-McGill cohort study.

METHODS

Women in the cohort were followed every 4-6 months, and at each clinic visit they were asked to complete a questionnaire and to provide a cervical sample for HPV testing. Specimens from 6093 patient visits (n=2209 women) were categorised according to date of LMP into four distinct phases: follicular (days 5-9), midcycle (days 10-15), luteal (days 16-22), or late luteal (days 23-31).

RESULTS

Compared with follicular phase (referent group), HPV detection did not differ according to reported LMP for midcycle (OR=1.14, 95% CI 0.95 to 1.37), luteal (OR=1.03, 95% CI 0.85 to 1.25), or late luteal menstrual phase (OR=1.01, 95% CI 0.83 to 1.24), and was also not influenced by OC use. Analyses restricted to high-risk HPV types (grouped) and HPVs 16 and 18 (separately), produced similar non-significant associations. For HPV-positive samples, we found that the menstrual phase did not influence the total viral load.

CONCLUSIONS

These results indicate HPV detection is not associated with menstrual phase. Our findings suggest that standardising the timing of specimen collection for HPV testing is not necessary.

Risk of cervical precancer and cancer among HIV-infected women with normal cervical cytology and no evidence of oncogenic HPV infection

CONTEXT

US cervical cancer screening guidelines for human immunodeficiency virus (HIV)-uninfected women 30 years or older have recently been revised, increasing the suggested interval between Papanicolaou (Pap) tests from 3 years to 5 years among those with normal cervical cytology (Pap test) results who test negative for oncogenic human papillomavirus (HPV). Whether a 3-year or 5-year screening interval could be used in HIV-infected women who are cytologically normal and oncogenic HPV-negative is unknown.

OBJECTIVE

To determine the risk of cervical precancer or cancer defined cytologically (high-grade squamous intraepithelial lesions or greater [HSIL+]) or histologically (cervical intraepithelial neoplasia 2 or greater [CIN-2+]), as 2 separate end points, in HIV-infected women and HIV-uninfected women who at baseline had a normal Pap test result and were negative for oncogenic HPV.

DESIGN, SETTING, AND PARTICIPANTS

Participants included 420 HIV-infected women and 279 HIV-uninfected women with normal cervical cytology at their enrollment in a multi-institutional US cohort of the Women's Interagency HIV Study, between October 1, 2001, and September 30, 2002, with follow-up through April 30, 2011. Semiannual visits at 6 clinical sites included Pap testing and, if indicated, cervical biopsy. Cervicovaginal lavage specimens from enrollment were tested for HPV DNA using polymerase chain reaction. The primary analysis was truncated at 5 years of follow-up.

MAIN OUTCOME MEASURE

Five-year cumulative incidence of cervical precancer and cancer.

RESULTS

No oncogenic HPV was detected in 369 (88% [95% CI, 84%-91%]) HIV-infected women and 255 (91% [95% CI, 88%-94%]) HIV-uninfected women with normal cervical cytology at enrollment. Among these oncogenic HPV-negative women, 2 cases of HSIL+ were observed; an HIV-uninfected woman and an HIV-infected woman with a CD4 cell count of 500 cells/μL or greater. Histologic data were obtained from 4 of the 6 clinical sites. There were 6 cases of CIN-2+ in 145 HIV-uninfected women (cumulative incidence, 5% [95% CI, 1%-8%]) and 9 cases in 219 HIV-infected women (cumulative incidence, 5% [95% CI, 2%-8%]). This included 1 case of CIN-2+ in 44 oncogenic HPV-negative HIV-infected women with CD4 cell count less than 350 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), 1 case in 47 women with CD4 cell count of 350 to 499 cells/μL (cumulative incidence, 2% [95% CI, 0%-7%]), and 7 cases in 128 women with CD4 cell count of 500 cells/μL or greater (cumulative incidence, 6% [95% CI, 2%-10%]). One HIV-infected and 1 HIV-uninfected woman had CIN-3, but none had cancer.

CONCLUSION

The 5-year cumulative incidence of HSIL+ and CIN-2+ was similar in HIV-infected women and HIV-uninfected women who were cytologically normal and oncogenic HPV-negative at enrollment.

Efficacy of the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine in women aged 15-25 years with and without serological evidence of previous exposure to HPV-16/18

In the Phase III PATRICIA study (NCT00122681), the human papillomavirus (HPV)-16/18 AS04-adjuvanted vaccine (Cervarix(®), GlaxoSmithKline Biologicals) was highly efficacious against HPV-16/18 infections and precancerous lesions in women HPV-16/18 deoxyribose nucleic acid (DNA) negative and seronegative at baseline. We present further data on vaccine efficacy (VE) against HPV-16/18 in the total vaccinated cohort including women who may have been exposed to HPV-16/18 infection before vaccination. In women with no evidence of current or previous HPV-16/18 infection (DNA negative and seronegative), VE was 90.3% (96.1% confidence interval: 87.3-92.6) against 6-month persistent infection (PI), 91.9% (84.6-96.2) against cervical intraepithelial neoplasia (CIN)1+ and 94.6% (86.3-98.4) against CIN2+ [97.7% (91.1-99.8) when using the HPV type assignment algorithm (TAA)]. In women HPV-16/18 DNA negative but with serological evidence of previous HPV-16/18 infection (seropositive), VE was 72.3% (53.0-84.5) against 6-month PI, 67.2% (10.9-89.9) against CIN1+, and 68.8% (-28.3-95.0) against CIN2+ [88.5% (10.8-99.8) when using TAA]. In women with no evidence of current HPV-16/18 infection (DNA negative), regardless of their baseline HPV-16/18 serological status, VE was 88.7% (85.7-91.1) against 6-month PI, 89.1% (81.6-94.0) against CIN1+ and 92.4% (84.0-97.0) against CIN2+ [97.0% (90.6-99.5) when using TAA]. In women who were DNA positive for one vaccine type, the vaccine was efficacious against the other vaccine type. The vaccine did not impact the outcome of HPV-16/18 infections present at the time of vaccination. Vaccination was generally well tolerated regardless of the woman's HPV-16/18 DNA or serological status at entry.

Validation of a low-cost human papillomavirus genotyping assay based on PGMY PCR and reverse blotting hybridization with reusable membranes

The genotyping of human papillomaviruses (HPV) is essential for the surveillance of HPV vaccines. We describe and validate a low-cost PGMY-based PCR assay (PGMY-CHUV) for the genotyping of 31 HPV by reverse blotting hybridization (RBH). Genotype-specific detection limits were 50 to 500 genome equivalents per reaction. RBH was 100% specific and 98.61% sensitive using DNA sequencing as the gold standard (n = 1,024 samples). PGMY-CHUV was compared to the validated and commercially available linear array (Roche) on 200 samples. Both assays identified the same positive (n = 182) and negative samples (n = 18). Seventy-six percent of the positives were fully concordant after restricting the comparison to the 28 genotypes shared by both assays. At the genotypic level, agreement was 83% (285/344 genotype-sample combinations; κ of 0.987 for single infections and 0.853 for multiple infections). Fifty-seven of the 59 discordant cases were associated with multiple infections and with the weakest genotypes within each sample (P < 0.0001). PGMY-CHUV was significantly more sensitive for HPV56 (P = 0.0026) and could unambiguously identify HPV52 in mixed infections. PGMY-CHUV was reproducible on repeat testing (n = 275 samples; 392 genotype-sample combinations; κ of 0.933) involving different reagents lots and different technicians. Discordant results (n = 47) were significantly associated with the weakest genotypes in samples with multiple infections (P < 0.0001). Successful participation in proficiency testing also supported the robustness of this assay. The PGMY-CHUV reagent costs were estimated at $2.40 per sample using the least expensive yet proficient genotyping algorithm that also included quality control. This assay may be used in low-resource laboratories that have sufficient manpower and PCR expertise.

Effect of the menstrual cycle and hormonal contraceptives on human papillomavirus detection in young, unscreened women

OBJECTIVE

To estimate the effect of the menstrual cycle and oral contraceptive pill (OCP) use on the prevalence, incidence, and persistence of human papillomavirus (HPV).

METHODS

A longitudinal study was conducted among 2,065 women aged 18-29 years. The women returned a self-collected cervicovaginal sample and filled out a questionnaire. A total of 1,812 women participated at all three time points, month 0, month 6, and month 12.

RESULTS

Low- and high-risk HPV prevalence at study entry was 8.9% and 11.8%, respectively. The annual incidence of low-risk HPV infections was 12.5% and the persistence was 2.0%. For high-risk HPV, the incidence and persistence was 12.1% and 4.5%, respectively. These results did not differ between OCP users and nonusers. A significant relationship between high-risk HPV detection and the timing of sampling was found when OCP users and nonusers were analyzed separately. In the second half of the menstrual cycle, high-risk HPV detection decreased in nonusers (P=.007) and increased in OCP users (P=.021). When women used OCPs continuously, high-risk HPV detection returned to the level of the first half of the menstrual cycle.

CONCLUSION

High-risk HPV detection was significantly influenced by sample timing in the menstrual cycle when analyzed separately for OCP users and women with a natural menstrual cycle. This may have implications in the future, when high-risk HPV detection may become a primary screening tool in cervical cancer prevention.

LEVEL OF EVIDENCE

II.

Human papillomavirus type 16 variants in paired enrollment and follow-up cervical samples: implications for a proper understanding of type-specific persistent infections

Prospective studies of the persistence of human papillomavirus (HPV) variants are rare and typically small. We sequenced HPV-16 variants in longitudinal pairs of specimens from 86 women enrolled in the ASCUS-LSIL Triage Study. A change of variants was identified in 4 women (4.7% [95% confidence interval, 1.3%-11.5%]). Among women with intervening HPV results (n = 60), a variant switch occurred in 2 of 11 who had evidence of intervening negativity for HPV-16, compared with 1 of 49 who consistently tested positive (P = .11). These results suggest the possibility that rare misclassification of transient infections as persistent infections occurs in natural history studies of type-specific HPV infections.

Relationship of serum antioxidant micronutrients and sociodemographic factors to cervical neoplasia: a case-control study

BACKGROUND

Although there have been some epidemiological studies on the effects of diet and nutritional status on cervical carcinogenesis, evidence for a protective effect of antioxidant micronutrients against cervical neoplasia is insufficient. The relationship between serum antioxidant micronutrients and sociodemographic factors and the risk of cervical neoplasia was investigated in this multi-center, case-control study.

METHODS

The study population included women with histopathological diagnosis of cervical intraepithelial neoplasia (CIN) 1 (n=147), CIN 2/3 (n=177), cervical cancer (n=160), and a control group (n=378). Epidemiological data were collected and the serum concentrations of beta-carotene, lycopene, zeaxanthin plus lutein, retinol, alpha-tocopherol, and gamma-tocopherol were measured using reverse-phase, gradient high-pressure liquid chromatography.

RESULTS

Cervical cancer was found to be associated with older age, increased body mass index, and lower socioeconomic status as measured by education level and income. The mean serum concentrations of beta-carotene, lycopene, zeaxanthin plus lutein, retinol, alpha-tocopherol, and gamma-tocopherol of cervical cancer patients were significantly lower than those of control subjects. Odds ratio adjusted for age, smoking status, alcohol consumption, and human papillomavirus infection status revealed a significant gradient of decreasing risk of CIN 1, CIN 2/3, and cervical cancer with increasing serum concentrations of most antioxidant micronutrients.

CONCLUSIONS

The results of this study show an inverse association between serum antioxidant micronutrient concentrations and the risk of cervical neoplasia. These results suggest that antioxidant micronutrients play a role in the prevention of cervical carcinogenesis.

Age-specific prevalence of infection with human papillomavirus in females: a global review

PURPOSE

Global data on age-specific prevalence of human papillomavirus (HPV) infection overall, and for high-risk HPV types 16 and 18, are essential for the future implementation of HPV prophylactic vaccines for cervical cancer prevention.

METHODS

A systematic review of peer-reviewed publications was conducted to summarize worldwide data on genital HPV-DNA prevalence in women. Studies with clear descriptions of polymerase chain reaction or hybrid capture detection assays were included.

RESULTS

A total of 346,160 women were included in 375 studies. Of 134 studies with age-stratified HPV prevalence data (116 low sexual risk populations, 18 high sexual risk populations), over 50% were from Europe and the Middle East (38%) and North America (19%), with smaller proportions from Asia and Australia (21%), Central and South America (11%), and Africa (10%). Across all geographical regions, data on HPV prevalence were generally limited to women over 18 years of age. Consistently across studies, HPV infection prevalence decreased with increasing age from a peak prevalence in younger women (< or =25 years of age). In middle-aged women (35-50 years), maximum HPV prevalence differed across geographical regions: Africa (approximately 20%), Asia/Australia (approximately 15%), Central and South America (approximately 20%), North America (approximately 20%), Southern Europe/Middle East (approximately 15%), and Northern Europe (approximately 15%). Inconsistent trends in HPV prevalence by age were noted in older women, with a decrease or plateau of HPV prevalence in older ages in most studies, whereas others showed an increase of HPV prevalence in older ages. Similar trends of HPV 16 and/or 18 prevalence by age were noted among 12 populations with available data.

DISCUSSION

Genital HPV infection in women is predominantly acquired in adolescence, and peak prevalence in middle-aged women appears to differ across geographical regions. Worldwide variations in HPV prevalence across age appear to largely reflect differences in sexual behavior across geographical regions. Further studies of HPV prevalence in adolescents are needed for all geographic regions.

Significance and possible causes of false-negative results of reflex human papillomavirus infection testing

BACKGROUND

The objective of this study was to assess the rate and possible reasons for false-negative (FN) reflex human papillomavirus (HPV)-DNA tests.

METHODS

The authors reviewed all ThinPrep cervical specimens that were submitted for reflex HPV-DNA testing using the Digene Hybrid Capture II (HC2) method from January 2002 to January 2004. Follow-up biopsies were reviewed. The results were considered HPV-FN if the HPV-DNA test was negative and the biopsy was positive for grade > or =2 cervical intraepithelial neoplasia (CIN2+), and the results were considered true positive (HPV-TP) if the HPV-DNA test was positive and the biopsy showed CIN2+. HPV-FN cases were compared with HPV-TP cases regarding the grade and extent of CIN, the number of abnormal cells on the original ThinPrep slide, and the presence of amplifiable, viral DNA on biopsy.

RESULTS

In total, 1520 (66%) of 2309 patients who had diagnoses of atypical squamous cells of undetermined significance (ASCUS) were negative for HPV DNA and 789 patients of 2309 patients (34%) were positive for HPV DNA. Three hundred sixteen women (40%) who had a positive HPV-DNA test underwent a biopsy. Of those, 36 biopsies (11%) showed CIN2+ (HPV-TP), and 154 biopsies (66%) showed CIN1. Cervical tissue was available for review from 82 women who had negative HPV-DNA tests; of these, 6 tissue samples (7%) showed CIN2+ (HPV-FN), and 13 tissue samples (16%) showed CIN1. Therefore, in the total ASCUS population that was triaged with reflex HPV testing, there were at least 42 women who were diagnosed with CIN2+, for an estimated CIN2+ FN fraction of 14% (6 of 42 women). HPV-FN lesions were smaller (but the difference was not statistically significant) and shed significantly fewer abnormal cells than HPV-TP cases. Polymerase chain reaction testing for viral DNA in the biopsy was detected in 3 of 6 women who had HPV-FN results; none of those positive results demonstrated a viral type that was not included in the Digene probes.

CONCLUSIONS

Although the rate of FN high-grade lesions was significantly higher than that reported in the ASCUS/Low-grade Squamous Intraepithelial Lesion Triage trial, most missed lesions were small and shed few abnormal cells. It was assumed that those lesions were either in early stages or in regressing stages, which made their clinical significance uncertain.

Comparison of Human Papilloma Virus Testing and Spectroscopy Combined With Cervical Cytology for the Detection of High-grade Cervical Neoplasia

OBJECTIVE

This study compared the performance of cervical cytology plus human papilloma virus testing (Pap + HPV) or cervical spectroscopy (Pap + CS) for identifying high-grade cervical neoplasia in a high-risk population of women referred for colposcopy.

MATERIALS AND METHODS

Each of 113 subjects underwent spectroscopy, thin-layer cytology, HPV testing, colposcopy, biopsy when indicated, and/or endocervical curettage. Evaluable data for analysis were collected for 102 of the subjects. Sensitivity and specificity were calculated for both strategies.

RESULTS

Pap + HPV and Pap + CS achieved equivalent sensitivities (95%) for high-grade lesions, with both detecting 17 of 18 histology confirmed cervical intraepithelial neoplasia (CIN) 2+ lesions. Pap + HPV had a specificity of only 27.4% compared with 65.5% for Pap + CS (p < .0001).

CONCLUSIONS

Spectroscopic interrogation of the cervix is equally sensitive and 2-fold more specific than HPV testing when combined with cervical cytology for identifying high-grade cervical neoplasia.

Alternating high-risk human papillomavirus infection: consequences of progression to cervical intraepithelial neoplasia

BACKGROUND

Nearly every Dutch woman will be exposed to genital human papillomavirus (HPV) at least once during her lifetime, and most likely several times. In the current study, the authors investigated the prevalence of high-risk-HPV (HR-HPV) infection and the likelihood of progression to cervical intraepithelial neoplasia (CIN).

METHODS

In this study, the course of HR-HPV infection in 703 women was observed. From a database of 720,016 negative cytology smears, the authors selected 703 women based on the availability of at least 2 HR-HPV polymerase chain reaction tests. The authors database stores not only the HPV data but also all other cytologic and histologic data, allowing the detection of women who progressed from negative cytology to CIN within a period of 10 years.

RESULTS

Of the 703 selected women, 159 were found to have alternating HR-HPV infection (change from a negative HR-HPV test to a positive test or vice versa), 40 had a persistently positive HR-HPV test, and 504 women had a persistently negative HR-HPV test. The percentage of alternating HPV infection declined over time from 37% to 7%. Of the women age older than 40 years, 17% had an alternating HR-HPV infection, 2 of whom developed CIN. These findings led the authors to conclude that all the women in the current study with an increased risk of developing type 2 or 3 CIN were identified using 2 HPV tests. Women age older than 40 years still have a significant risk of acquiring a HR-HPV.

CONCLUSIONS

In light of the current study findings, the authors believe it is worth considering the inclusion of women age 40 years and older who have negative cytology for HPV testing as part of the Dutch national screening program.

Easy and fast detection and genotyping of high-risk human papillomavirus by dedicated DNA microarrays

Persistent cervical high-risk human papillomavirus (HPV) infection is correlated with an increased risk of developing a high-grade cervical intraepithelial lesion. A two-step method was developed for detection and genotyping of high-risk HPV. DNA was firstly amplified by asymmetrical PCR in the presence of Cy3-labelled primers and dUTP. Labelled DNA was then genotyped using DNA microarray hybridization. The current study evaluated the technical efficacy of laboratory-designed HPV DNA microarrays for high-risk HPV genotyping on 57 malignant and non-malignant cervical smears. The approach was evaluated for a broad range of cytological samples: high-grade squamous intraepithelial lesions (HSIL), low-grade squamous intraepithelial lesions (LSIL) and atypical squamous cells of high-grade (ASC-H). High-risk HPV was also detected in six atypical squamous cells of undetermined significance (ASC-US) samples; among them only one cervical specimen was found uninfected, associated with no histological lesion. The HPV oligonucleotide DNA microarray genotyping detected 36 infections with a single high-risk HPV type and 5 multiple infections with several high-risk types. Taken together, these results demonstrate the sensitivity and specificity of the HPV DNA microarray approach. This approach could improve clinical management of patients with cervical cytological abnormalities.

Performance of cytology and human papillomavirus testing in relation to the menstrual cycle

Cervical smears prepared around the time of menses have been linked to unsatisfactory specimens and false negative results; however, it is unclear whether liquid-based cytology is similarly affected and data relating date of last menstrual period (LMP) to human papillomavirus (HPV) DNA testing are conflicting. Accordingly, we evaluated liquid-based cytology and HPV test results using Hybrid Capture 2 and PCR by LMP (days 0-10; 11-21; 22-28). We studied 5060 participants in ALTS, the Atypical Squamous Cells of Undetermined Significance (ASCUS) Low Grade Squamous Intraepithelial Lesion (LSIL) Triage Study. On average, women had 3.4 examinations (median 4, range 1-5) during a 2-year period of observation permitting an examination of intra-individual variation in cytology and HPV by LMP. Although uncommon, unsatisfactory cytology specimens were most likely on days 0-10. For satisfactory specimens, the frequency with which cytologic categories were reported varied by time since LMP, although differences were modest and did not affect the chance of abnormal cytology or its severity among women diagnosed with CIN2+. The frequency of positive HC2 tests did not vary with date of LMP. Among HPV infected women, independent of eventual diagnosis and the number of viral genotypes present, mid-cycle specimens yielded the highest frequency of LSIL cytologic interpretations and the highest HPV load; however, the magnitude of these effects were small. Intraindividual correlations of cytology or HPV by LMP were generally weak. We conclude that mid-cycle specimens yield slightly higher HPV DNA loads and slightly increased LSIL interpretations, but the clinical impact is marginal. Standardizing collection times would slightly improve interpretation of trends in HPV load. Finally, these data are consistent with the view that the biological properties of the HPV-infected cervix vary with the date of the LMP.

Dynamic behavioural interpretation of cervical intraepithelial neoplasia with molecular biomarkers

The microscopic phenotype of cervical intraepithelial neoplasia (CIN) reflects a fine balance between factors that promote or reduce CIN development. A shortcoming of the current grading system is its reliance on static morphology and microscopic haematoxylin-eosin features of the epithelium alone. In reality, CIN is a dynamic process, and the epithelium may exhibit differing results over time. Functional biomarkers p16, Ki-67, p53, retinoblastoma protein cytokeratin (CK)14 and CK13, help in the assessment of an individual CIN's lesion's potential for progression and regression. The aggregate information provided by these biomarkers exceeds the value of the classic grading system. Consequently, many more CINs that will either regress or progress can be accurately identified. These findings agree with known molecular interactions between HPV and the host. For accurate interpretation of a CIN, it is essential that these biomarkers be determined quantitatively and separately in the superficial, middle and deep layers of the epithelium. Such geography-specific epithelial evaluations of quantitative biomarkers emphasise the dynamic nature of a particular CIN lesion, thereby changing the art of static morphology grading into dynamic interpretation of the diseased tissue, with a strong prognostic effect.

The prevention of cervical cancer in developing countries

Cervical cancer remains the commonest cancer cause of death among women in developing countries, largely due to the failure to establish cytologically based cervical cancer screening programmes. There are many barriers to the establishment of screening programmes in poor countries ranging from limited financial, human and health resources to the complex infrastructural requirements of traditional screening programmes. Alternative approaches to cervical cancer prevention are currently being investigated, including primary prevention with prophylactic vaccines against human papillomavirus to alternative screening tests and protocols. These will be explored in this review.

Molecular diagnosis of human papillomavirus (HPV) infections

Human papillomaviruses (HPVs) comprise more than 100 genotypes. The mucosal types can be divided into high-risk and low-risk (LR) types depending on the associated disease risk. HPV infection is mainly diagnosed by molecular methods, since reliable serological tools are not available and culture of the virus is not possible. Accurate molecular diagnostic techniques that can be used to inform patient management and follow-up after treatment are now available for detection and identification of HPV. The diagnosis of HPV infections in patients at risk of disease in a clinical setting requires a different approach from that used for epidemiological studies, vaccination trials and natural history studies. This review describes the different molecular methods available for HPV detection and genotyping and their possible clinical utility.

The role treatment for cervical intraepithelial neoplasia plays in the disappearance of human papilloma virus

OBJECTIVE

To explore the role played by excision of the transformation zone in women diagnosed with cervical intraepithelial neoplasia (CIN) in the disappearance of human papillomavirus (HPV).

MATERIAL AND METHODS

In a retrospective, cohort study, women with CIN who were treated by loop electrosurgical excision procedure of the transformation zone were compared with another group of women with CIN who were managed expectantly. The decision to treat or manage expectantly was made by one of the authors on clinical grounds. All patients were evaluated with cervical cytologic analysis, pathologic examination of excised tissue, and HPV DNA testing, which was considered positive when high-risk HPV types were detected. Among women treated with loop electrosurgical excision procedure, the median lag time was calculated from diagnosis of CIN to treatment. The median time for conversion from HPV-positive to HPV-negative status in both groups was compared, as well as the 1- and 2-year cure rates (defined as converting to HPV-negative status) in the treated and untreated groups.

RESULTS

In the treated group, 12% had CIN 1, 83% had CIN 2,3, 2% had cancer, and 3% had normal pathologic results. In the untreated group, 82% had CIN 1, 16% had CIN 2,3, and 2% had normal pathologic results (p < 0.0001). The lag time from the initial diagnosis of CIN to treatment was less than 1 month. The median follow-up time was 7 months (range, 1-121 months) in the treated group and 13 months (range, 1-70 months) in the untreated group. The 1-year rates of conversion to HPV-negative status, defined as the cure rates in the treated and untreated groups, were 65% (+/- 6%) and 23% (+/- 7%), respectively, and the 2-year cure rates in the treated and untreated groups were 90% (+/- 4%) and 56% (+/- 11%), respectively (p < 0.0001). Median time to conversion to a negative HPV status was 7.7 months for the treated patients compared with 19.4 months in the untreated patients (p < 0.0001).

CONCLUSIONS

Women treated by loop electrosurgical excision procedure are more likely convert to HPV-negative status at 1 and 2 years and do so significantly sooner than those managed expectantly.

HPV prevalence and concordance in the cervix and oral cavity of pregnant women

OBJECTIVES

This investigation examined human papillomavirus (HPV) in pregnant women in order to characterize viral prevalence, types and concordance between infection in the cervix and in the oral cavity.

METHODS

A total of 577 pregnant women seeking routine obstetric care were evaluated for HPV infection in their cervix during gestation and immediately before delivery, and in the oral cavity during gestation. Male partners present during the gestational clinic visit also provided a specimen from their oral cavity. HPV assessment was performed by PCR, dot blot hybridization and DNA sequencing. A sexual and health questionnaire was completed by the pregnant women.

RESULTS

HPV prevalence in women was 29% in the cervix and 2.4% in the oral cavity. Among those with both gestational and delivery specimens, 35% were infected at least once and 20% had infection at both intervals. At delivery, 68% of infected women had an oncogenic HPV type in the cervix. There was no type-specific HPV concordance between the two cervical specimens, nor cervical and oral results in women, nor with cervical and oral findings between partners.

CONCLUSION

The lack of association in HPV positivity and types between the cervix and oral cavity in these women suggests that self-inoculation is uncommon. This source of infection does not appear to be from oral contact with a current male partner, since there also was no concordance between partners. These results suggest either other modes of HPV transmission or differences in susceptibility to HPV infection or its clearance in the oral cavity and genital mucosa.

Human papillomavirus testing and screening

Cervical cancer is a largely preventable disease through the detection, treatment and follow-up of its precursors. Traditionally, this has been accomplished through screening women with cervical cytology, and referring women with abnormal cytology for colposcopy, histological sampling and treatment. In organized programmes that achieve wide coverage of the target population at frequent intervals, this approach has resulted in a considerable reduction in cervical cancer. Recently, however, the development of reliable and reproducible tests for the detection of human papillomavirus (HPV) infection of the cervix (which is now accepted to be causally associated with the development of almost all cervical cancers) has led to the evaluation of HPV de-oxyribonucleic acid (DNA) testing as either an alternative or adjunctive test to cytology for the detection of cervical cancer and its precursors. There is now a large body of data supporting the clinical utility of HPV DNA testing for the prevention of cervical cancer, particularly in the settings of primary screening of women older than 30 years, in the triage of women with equivocal cytology and for the follow-up of women post-treatment.

Efficacy of a bivalent L1 virus-like particle vaccine in prevention of infection with human papillomavirus types 16 and 18 in young women: a randomised controlled trial

BACKGROUND

Vaccination against the most common oncogenic human papillomavirus (HPV) types, HPV-16 and HPV-18, could prevent development of up to 70% of cervical cancers worldwide. We did a randomised, double-blind, controlled trial to assess the efficacy, safety, and immunogenicity of a bivalent HPV-16/18 L1 virus-like particle vaccine for the prevention of incident and persistent infection with these two virus types, associated cervical cytological abnormalities, and precancerous lesions.

METHODS

We randomised 1113 women between 15-25 years of age to receive three doses of either the vaccine formulated with AS04 adjuvant or placebo on a 0 month, 1 month, and 6 month schedule in North America and Brazil. Women were assessed for HPV infection by cervical cytology and self-obtained cervicovaginal samples for up to 27 months, and for vaccine safety and immunogenicity.

FINDINGS

In the according-to-protocol analyses, vaccine efficacy was 91.6% (95% CI 64.5-98.0) against incident infection and 100% against persistent infection (47.0-100) with HPV-16/18. In the intention-to-treat analyses, vaccine efficacy was 95.1% (63.5-99.3) against persistent cervical infection with HPV-16/18 and 92.9% (70.0-98.3) against cytological abnormalities associated with HPV-16/18 infection. The vaccine was generally safe, well tolerated, and highly immunogenic.

INTERPRETATION

The bivalent HPV vaccine was efficacious in prevention of incident and persistent cervical infections with HPV-16 and HPV-18, and associated cytological abnormalities and lesions. Vaccination against such infections could substantially reduce incidence of cervical cancer.

Cervical HPV infection and neoplasia in a large population-based prospective study: the Manchester cohort

Cytology and histology records and cervical samples for HPV assay were obtained from a prospective cohort of 49 655 women attending clinics for routine cervical cytology in or near Manchester between 1988 and 1993. The women were followed up for cytological abnormality and neoplasia through the cytology laboratory's records. HPV at entry was assayed in an age- and period-stratified random sample of 7278 women and in prevalent and incident CIN3 cases. The prevalence of newly diagnosed CIN3 increased with time since last normal smear, indicating that most cases persist for several years. CIN3 prevalence did not increase further for screening intervals exceeding 5 years, however, suggesting that CIN3 eventually regresses cytologically. CIN2 prevalence increased less steeply with screening interval, while the prevalence of lesser abnormality was almost independent of screening interval. The prevalence of oncogenic HPV at entry declined from 19% among women aged under 25 to less than 3% at age 40 or above. Oncogenic HPV infection was strongly predictive of subsequent CIN3 (OR 17.2, 95% CI 10.4–28.4), but only weakly related to CIN2 (OR 2.3, 95% CI 0.5–10.7) and lesser abnormality (OR 1.4, 95% CI 0.8–2.5). At current incidence rates, the lifetime risk of developing CIN3 will be 9% in this population. The cumulative risk of CIN3 diagnosis among cytologically normal women with oncogenic HPV detected at entry was 28% (CI 18–43%) after 14 years. Persistence of oncogenic HPV may be more sensitive and specific than cytology for early detection of CIN3 and invasive cancer.

Epidemiological and clinical aspects of human papillomavirus detection in the prevention of cervical cancer

Cervical cancer is a major cause of death, and the second most frequent cancer in women worldwide. Many studies have indicated a causal relation between genital human papillomavirus (HPV) infections and cervical cancer. High-risk HPV genotypes have been detected in almost 100% of all cervical cancers, and the process of HPV mediated carcinogenesis has been partly clarified. The concept that HPV is a obligatory cause in cervical cancer development has lead to extensive research regarding the incorporation of HPV detection in (1) cervical cancer prevention programs, (2) triage of women with abnormal cervical scrapes in the screening program, and (3) follow-up of patients treated for cervical intraepithelial neoplasia (CIN). Epidemiological studies indicate that 50% of women becoming sexually active contract a genital HPV infection within 2 years. The lifetime risk of a genital HPV infection is estimated to be 80%, but very few of these women will develop cervical cancer. Several studies have shown that the persistence of genital HPV infections is especially related to the development of cervical cancer. As a result, HPV detection at a single moment was shown to be of limited clinical value in the triage of patients with abnormal cervical scrapes, or during follow-up after treatment for CIN. Furthermore, major variations in the sensitivity of different HPV detection methods, as well as differences in HPV detection related to the menstrual cycle, have shown that many facts regarding HPV transmission, replication, and detection need to be clarified, before HPV detection can be of clinical value.

Persistence and load of high-risk HPV are predictors for development of high-grade cervical lesions: a longitudinal French cohort study

Oncogenic HPV types are the major cause of worldwide cervical cancer, but only a small proportion of infected women will develop high-grade cervical intraepithelial neoplasia or cancer (CIN2/3+). We performed a prospective study including 781 women with normal, atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LGSIL) cytology, and infected or not by high-risk (HR) HPV tested by Hybrid Capture II. Women were followed up every 6 months for a median period of 22 months. Among the HR-HPV-positive women at entry, more than half cleared their virus in 7.5 months; the clearance rate was greater for low viral loads than for high loads and also was higher in women with an initial ASCUS/LGSIL smear than in women with normal cytology. The incidence of cytologic abnormalities strongly depended on baseline viral load and HR-HPV persistence. Maintenance of cytologic abnormalities was associated with the outcome of HR-HPV status (negative<transient<persistent) but not with baseline load. Progression to CIN2/3+ was achieved only in women with persistent HR-HPV infection. The risk of CIN2/3+ also was increased with initial high loads (> or =100 pg/mL). Conversely, women who were consistently HR-HPV negative or transiently HR-HPV positive, whatever the cytology at baseline was, did not develop CIN2/3+ during follow-up. Age seemed to affect only the rate of incident HR-HPV infection. In conclusion, our data suggest that women repeatedly tested positive for HR-HPV are at risk of developing CIN2/3+, even when initial cytology is normal. A high viral load could be used as a short-term marker of progression toward precancerous lesions, although lower load does not inevitably exclude progressive disease.

Folate, vitamin B12, and homocysteine status. findings of no relation between human papillomavirus persistence and cervical dysplasia

OBJECTIVES

Human papillomavirus (HPV) infections are the cause of most, if not all, cervical cancers. Women consistently positive for oncogenic type HPV infections have a greater risk of developing cervical dysplasia compared with women transiently infected. HPV infection alone appears to be insufficient to produce disease, suggesting that other cofactors may be needed. Folate, vitamin B12, and homocysteine, through their role in DNA methylation, may be involved in cervical neoplasia.

METHODS

This study examined the associations between HPV persistence and circulating folate, vitamin B12, and homocysteine levels among 91 low-income Hispanic women. Further, the relation of these nutrients to cervical pathology was evaluated. HPV status was determined at two visits approximately 3 mo apart.

RESULTS

Adjusted mean circulating concentrations of folate, vitamin B12, and homocysteine were not statistically different between women with two positive HPV tests, one positive test, or two negative HPV tests. No association was observed between tertiles of folate, vitamin B12, or homocysteine and HPV persistence risk. Further, adjusted mean levels of these nutrients were not statistically different between cytologic grades.

CONCLUSIONS

Results from this small study did not support a role for folate, vitamin B12, or homocysteine in HPV persistence or cervical dysplasia.

Tampon samplings with longer cervicovaginal cell exposures are equivalent to two consecutive swabs for the detection of high-risk human papillomavirus

BACKGROUND

Self-sampling for human papillomavirus (HPV) is useful for triage of ASCUS Papanicolaou (Pap) smears. Tampons with 10-second cervicovaginal cell exposure can detect HPV but appear to be less efficient than two consecutive swabs.

GOAL

The purpose of this study was to evaluate increased vaginal tampon exposures for detecting high-risk HPV.

STUDY DESIGN

This longitudinal cohort study followed women who self-sampled weekly with tampons for progressively longer periods of time. A tampon was inserted for 10 seconds at the office visit and 1 hour, 4 hours, and overnight for the three subsequent home samples. Two concurrent swabs were used with each tampon sampling for contemporaneous comparisons. The MY09/MY11 PCR primer system with reverse line blot detection strips was used to detect 18 distinct high-risk HPV types.

RESULTS

Of the 309 tampons and 618 swabs used at home, 83% were returned. Among normal women, the 10-second tampon detected fewer with normal histology and high-risk HPV than did its swabs ( = 0.0412), but the 1-hour, 4-hour, and overnight tampons had high-risk-HPV detection rates equal to their swabs. In women with CIN, all tampons and swabs equally identified those with high-risk HPV.

CONCLUSION

Self-sampling for HPV detection is acceptable, feasible, and technically accurate for both tampons with longer cervicovaginal exposures and swabs. The choice of technique is dependent on the woman, her culture, and her clinician.

Fluctuations in prevalence of cervical human papillomavirus in women frequently sampled during a single menstrual cycle

In the last few years much attention has been focused on the implementation of human papillomavirus detection in population based screening programmes to identify women at risk for cervical cancer. Short-term fluctuations in prevalence of human papillomavirus were investigated within a single menstrual cycle. The highest prevalence was found at the follicular phase (55%), whereas the cumulative prevalence was 75%.

Is use of hormone replacement therapy associated with increased detection of human papillomavirus and potential risk of HPV-related genital cancers?

Oral contraceptives (OC) are a risk factor for female genital cancers and in vivo studies have shown that progestins stimulate human papillomavirus (HPV) gene expression. A similar role for hormone replacement therapy (HRT) has received little evaluation. Cervical/vaginal specimens were obtained to detect HPV from postmenopausal women (n = 429) seeking annual gynaecologic care. HPV was detected in 14% of women and 4.4% had high-risk, oncogenic types. HPV prevalence was similar across current, past and never HRT users. After adjustment for HPV-related risk factors, current and past user status showed no increased viral detection compared with never users. HRT duration also did not elevate risk among current users. However, longer duration (adj. OR 1.5/year, 95% CI 1.0-2.3) and longer latency (adj. OR 1.2/year, 95% CI 0.9-1.7) among past users of oestrogen/progestin regimens were associated with greater risk. Overall use of HRTs was not associated with HPV detection or disease. However, past users of combination HRTs had significantly greater risk of HPV detection with longer HRT duration and latency, similar to OC-HPV findings. The recommendation that postmenopausal women continue HRTs long term may lead to an increased development of HPV-related diseases, of particular concern among those who discontinue HRTs and subsequent gynaecologic care for early cancer detection.

Molecular detection and genotyping of human papillomavirus

Human papillomavirus infections are associated with the development of cervical neoplasia. Human papillomavirus is a group of heterogeneous viruses, comprising many genotypes, which can be divided into high-risk and low-risk types, depending on their association with disease. Therefore, accurate molecular diagnostic tools are required for detection and identification of human papillomavirus. Monitoring of human papillomavirus infection is necessary for adequate patient management and follow-up during treatment. This review describes the different molecular methods available for human papillomavirus detection and identification of genotypes.

High-risk HPVs and risk of cervical neoplasia: a nested case-control study

The purpose of this nested case-control study was to estimate the risk of SIL development among a cohort of women providing cervical samples as part of their family planning visit at baseline in 1991-1992. All women had normal cervical cytology (N = 2905) at baseline and provided a cervical sample for subsequent HPV typing. Among this cohort, 426 women developed SIL (22 HSIL and 404 LSIL), 619 developed atypia, and 1860 remained cytologically normal. Two controls per case were sampled from those who remained normal. PCR-based methods with L1 consensus primers were used to assess high-risk HPV positivity. Having an oncogenic HPV type at baseline was associated with an almost fourfold increased risk of HSIL development (relative risk (RR) = 3.8; 95% CI, 1.5--9.0) and a 70% increased risk of LSIL development (RR = 1.7; 95% CI, 1.2--2.3%). The association between HPV positivity and SIL development was strongest in the first year of follow-up (RR = 9.2 for HSIL and 2.5 for LSIL development). The decline in HPV-associated SIL risk may be a function of having only one measure of HPV positivity (at baseline).

The prevalence of genital human papillomavirus infections in abused and nonabused preadolescent girls

OBJECTIVE

To compare the prevalence of genital human papillomavirus (HPV) infections in sexually abused and nonabused preadolescent girls and assess the feasibility of conducting a longitudinal study of the natural history of HPV infection in this population.

METHOD

Consecutively referred, 5- to 12-year-old girls who were evaluated for sexual abuse by a Child Advocacy and Protection Team were invited to participate in the study. During a standard forensic medical examination, 2 specimens for HPV testing were obtained (one by rubbing a Dacron swab over the perineum and the other by lavaging the vagina with phosphate-buffered saline). The specimens were evaluated for HPV DNA by polymerase chain reaction using MY09/11 consensus primers and high-risk (16,18,31,33,35,39,45,51,52, 56,58) and low-risk (6,11,42,43,44) types were detected with a solution hybridization assay, the SHARP Signal System (Digene Diagnostics). The genital area was examined for warts and subclinical, colposcopic evidence of HPV. Participants were invited to return for longitudinal evaluation at 4-month intervals for 2 years.

RESULTS

Sexual abuse was confirmed in 29 (72.5%) of the 40 study participants, suspected in 2 (5%), and ruled out in 9 (22.5%). None of the girls had genital warts or abnormal colposcopic findings. HPV DNA was detected in 5 (16%) of the 31 girls with confirmed or suspected sexual abuse (1 with high-risk and 4 with low-risk types) and none of the nonabused girls (Fisher's exact test). Girls who tested positive and negative for HPV did not differ significantly in age or type of abuse. Despite close telephone follow-up and numerous attempts to schedule appointments, none of the participants returned for follow-up.

CONCLUSIONS

Genital HPV infection is more common among sexually abused than nonsexually abused girls, with the majority of infections not clinically apparent. Because it is so difficult to study the natural history of these infections in abused children, it may be necessary to draw inferences about the long-term sequelae of pediatric HPV infections from longitudinal studies of girls who voluntarily initiate sexual activity soon after menarche.

A population-based five-year follow-up study of cervical human papillomavirus infection

OBJECTIVE

The purpose of this study was to determine the long-term tendency for cervical human papillomavirus infections to persist in the general population.

STUDY DESIGN

From 500 women who participated in a 1991 population-based survey, 90 healthy women with normal results of cytologic examination (women with human papillomavirus deoxyribonucleic acid detected and age-matched control women without human papillomavirus deoxyribonucleic acid detected) were interviewed and examined 5 years later colposcopically, cytologically, and with human papillomavirus serologic testing and human papillomavirus deoxyribonucleic acid testing by polymerase chain reaction with 2 different consensus primer pairs (MY09 and MY11 and GP5(+) and GP6(+)), type-specific polymerase chain reaction, and deoxyribonucleic acid sequencing.

RESULTS

The 5-year human papillomavirus clearance rate was 92%. Only human papillomavirus type 16 infections persisted. Colposcopic impression of grade 2 cervical intraepithelial neoplasia was associated with persistent human papillomavirus 16 infection (P <.03). Human papillomavirus detection was associated with sexual history. Human papillomavirus type was the only determinant of human papillomavirus persistence.

CONCLUSION

The high clearance rates in a population-based setting with a 5-year follow-up period imply that inclusion of human papillomavirus deoxyribonucleic acid testing in population-based cervical screening programs should target persistent infection.

Human papillomavirus DNA testing for cervical cancer screening in low-resource settings

BACKGROUND

In many low-resource settings, there are barriers to cytologic screening for cervical cancer. This study evaluates human papillomavirus (HPV) DNA testing as an alternative screening method.

METHODS

Cervical samples from 2944 previously unscreened South African women aged 35-65 years were tested for high-risk types of HPV with the use of the Hybrid Capture I (HCI) assay. Women also had a Pap smear, direct visual inspection of the cervix, and Cervicography(TM). Women positive on any screening test were referred for colposcopy. Samples from women with biopsy-confirmed, low-grade squamous intraepithelial lesions (SILs) (n = 95), high-grade SILs (n = 74), or invasive cervical cancer (n = 12) and a random sample of women with no cervical disease (n = 243) were retested for HPV DNA with the use of the more sensitive Hybrid Capture II (HCII) assay. All P values are two-sided.

RESULTS

High-risk HPV DNA was detected in 73.3% and 88.4% of 86 women with high-grade SIL or invasive cancer and in 12.2% of 2680 and 18.1% of 243 women without evidence of cervical disease, with the use of the HCI and HCII assays, respectively. HPV DNA testing with the HCII assay was more sensitive than cytology for detecting high-grade SIL and invasive cancer (McNemar's test, P =.04), and testing with the HCI assay was of equivalent sensitivity (P =.61). Cytology had a statistically significantly better specificity (96.8%) than either the HCI assay (87.8%) or the HCII assay (81.9%) (P<.01). Receiver operating characteristic curves identified test cutoff values that allow HPV DNA testing to identify 57% of women with high-grade SIL or cancer, while classifying less than 5% of women with no cervical disease as HPV DNA positive.

CONCLUSIONS

HPV DNA testing has a sensitivity equivalent to, or better than, that of cytology. Since HPV DNA testing programs may be easier to implement than cytologic screening, HPV testing should be considered for primary cervical cancer screening in low-resource settings.

Papillomavirus detection: demographic and behavioral characteristics influencing the identification of cervical disease

OBJECTIVE

This study was undertaken to assess the association between detection of high-risk types of human papillomavirus and various demographic and behavioral characteristics and to further relate this association to cervical histopathologic findings.

STUDY DESIGN

A total of 1007 patients with a Papanicolaou test result reported as high-grade squamous intraepithelial lesion or with 2 results reported as atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion were referred from city and county clinics to a colposcopic clinic. All women had a cervical smear obtained, underwent colposcopically directed biopsy and endocervical curettage, and had a specimen taken for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction. Demographic information was obtained from each patient.

RESULTS

Human papillomavirus deoxyribonucleic acid was identified in 655 (66%) of the specimens. High-risk human papillomavirus types (16, 18, 31, 33, and 35) were detected in 463 (70.7%) of these specimens. The prevalence of evidence of human papillomavirus (koilocytosis) and grade 1 cervical intraepithelial neoplasia in the biopsy specimen decreased significantly with age, whereas the prevalence of grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen increased with age. There was a significant age-dependent decreasing trend in detection of high-risk human papillomavirus deoxyribonucleic acid among women who had human papillomavirus-associated changes, grade 1 cervical intraepithelial neoplasia, and grade 2 or 3 cervical intraepithelial neoplasia in the biopsy specimen. The prevalences of high-risk human papillomavirus among patients with grade 1 cervical intraepithelial neoplasia and grade 2 or 3 cervical intraepithelial neoplasia were similar, and both were significantly higher than among women with no evidence of cervical intraepithelial neoplasia or koilocytosis in the biopsy specimen. Risk factors associated with grade 2 or 3 cervical intraepithelial neoplasia were different from those associated with human papillomavirus-associated changes and with grade 1 cervical intraepithelial neoplasia.

CONCLUSION

The detection of high-risk human papillomavirus was age-dependent for all histologic categories. Patients with grade 2 or 3 cervical intraepithelial neoplasia had a prevalence of high-risk human papillomavirus that was similar to that among women with grade 1 cervical intraepithelial neoplasia but significantly higher than that among women whose biopsy specimens appeared normal or demonstrated only the presence of human papillomavirus-induced changes (koilocytosis). This suggests that separation of human papillomavirus-associated changes only from grade 1 cervical intraepithelial neoplasia may be of significance in tissue diagnosis.

Synthesis of IFN-gamma by CD8(+) T cells is preserved in HIV-infected women with HPV-related cervical squamous intraepithelial lesions

OBJECTIVE

The aim of this study was to investigate whether coinfection with HIV affects the synthesis of Th1 and Th2 cytokines by peripheral blood T cells of women infected with human papillomavirus (HPV).

METHODS

Cervical swabs and peripheral blood were obtained from women referred for colposcopy. HPV DNA by Digene's hybrid capture assay, HIV RNA by Roche's Amplicor assay, and cytokine synthesis of T-cell subsets by flow cytometry were assessed. HPV-associated cervical and HIV-associated immune deficiency diseases were staged using the Bethesda System and the Centers for Disease Control criteria, respectively.

RESULTS

Patients with HIV and/or HPV infections had lower percentages of IL-2(+) and higher percentages of IL-10(+) T cells than healthy women. Furthermore, women with both virus infections (HIV(+)/HPV(+)) had significantly fewer IL-2(+) CD4(+), IFN-gamma(+) CD4(+), and TNF-alpha(+) CD4(+) T cells than women with HPV infection alone (HPV(+)). Whereas HIV(+) and healthy women had similar numbers of IFN-gamma(+) CD8(+) T cells, HPV(+) women had significantly fewer IFN-gamma(+) CD8(+) T cells than healthy women.

CONCLUSION

HIV infection adversely affects the synthesis of Th1 cytokines by CD4(+), but not IFN-gamma synthesis by CD8(+) T cells of women with active HPV infection. The increase in IFNgamma(+) CD8(+) T cells, a phenotype consistent with cytotoxic T lymphocytes, may account for the stable HIV disease of the women studied. However, the increase in IFN-gamma(+) CD8(+) T cells is less likely to be HPV-specific as there was a higher incidence of HPV-related cervical SIL in HIV(+)/HPV(+) women compared with HPV(+) women.

Genital human papillomavirus infection among women recruited for routine cervical cancer screening or for colposcopy determined by Hybrid Capture II and polymerase chain reaction

The purpose of this study was to evaluate the clinical use of the Hybrid Capture (HC)-II system for the detection of human papillomavirus (HPV) DNA to identify women at risk of progression to high grade squamous intraepithelial lesions (HGSIL) and carcinomas by differentiating low risk (LR) HPV types (6, 11, 42, 43, 44) and high/intermediate risk (HR) HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68). Five hundred and ninety-six women were enrolled in the study. Among them, 466 attended the hospital for routine cytologic screening and 130 were referred for colposcopy because of an abnormal Pap smear. The presence of HPV DNA was tested in cervical samples collected with the Digene Cervical Sampler in Digene Specimen Transport Medium (Digene Corporation, Silver Spring, MD, U.S.A.) using the HC-II assay. Results were compared with those obtained by polymerase chain reaction (PCR) using the MY09-MY11 primers followed by several hybridizations with specific probes. The overall HPV positivity was 32.9% by HC-II and 37.8% by PCR. Among cytologically normal smears, 19.5% were positive by HC-II (14.3% HR) and 25.1% by PCR. Of the atypical squamous cells of undetermined significance samples, 52.9% were positive by HC-II (41.1% HR) and 55.9% by PCR. Of the low grade SIL, 64.5% were positive by HC-II (59.4% HR) and 68.7% by PCR. The HPV positivity rate was found identical by both techniques in high grade smears (81.6%) and squamous cervical carcinomas (100%). By using PCR as the reference method, the sensitivity of HC-II was higher among women with abnormal cytology than with normal cytology (87.3% vs. 70%). Specificity was 80.8% and 97.5%, respectively. In summary, these results indicate that the HC-II method and MY-PCR identified nearly equivalent prevalences of HPV in cervical smear specimens.

Epidemiology of genital human papillomavirus

Genital human papillomavirus (HPV) infection is the most common sexually transmitted viral infection and the major risk factor for cervical neoplasia worldwide; however, little is still known about the epidemiology and natural history of the disease. Prospective cohort studies currently being conducted will increase our knowledge and understanding of these issues and provide critical information for the formulation of future primary and secondary prevention strategies.

Is human papillomavirus testing an effective triage method for detection of high-grade (grade 2 or 3) cervical intraepithelial neoplasia?

OBJECTIVE

Our purpose was to assess the usefulness of the polymerase chain reaction assay for detection of human papillomavirus infection for prognostic value in the triage strategies for high-grade (grade 2 or 3) cervical intraepithelial neoplasia in women referred for colposcopy after abnormal Papanicolaou smears.

STUDY DESIGN

A total of 1007 women referred to a colposcopic clinic providing care for an indigent population were studied. Four hundred fifty-four women were referred after two Papanicolaou smears reported as atypical squamous cells of undetermined significance or low grade-squamous cervical intraepithelial lesion, and 553 were referred after a single smear reported as high-grade squamous intraepithelial lesion. All women had a cervical smear, colposcopy-directed biopsy, and endocervical curettage performed. A sample for human papillomavirus deoxyribonucleic acid detection by polymerase chain reaction was obtained.

RESULTS

High-risk human papillomavirus types were detected in 463 (46%) of 1007 women studied. There was a significant increase of the frequency of high-risk human papillomavirus by the increasing severity of biopsy findings ranging from 32.7% in women without cervical intraepithelial neoplasia on biopsy to 60% in women having grade 2 or 3 on the biopsy specimen. Women having a negative Papanicolaou smear found to have high-risk human papillomavirus deoxyribonucleic acid at the time of colposcopy had a significantly higher rate of grade 2 or 3 cervical intraepithelial neoplasia on the biopsy specimen than did women without high-risk human papillomavirus. There was no such difference observed in women with a cytologic finding of low- or high-grade squamous intraepithelial lesions at the time of colposcopy. The polymerase chain reaction assay appears to be more sensitive than the commercial human papillomavirus profile test. The positive predictive value for grade 2 or 3 cervical intraepithelial neoplasia of both tests was similar (21.7% and 22.8%, respectively).

CONCLUSION

The human papillomavirus is associated with high-grade cervical intraepithelial neoplasia, but the screening for human papillomavirus deoxyribonucleic acid does not have prognostic value in women reported as having atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions on two precolposcopy Papanicolaou smears.

A longitudinal study of human papillomavirus carriage in human immunodeficiency virus-infected and human immunodeficiency virus-uninfected women

OBJECTIVE

We sought to determine the relationship of human immunodeficiency virus serostatus to carriage of oncogenic human papillomavirus.

MATERIAL AND METHODS

A total of 268 human immunodeficiency virus-infected and 265 human immunodeficiency virus-uninfected women were seen every 6 months, at which time they had laboratory tests performed including a CD4 count. Human papillomavirus deoxyribonucleic acid was analyzed by polymerase chain reaction. Statistical methods included Kaplan-Meier and Cox's proportional hazard models.

RESULTS

The prevalence at baseline of any human papillomavirus type was 73% and 43% among human immunodeficiency virus-seropositive and seronegative women, respectively (p < 0.0001) and of oncogenic types was 32.5% and 17.0% (p < 0.001). The prevalence of oncogenic human papillomavirus was higher in women with CD4 counts <200 mm3 (p < 0.001). The rate of detection of new oncogenic human papillomavirus per 100 patient years of follow-up in human immunodeficiency virus-seropositive women was almost three times higher than among human immunodeficiency virus-seronegative women (p < 0.01). The rate of loss of an oncogenic human papillomavirus was higher in the human immunodeficiency virus-seronegative women but the difference was not significant. The relative risk of a human immunodeficiency virus-infected woman who did not initially have a specific type of oncogenic human papillomavirus having one detected during follow-up was 6.6 times greater than among human immunodeficiency virus-negative women (p < 0.001).

CONCLUSIONS

Human immunodeficiency virus-seropositive women are more likely to have newly detectable oncogenic types of human papillomavirus at follow-up and to show persistent carriage of oncogenic types of human papillomavirus types. Among human immunodeficiency virus-infected women, those with higher CD4 counts were more likely to have a newly detected oncogenic human papillomavirus during follow-up.