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Zhang J, Sun Y, Chen X, Ye Y, Shen W, Ye X, Lin Y, Lin Z, Tan S, Gao M, Ding Y, He N, Lin H, Liu X. Incidence, clearance, and factors associated with anal human papilloma virus infection among men with HIV. AIDS 2024; 38:9-20. [PMID: 37861684 DOI: 10.1097/qad.0000000000003755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
OBJECTIVES This study aims to estimate the incidence and persistence/clearance of anal human papilloma virus (HPV) infection and related factors among men with HIV in Taizhou, China. DESIGN A prospective cohort study. METHODS Men with HIV were recruited and followed up from 2016 to 2021. Questionnaire surveys were used to collect social-demographic and behavioral characteristics, and anal swabs were collected for HPV Genotyping. RESULTS A total of 675 men with HIV were recruited and followed up. After an average follow-up time of 1.75 years, HPV39 (3.8/100 person-years), HPV52 (3.6/100 person-years), HPV51 (3.1/100 person-years), HPV58 (2.5/100 person-years) and HPV16 (2.4 cases/100 person-years) in the high-risk types showed the highest incidence rate. In marriage with woman [adjusted hazard ratio (aHR) = 0.44, 95% confidence interval (CI) 0.20-0.99] showed an inverse association with HPV incidence, while bisexuality or undetermined sexual orientation (aHR = 2.62, 95% CI 1.08-6.36) showed a positive association. For those infected at baseline, the top three high-risk HPV with the lowest clearance density were HPV52 (32.2/100 person-years), HPV58 (38.1/100 person-years), and HPV16 (43.5/100 person-years). Daily consumption of 1-28 g alcohol (aHR = 0.62, 95% CI 0.41-0.95) showed an inverse association with HPV clearance, while illicit drug use (aHR = 3.24, 95% CI 1.59-6.59) showed a positive association. CONCLUSION Anal HPV infection and clearance were both active in men with HIV in China. Marriage status and sexuality were associated with the incidence of HPV infection, while substance use including alcohol and illicit drug were associated with HPV clearance. More studies are needed to explore the risk factors of HPV persistence.
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Affiliation(s)
- Jing Zhang
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
- Xuhui District Center for Disease Control and Prevention, Shanghai
| | - Yu Sun
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
| | - Xiaoxiao Chen
- Taizhou City Center for Disease Control and Prevention
| | - Yiwen Ye
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
| | - Weiwei Shen
- Taizhou City Center for Disease Control and Prevention
| | - Xiaohong Ye
- Linhai District Center for Disease Control and Prevention
| | - Yajun Lin
- Sanmen District Center for Disease Control and Prevention
| | - Zhebin Lin
- Wenlin District Center for Disease Control and Prevention
| | - Shigang Tan
- Huangyan District Center for Disease Control and Prevention, Zhejiang Province, China
| | - Meiyang Gao
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
| | - Yingying Ding
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
| | - Na He
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
| | - Haijiang Lin
- Taizhou City Center for Disease Control and Prevention
| | - Xing Liu
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University
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Human Papillomavirus Genotypes Infecting the Anal Canal and Cervix in HIV+ Men and Women, Anal Cytology, and Risk Factors for Anal Infection. Pathogens 2023; 12:pathogens12020252. [PMID: 36839524 PMCID: PMC9963202 DOI: 10.3390/pathogens12020252] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/08/2023] Open
Abstract
The incidence of anal intraepithelial neoplasias associated with HPV is rising worldwide. In the general population, this pathology is rare, but individuals living with HIV/AIDS are at a significantly higher risk. We aimed to study HPV infection and performed cytological screening to study the epidemiological and behavioral determinants in a group of men and women living with HIV from a region in Mexico with high HIV incidence. This was a cross-sectional study including adults living with HIV/AIDS performed in Merida (Mexico). We invited patients of public HIV/STD clinics and those affiliated with social organizations of people living with HIV to participate in the study. Participants responded to an instrument to assess their risky behaviors and clinical history. Swabs from the anal canal and cervix and anal cytology specimens were obtained by medical staff from women and by self-sampling from men. For the 200 participants, 169 men and 31 women, anal HPV PCR tests resulted in 59.8% positivity (62.6% of men and 45.2% of women), and 17 genotypes were identified. The most frequent high-risk (HR) types for the anal canal were: HPV33 (35.3%), HPV58 (20.6%), HPV66 (18.6%), HPV45 (17.6%), and HPV16 (14.7%). Multiple genotypes were found in over 80% of the participants. Receptive anal intercourse in the previous 12 months, inconsistent condom use, and detectable HIV titers (≥50 cc/mL) were associated with HPV infection (p < 0.05). Cytology (smears and liquid-based) identified that 34.6% of the participants had low-grade squamous intraepithelial lesions (LSILs), and 3.5% had high-grade squamous intraepithelial lesions (HSILs). Neither HPV nor lesions were associated with low CD4+ counts (<200 cells/mm3, p > 0.05). Of the women, 60% were infected in the cervix and 45% in the anal canal, with an agreement of at least one genotype in 90%. The HR-HPV types associated with HSILs were HPV66, 33, 52, 51, 45, 18, and 68.
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Zhang J, Chen X, Ye Y, Shen W, Ye X, Lin Y, Lin Z, Tan S, Gao M, Ding Y, Lin H, Wang Y, He N, Liu X. Increased CD4 + T cell count is associated with lower anal human papillomavirus prevalence among HIV-positive male cohort in Taizhou, China: a cross-sectional study. BMC Infect Dis 2022; 22:250. [PMID: 35287600 PMCID: PMC8919533 DOI: 10.1186/s12879-022-07251-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 03/07/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives This study aims to investigate the association between CD4+ T cell count and combined antiretroviral therapy (cART) with the prevalence of anal human papillomavirus (HPV) infection among HIV-positive male cohort in China. Methods A survey was conducted in men from a HIV cohort in Taizhou, China between 2016 and 2019. A face-to-face questionnaire interview was administered, and an anal-canal swab was collected for HPV genotyping. Results A total of 766 HIV-positive men were recruited. The HPV prevalence was lower among those with increased CD4+ T cell count than those with decreased or unchanged (46.5 vs. 56.6%, p = 0.033) from baseline. In multivariable models, having the current CD4+ T cell count of 350–499 cells/µL (aOR 0.28, 95% CI 0.13–0.64), and of ≥ 500 cells/µL (aOR 0.26, 95% CI 0.11–0.60) were associated with lower prevalence of any type HPV infection compared with those with < 200 cells/µL. Having taken NVP + 3TC + AZT was inversely associated with any high-risk (HR)-HPV (aOR 0.47, 95% CI 0.25–0.90) and any low-risk (LR)-HPV infection (aOR 0.40, 95% CI 0.18–0.88), compared with those taking EFV + 3TC + TDF. Conclusions Increased CD4+ T cell count at follow-up was significantly associated with lower prevalence of anal HPV infection. Inverse associations between NVP + 3TC + AZT and HR-HPV or LR-HPV infecton were observed.
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Affiliation(s)
- Jing Zhang
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Xiaoxiao Chen
- Taizhou City Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Yiwen Ye
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Weiwei Shen
- Taizhou City Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Xiaohong Ye
- Linhai District Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Yajun Lin
- Sanmen District Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Zhebin Lin
- Wenling District Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Shigang Tan
- Huangyan District Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Meiyang Gao
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Yingying Ding
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Haijiang Lin
- Taizhou City Center for Disease Control and Prevention, Taizhou, Zhejiang, China
| | - Youyi Wang
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Na He
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Xing Liu
- Department of Epidemiology, School of Public Health, and the Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China.
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Mondatore D, Bai F, Augello M, Giovenzana M, Pisani Ceretti A, Bono V, Opocher E, d’Arminio Monforte A, Marchetti GC, Tincati C. Persistence of High Peripheral Activated CD8+ T-cells and Not a Low CD4:CD8 Ratio Predict cytologic HPV-Related Dysplasia in cART-Treated, HIV-Positive Subjects. Open Forum Infect Dis 2022; 9:ofac046. [PMID: 35291446 PMCID: PMC8918388 DOI: 10.1093/ofid/ofac046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 01/27/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
People with HIV are at increased risk of HPV-disease progression, given the persistence of immune activation and residual inflammation despite effective cART. Whether a low CD4:CD8 T-cell ratio, known to mirror peripheral immune dysfunction, associates with Squamous Intraepithelial Lesions (SIL) is unknown.
Methods
Retrospective cohort study on cART-treated HIV-positive subjects undergoing screening for HPV-related dysplasia (anal/cervical cytology and HPV genotyping). SIL was defined as the presence of either atypical squamous cells of undetermined significance (ASCUS), Low-grade SIL or High-grade SIL. Demographic and viro-immunological parameters (T-cell count, CD4:CD8 T-cell ratio, CD8+CD38+ T-cells percentage) at the time of screening were analyzed by Chi square, Mann Whitney test and multivariate logistic regression analysis.
Results
419 cART-treated subjects were included. Half of the patients had cervical/anal SIL. Individuals with SIL were more commonly males, MSM, co-infected with Treponema pallidum, treated with Integrase Inhibitors (INSTI)-based cART regimens and with a shorter time since HIV diagnosis and cART initiation than subjects with normal cytology. CD38+CD8+ T-cells percentage, but not the CD4:CD8 T-cell ratio, correlated with SIL. HPV infection, especially with multiple and high-risk genotypes, was confirmed associated with SIL. In multivariate analysis, the only factors independently associated with cervical/anal dysplasia were HPV infection and harbouring higher percentages of peripheral activated CD38+CD8+ T-cells.
Conclusions
HPV infection is the major driver of dysplasia in the setting of HIV infection. CD8+CD38+ T-cells also resulted an independent predictor of dysplasia in cART-treated subjects, while the CD4:CD8 T-cell ratio did not. In the setting of HIV-HPV co-infection, the CD4:CD8 T-cell ratio may not fully capture the alterations of HPV-specific immunity.
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Affiliation(s)
- D Mondatore
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - F Bai
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - M Augello
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - M Giovenzana
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - A Pisani Ceretti
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - V Bono
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - E Opocher
- Department of Health Sciences, Hepato-biliopancreatic and Digestive Surgery, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - A d’Arminio Monforte
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - G C Marchetti
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
| | - C Tincati
- Department of Health Sciences, Clinic of Infectious Diseases, ASST Santi Paolo e Carlo, University of Milan, Italy
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5
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Wong IKJ, Poynten IM, Cornall A, Templeton DJ, Molano M, Garland SM, Fairley CK, Law C, Hillman RJ, Polizzotto MN, Grulich AE, Jin F. Sexual behaviours associated with incident high-risk anal human papillomavirus among gay and bisexual men. Sex Transm Infect 2021; 98:101-107. [PMID: 33727339 PMCID: PMC8862078 DOI: 10.1136/sextrans-2020-054851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/18/2021] [Accepted: 02/24/2021] [Indexed: 02/03/2023] Open
Abstract
Objective High-risk human papillomavirus (HRHPV) causes anal cancer, which disproportionately affects gay and bisexual men (GBM). We examined sexual behaviours associated with incident anal HRHPV in an observational cohort study of GBM in Sydney, Australia. Methods GBM aged 35 years and above were enrolled in the Study of the Prevention of Anal Cancer. Detailed information on sexual practices in the last 6 months, including receptive anal intercourse (RAI) and non-intercourse receptive anal practices, was collected. Anal human papillomavirus (HPV) testing was performed at the baseline and three annual follow-up visits. Risk factors for incident HRHPV were determined by Cox regression using the Wei-Lin-Weissfeld method. Results Between 2010 and 2015, 617 men were recruited and 525 who had valid HPV results at baseline and at least one follow-up visit were included in the analysis. The median age was 49 years (IQR 43–56) and 188 (35.8%) were HIV-positive. On univariable analysis, incident anal HRHPV was associated with being HIV-positive (p<0.001), having a higher number of recent RAI partners regardless of condom use (p<0.001 for both), preference for the receptive position during anal intercourse (p=0.014) and other non-intercourse receptive anal sexual practices, including rimming, fingering and receptive use of sex toys (p<0.05 for all). In multivariable analyses, being HIV-positive (HR 1.46, 95% CI 1.09 to 1.85, p=0.009) and reporting condom-protected RAI with a higher number of sexual partners (p<0.001) remained significantly associated with incident HRHPV. When stratified by recent RAI, non-intercourse receptive anal practices were not associated with incident HRHPV in men who reported no recent RAI. Conclusion GBM living with HIV and those who reported RAI were at increased of incident anal HRHPV. Given the substantial risk of anal cancer and the difficulty in mitigating the risk of acquiring anal HRHPV, HPV vaccination should be considered among sexually active older GBM. Trial registration number ANZCTR365383.
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Affiliation(s)
- Ian K J Wong
- The Kirby Insitute, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Alyssa Cornall
- Department of Obstetrics and Gynaecology, University of Melbourne, Infection & Immunity, The Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Women's Infectious Disease, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - David J Templeton
- The Kirby Insitute, UNSW Sydney, Sydney, New South Wales, Australia.,Department of Sexual Health and Sexual Assault Medicine, Sydney Local Health District, Camperdown, New South Wales, Australia.,Discipline of Medicine, Central Clincal School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Monica Molano
- Centre for Women's Infectious Disease, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Suzanne M Garland
- Department of Obstetrics and Gynaecology, University of Melbourne, Infection & Immunity, The Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.,Centre for Women's Infectious Disease, The Royal Women's Hospital, Melbourne, Victoria, Australia
| | | | - Carmella Law
- HIV and Immunology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Richard J Hillman
- HIV and Immunology, St Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Andrew E Grulich
- The Kirby Insitute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Fengyi Jin
- The Kirby Insitute, UNSW Sydney, Sydney, New South Wales, Australia
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Farahmand M, Monavari SH, Tavakoli A. Prevalence and genotype distribution of human papillomavirus infection in different anatomical sites among men who have sex with men: A systematic review and meta-analysis. Rev Med Virol 2021; 31:e2219. [PMID: 33527636 DOI: 10.1002/rmv.2219] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 01/12/2021] [Indexed: 12/15/2022]
Abstract
Men who have sex with men (MSM) are at increased risk of human papillomavirus (HPV) infection because of their high-risk sexual behaviours. In this study, a meta-analytic approach was used to systematically analyse the literature to elucidate the prevalence and genotype distribution of anal, penile, oral and urethral HPV infection among MSM in the world. To carry out this systematic review, five electronic databases including Web of Science, PubMed, Scopus, Embase, and Google Scholar were searched for relevant studies published from January 2012 to November 2019, and pertinent data were collected from the eligible articles. The pooled HPV prevalence was calculated for each anatomical region using a random-effect model weighted by the inverse variance method. The meta-analysis was performed using the "Metaprop" function in the R package Meta. The overall pooled prevalence of anal, penile, oral and urethral HPV infection among MSM were 78.4% (95% confidence interval [CI]: 75.6%-81.0%), 36.2% (95% CI: 29.1%-44.0%), 17.3% (95% CI: 13.6%-21.7%) and 15.4% (95% CI: 7.8%-27.9%), respectively. Stratified analyses showed that the prevalences of HPV were significantly higher in HIV-positive than HIV-negative MSM. The most frequent HPV high-risk type detected in the anus, penis and oral cavity was HPV-16 (19.9%, 4.9% and 3.1%, respectively). HPV infection is rising in MSM because of high-risk sexual behaviours, suggesting an increased future risk of developing HPV-related diseases and malignancies in this population.
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Affiliation(s)
- Mohammad Farahmand
- Department of Virology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Hamidreza Monavari
- Department of Medical Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Ahmad Tavakoli
- Department of Medical Virology, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran.,Research Center of Pediatric Infectious Diseases, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran
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Prevalence and genotypes of anal human papillomavirus infection among HIV-positive vs. HIV-negative men in Taizhou, China. Epidemiol Infect 2020; 147:e117. [PMID: 30868975 PMCID: PMC6518779 DOI: 10.1017/s0950268818003205] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This study aims to investigate the prevalence and genotype distribution of anal human papillomavirus (HPV) infection among men with different sexual orientations with or without human immunodeficiency virus (HIV) in China. A cross-sectional study was conducted during 2016-2017 in Taizhou City, Zhejiang Province. Convenient sampling was used to recruit male participants from HIV voluntary counselling and testing clinics and Center for Disease Control and Prevention. A face-to-face questionnaire interview was administered and an anal-canal swab was collected for HPV genotyping. A total of 160 HIV-positive and 113 HIV-negative men participated in the study. The prevalence of any type HPV was 30.6% for heterosexual men, 74.1% for homosexual and 63.6% for bisexual men among HIV-positive participants, while the prevalence was 8.3%, 29.2% and 23.8% respectively among HIV-negatives. The most prevalent genotypes were HPV-58 (16.9%), HPV-6 (15.6%) and HPV-11 (15.0%) among HIV-positive men, and were HPV-16 (4.4%), HPV-52 (4.4%) and HPV-6 (3.5%) among HIV-negative men. Having ever had haemorrhoids and having ever seen blood on tissue after defaecation was associated with HPV infection. One-fourth of the HPV infections in this study population can be covered by the quadrivalent vaccine in market. The highly prevalent anal HPV infection among men especially HIV-infected men calls for close observation and further investigation for anal cancer prevention.
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8
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Kelly H, Chikandiwa A, Alemany Vilches L, Palefsky JM, de Sanjose S, Mayaud P. Association of antiretroviral therapy with anal high-risk human papillomavirus, anal intraepithelial neoplasia, and anal cancer in people living with HIV: a systematic review and meta-analysis. Lancet HIV 2020; 7:e262-e278. [PMID: 32109408 DOI: 10.1016/s2352-3018(19)30434-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effect of antiretroviral therapy (ART) on the natural history of anal high-risk HPV and anal lesion progression is not well established. We reviewed the association of ART and other HIV-related factors on anal HPV infection, anal intraepithelial neoplasia (AIN), and anal cancer among people living with HIV. METHODS For this systematic review and meta-analysis, we searched MEDLINE and EMBASE for studies published between Jan 1, 1996, and Oct 30, 2019, that reported the association of HIV-related exposures (ART or highly active ART [HAART], HIV-RNA plasma viral load [PVL], and nadir or current CD4 cell count) with outcomes of anal high-risk HPV prevalence, incidence, and persistence; prevalence, incidence, progression, or regression of anal histological and cytological abnormalities; and anal cancer incidence. Effect estimates were extracted whenever available; otherwise, they were calculated from raw data. We assessed the risk of bias of included studies using the Newcastle-Ottawa scale, and random-effects meta-analyses were done to examine heterogeneity using the I2 statistic. This study is registered on the PROSPERO database, CRD42018007271. FINDINGS We identified 6777 studies, of which 5377 were excluded before full-text review. 122 studies providing estimates for 130 distinct populations matched the inclusion criteria. The populations comprised 417 006 people living with HIV (women, men who have sex with men, and men who have sex with women). 41 (32%) population estimates were not stratified by sex or sexual orientation. People living with HIV receiving ART had 35% lower high-risk HPV prevalence than ART-naive people (crude odds ratio [OR] 0·65, 95% CI 0·54-0·79; I2 12·1%, p=0·31) in 18 studies, and prolonged ART use was associated with a 10% reduction per year in high-risk HPV prevalence in two studies (adjusted OR 0·90, 0·85-0·95; I2 0%, p=0·88). People living with HIV with undetectable PVL had lower HSIL-AIN2+ prevalence than those with detectable PVL (crude OR 0·84, 0·72-0·98; I2 0%, p=0·80) in 16 studies, particularly if sustained for more than 1 year (crude OR 0·62, 0·47-0·81; I2 0%, p=0·51). ART was not associated with anal cancer incidence when adjusted for years living with HIV in three studies (adjusted hazard ratio [HR] 1·11, 95% CI 0·68-1·80; I2 0%, p=0·57), but ART users with sustained undetectable HIV PVL had 44% lower risk of anal cancer than those without (adjusted HR 0·56, 0·44-0·70; I2 0%, p=0·94) and for each increase in nadir CD4 cell counts of 100 cells per μL, there was a 40% decrease in anal cancer incidence (crude HR 0·60, 0·46-0·78; I2 21·7%, p=0·26). INTERPRETATION Effective ART use and early initiation at high nadir CD4 counts might reduce anal high-risk HPV infection and anal cancer risk. Although most studies were cross-sectional in design and few adjusted for potential confounders, this analysis provides comprehensive estimates of the effect of ART and HIV-related factors on the natural history of anal HPV-related disease in people living with HIV. FUNDING EU Marie Skłodowska-Curie Actions programme.
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Affiliation(s)
- Helen Kelly
- Cancer Epidemiology Research Program, Catalan Institute of Oncology, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laia Alemany Vilches
- Cancer Epidemiology Research Program, Catalan Institute of Oncology, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joel M Palefsky
- Department of Infectious Diseases, School of Medicine, University of California, San Francisco, CA, USA
| | - Silvia de Sanjose
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Barcelona, Spain; PATH, Seattle, WA, USA
| | - Philippe Mayaud
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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9
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Piyathilake CJ, Badiga S, Kumar R, Crowley MR, Burkholder GA, Raper JL. A rigorous exploration of anal HPV genotypes using a next-generation sequencing (NGS) approach in HIV-infected men who have sex with men at risk for developing anal cancer. Cancer Med 2019; 9:807-815. [PMID: 31769225 PMCID: PMC6970045 DOI: 10.1002/cam4.2720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 11/30/2022] Open
Abstract
Background There are no HPV‐based measures for managing anal cancer (AC) in HIV‐infected (HIV+) men who have sex with men (MSM) because of the high positivity of high‐risk (HR)‐HPVs. As next‐generation sequencing (NGS) is able to describe the composition of HPVs as percent (%) reads rather than positive vs negative results, we used NGS approach to detect HPVs in anal samples of HIV+ MSM to test its ability to differentiate those who are diagnosed with atypical squamous cells of unknown significance or greater (ASCUS+) from those who are free of such lesions and to understand the burden of HPV infections in relation to HPV vaccines. Methods Study included 81 HIV+ MSM characterized for demographics, patient‐reported outcome measures, HIV related laboratory measures and anal cytology. We summarized NGS HPV data using % read cut points (>0%‐>30%) and tested the relationship between % reads of HR‐HPVs and risk of ASCUS+ using logistic regression. Results Forty‐six HPVs were detected at the >0% read cut point. The prevalence of any HR‐HPVs varied from 100% to 40% with >0% to >30% reads while ≥99% were infected with HR‐HPVs included or not included in the 9 valent HPV vaccine at the >0% read cut point. MSM with >30% HR‐HPV reads were 4.5 times more likely to be diagnosed with ASCUS+ compared to ≤30% reads (P = .033). Conclusion NGS‐based approach is more accurate than PCR‐based HPV testing for identifying HIV+ MSM at risk for developing AC. We raise the concern regarding the efficacy of current HPV vaccines for preventing AC in this high‐risk population.
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Affiliation(s)
- Chandrika J Piyathilake
- Department of Nutrition Sciences, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Suguna Badiga
- Department of Nutrition Sciences, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Ranjit Kumar
- UAB Center for Clinical & Translational Science, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Michael R Crowley
- Department of Genetics, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Greer A Burkholder
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - James L Raper
- Division of Infectious Diseases, Department of Medicine, The University of Alabama at Birmingham (UAB), Birmingham, AL, USA
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10
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Posso H, León-Maldonado L, Allen-Leigh B, Salmerón J, Quiterio M, Giuliano AR, Sudenga SL, Nyitray AG, Torres BN, Abrahamsen M, Lazcano-Ponce E. Prevalence and incidence of anal human papillomavirus infection in Mexican men: Need for universal prevention policies. SALUD PUBLICA DE MEXICO 2019; 60:645-652. [PMID: 30699269 DOI: 10.21149/8454] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 08/30/2018] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE Describe the natural history of anal HPV among men. MATERIALS AND METHODS Prospective study among men 18-70 years (n=665), from Cuernavaca, Mexico who completed questionnaires and provided specimens (HPV genotyped) at enrollment and 1+ follow-up visit. HPV prevalence and incidence were estimated. Prevalence ratios were calculated with Poisson regression using robust variance estimation. Person-time for incident HPV infection was estimated using number of events modeled as Poisson variable for total person-months. RESULTS Anal infection prevalence: any HPV type=15%, high-risk=8.4%, HPV16=1.4%, tetravalent vaccine types (4vHPV)=4.4%, nonavalent vaccine types (9vHPV)=6.3%. Factors associated with prevalence: 50+ lifetime female sex partners (adjusted prevalence ratio, a PR=3.25, 95% CI:1.12- 9.47), 10+ lifetime male sex partners (aPR=3.06, 95%CI:1.4- 6.68), and 1+ recent male anal sex partners (aPR=2.28, 95%CI:1.15-4.5). Anal incidence rate: high-risk HPV=7.8/1000 person-months (95%CI:6.0-10.1), HPV16=1.8/1000 personmonths (95%CI:1.1-2.9),4vHPV=3.4/1000 person-months (95%CI:2.3-4.9) and 9vHPV=5.5/1000 person-months (95%CI:4.1-7.5). CONCLUSIONS Implementation of universal HPV vaccination programs, including men, is a public health priority.
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Affiliation(s)
- Hector Posso
- Universidad de la Sabana. Chia-Cundinamarca, Colombia
| | - Leith León-Maldonado
- Cátedra Conacyt, Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México
| | - Betania Allen-Leigh
- Dirección de Salud Reproductiva, Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México
| | - Jorge Salmerón
- Centro de Investigación en Políticas, Población y Salud, Facultad de Medicina, Universidad Nacional Autónoma de México. Ciudad de México, México.,Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México
| | - Manuel Quiterio
- Unidad de Investigación Epidemiológica y en Servicios de Salud, Instituto Mexicano del Seguro Social. Cuernavaca, Morelos, México
| | - Anna R Giuliano
- Center for Infection Research in Cancer, Moffitt Cancer Center and Research Institute.Tampa, Florida
| | - Staci L Sudenga
- Center for Infection Research in Cancer, Moffitt Cancer Center and Research Institute.Tampa, Florida
| | - Alan G Nyitray
- Department of Epidemiology, The University of Texas School of Public Health. Houston, Texas, USA
| | - B Nelson Torres
- Center for Infection Research in Cancer, Moffitt Cancer Center and Research Institute.Tampa, Florida
| | - Martha Abrahamsen
- Center for Infection Research in Cancer, Moffitt Cancer Center and Research Institute.Tampa, Florida
| | - Eduardo Lazcano-Ponce
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública. Cuernavaca, Morelos, México
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11
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Combes JD, Heard I, Poizot-Martin I, Canestri A, Lion A, Piroth L, Didelot JM, Ferry T, Patey O, Marchand L, Flejou JF, Clifford GM, Etienney I. Prevalence and Risk Factors for Anal Human Papillomavirus Infection in Human Immunodeficiency Virus-Positive Men Who Have Sex with Men. J Infect Dis 2018; 217:1535-1543. [PMID: 29394362 DOI: 10.1093/infdis/jiy059] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 01/25/2018] [Indexed: 03/25/2024] Open
Abstract
Background We assessed prevalence and risk factors for anal human papillomavirus (HPV) in human immunodeficiency virus (HIV)-positive men who have sex with men (MSM), who are at high-risk of HPV-related anal cancer. Methods APACHES is a multicentric, prospective study of anal HPV infection and lesions in HIV-positive MSM aged ≥35 years. At baseline, participants underwent anal swabs for HPV and cytology, plus high-resolution anoscopy. High-risk HPV (HR-HPV) was tested by Cobas4800, with genotyping of HR-HPV positives by PapilloCheck. Results Among 490 participants, prevalence of HPV16 and HR-HPV was 29% and 70%, respectively, and did not differ significantly by age, sexual behavior, or markers of HIV or immune deficiency. Smoking was the only, albeit weak (odds ratio, 1.8; 95% confidence interval, 1.2-2.7), predictor of HR-HPV. High-risk HPV and HPV16 prevalence increased strongly with anal diagnosis severity, both by worse cytological/histological (composite) diagnosis at APACHES baseline and worse historical diagnosis. HPV16 rose from 19% among participants who were negative for lesions to 63% among participants with high-grade lesions. In contrast, non-HPV16 HR-HPVs were less prevalent in high-grade (37%) than negative (64%) composite diagnosis, and their causal attribution was further challenged by multiple HPV infections. Conclusions Human papillomavirus 16 is ubiquitously frequent among human immunodeficiency virus -positive men having sex with men, and more strongly associated with high-grade anal lesions than other high-risk types, confirming it as a target for anal cancer prevention.
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Affiliation(s)
| | - Isabelle Heard
- Centre National de Référence des HPV, Institut Pasteur, Paris
- Hôpital Tenon, AP-HP, Paris
| | - Isabelle Poizot-Martin
- Service d'Immuno-Hématologie Clinique, Université Aix Marseille, APHM Sainte-Marguerite, Marseille
- Inserm U912 (SESSTIM), Marseille
| | - Ana Canestri
- Service des Maladies Infectieuses et Tropicales, Hôpital Tenon, AP-HP, Paris
| | - Annie Lion
- Service des Maladies de l'Appareil Digestif, CHU Pontchaillou, Rennes
| | - Lionel Piroth
- Département d'Infectiologie, CHU de Dijon
- INSERM CIC 1432, Université de Bourgogne, Dijon
| | - Jean-Michel Didelot
- Département d'Hépato-Gastroentérologie, CHU Saint Eloi et Université de Montpellier, Montpellier
| | - Tristan Ferry
- Département d'Infectiologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon
| | - Olivier Patey
- Service de Maladies Infectieuses et Tropicales, Centre Hospitalier de Villeneuve-Saint-Georges, Villeneuve-Saint-Georges
| | - Lucie Marchand
- ANRS (France Recherche Nord et Sud Sida-HIV et Hépatites), Paris
| | - Jean-Francois Flejou
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Saint-Antoine, GH HUEP, AP-HP, Paris
- Faculté de Médecine Sorbonne Université, Paris
| | | | - Isabelle Etienney
- Service de Proctologie Médico-Interventionnelle, Groupe Hospitalier Diaconesses Croix-Saint-Simon, Paris, France
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12
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Vergara-Ortega DN, Sevilla-Reyes EE, Herrera-Ortiz A, Torres-Ibarra L, Salmerón J, Lazcano-Ponce E, Sánchez-Alemán MA. Real time PCR to evaluate HSV-2 shedding from anal and genital samples among men who have sex with men, living with HIV. J Med Virol 2018; 90:745-752. [PMID: 29236293 DOI: 10.1002/jmv.25003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/05/2017] [Indexed: 01/06/2023]
Abstract
This study shows the relative quantification of HSV-2 by qPCR, using the MIQE Guidelines. The reaction efficiency was evaluated, and the relative quantification used the R = 2-ΔCq method. The relative quantification of HSV-2 was conducted with anal and genital samples from men who have sex with men (MSM), living with HIV. The presence of a single amplification product was validated with a dissociation curves profile and the determination of the melting temperature. The limit of detection for β-globin was determined as 3.3 × 10-5 ng/μL, and for HSV-2 at 6.0 × 10-6 ng/μL. The efficiency for β-globin was 100.2% and for HSV-2 was 106.8%. From 336 MSM, 2.1% and 3.9% individuals presented anal or genital HSV-2 shedding, respectively. The HSV-2 viral load was 9.2 RU, individuals with fewer CD4+ presented higher HSV-2 viral load. The qPCR method is reproducible and has optimal reaction efficiency.
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Affiliation(s)
- Dayana N Vergara-Ortega
- Centro de Investigación sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos
| | - Edgar E Sevilla-Reyes
- Centro de Investigación en Enfermedades Infecciosas, Instituto Nacional de Enfermedades Respiratorias, Mexico
| | - Antonia Herrera-Ortiz
- Centro de Investigación sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos
| | - Leticia Torres-Ibarra
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos
| | - Jorge Salmerón
- Universidad Nacional Autónoma de México, Ciudad de Mexico, Mexico
| | - Eduardo Lazcano-Ponce
- Centro de Investigación en Salud Poblacional, Instituto Nacional de Salud Pública, Cuernavaca, Morelos
| | - Miguel A Sánchez-Alemán
- Centro de Investigación sobre Enfermedades Infecciosas, Instituto Nacional de Salud Pública, Cuernavaca, Morelos
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13
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HPV genotypes detected by linear array and next-generation sequencing in anal samples from HIV positive men who have sex with men in Mexico. Arch Virol 2018; 163:925-935. [PMID: 29299683 DOI: 10.1007/s00705-017-3697-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 11/20/2017] [Indexed: 12/17/2022]
Abstract
The incidence of anal cancer has been rising, especially in HIV+ patients and has been associated with HPV infection. HIV+ patients are more at risk of HPV coinfection and are seven times more likely to have persistent HPV infection; moreover, HIV+ men have an increased risk of developing anal cancer compared to HIV+ women. The development of screening strategies for the detection of HPV in HIV+ men is of major importance; however, there is not enough information about the HPV genotypes and variants that are colonizing the anal epithelia of HIV+ men in diverse geographical regions. Therefore, this work was aimed at identifying HPV genotypes present in the anal epithelium of HIV+ men who have sex with men (MSM), with or without anal lesions (n = 75). For HPV genotyping, two approaches were performed: Linear Array HPV Genotyping Test and next-generation sequencing (NGS). In general, the six most frequent HPV genotypes found by Linear Array were HPV6, 62, 61, 81, 16 and 51. On the other hand, employing NGS, a total of 36 HPV genotypes belonging to both alpha and beta genera were found. The genotypes with the greatest number of reads, according to the diagnostic group, were: HPV81, 45, 6, 51 and 61 in MSM without anal lesions (WAIN); HPV6, 61, 70, 62 and 66 in MSM with atypical lesions (AAL); HPV6, 11, 66, 81 and 61 in MSM with anal intraepithelial neoplasia grade I (AIN I); and HPV16, 81, 58, 61 and 52 with AIN III. Additionally, a great diversity of L1 variants was observed, especially in genotypes HPV16, 58, 61, 52, 45 and 59.
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14
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Ahmed HG, Bensumaidea SH, Alshammari FD, Alenazi FSH, ALmutlaq BA, Alturkstani MZ, Aladani IA. Prevalence of Human Papillomavirus subtypes 16 and 18 among Yemeni Patients with Cervical Cancer. Asian Pac J Cancer Prev 2017; 18:1543-1548. [PMID: 28669165 PMCID: PMC6373819 DOI: 10.22034/apjcp.2017.18.6.1543] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background: The Human Papillomavirus (HPV) is a DNA tumor virus that causes epithelial proliferation. There
are more than 100 HPV subtypes, of which 13 subtypes are regarded as high risk subtypes that can cause cancers of
epithelial mucosal surfaces. High risk human papilloma viruses (HR-HPV) subtypes 16 and 18 plays a major role in
the etiology of cervical cancer worldwide. Therefore, the aim of this study was to screen for the existence of HPV16
and HPV18 among Yemeni women with cervical lesions. Methodology: Formalin fixed paraffin wax processed tissue
blocks were retrieved for 200 patients (150 were previously diagnosed with cervical cancer and the remaining 50 were
diagnosed with different benign conditions). Results: Of the 200 cervical cancer tissue specimens, HR-HPV 16 was
identified in 74/200 (37%) samples and couldn’t be recognized in 126/200(63%) tissue samples. HR-HPV 18 was
identified in 32/200 (16%) specimens and couldn’t be recognized in 168/200(84%) tissue specimens. Conclusion:
HR-HPV subtypes were prevalent among Yemeni women with cervical cancer, with significant increase of HR-HPV
subtype 16 over the HR-HPV subtype 18.
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Affiliation(s)
- Hussain Gadelkarim Ahmed
- Department of Pathology College of Medicine, University of Hail, Kingdom of Saudi Arabia (KSA).,Department of Histopathology and Cytology, FMLS, University of Khartoum, Sudan.
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15
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Lee CH, Lee SH, Lee S, Cho H, Kim KH, Lee JE, Jung EJ, Lee SJ, Kim EJ, Kim KH, Moon E, Cho HJ. Anal Human Papillomavirus Infection among HIV-Infected Men in Korea. PLoS One 2016; 11:e0161460. [PMID: 27548632 PMCID: PMC4993367 DOI: 10.1371/journal.pone.0161460] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/05/2016] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Little is known about the epidemiology on human papillomavirus (HPV) infection among HIV-infected men in Korea. The objective of this study was to determine the prevalence, genotype distribution and risk factors associated with anal HPV infection among HIV-infected men in Korea. METHODS A single-center cross-sectional study was conducted with HIV-infected men in Korea. Participants completed a detailed sexual behavior risk factor questionnaire. Anal samples were collected for cytology and HPV genotyping. Factors associated with anal HPV infection were assessed using multivariable logistic regression, stratifying by sexual behaviour. RESULTS A total of 201 HIV-infected men were included in the study: 133 were from men who have sex with men (MSM) and 68 from men who have sex with women (MSW). Any anal HPV infection was detected in 82.7% of HIV-infected MSM and in 51.5% of HIV- infected MSW (P < 0.001). High-risk HPV (HR-HPV) prevalence was higher among MSM (47.4%) than MSW (25.0%; P = 0.002). The HR-HPV types identified most frequently were HPV 16 (11%), HPV 18 (9.9%), and HPV 58 (5%) in MSM, and HPV 58(11%) and HPV 16 (8.9%) in MSW. Prevalence of any HPV types in 9-valent vaccine types was higher among MSM than MSW (47.4% vs 22.1%. P = 0.001). Abnormal anal cytology was more commonly detected in MSM than MSW (42.9% vs.19.1%, P < 0.001). In HIV-infected MSM, higher number of lifetime male sex partners was significantly associated with any anal HPV infection, but age was a significant risk factor associated with anal HR-HPV infection. CONCLUSION Anal HPV infection was highly prevalent in HIV-infected MSM in Korea, and also commonly found in HIV-infected MSW. In HIV-infected MSM, the significant risk factor for being infected with any HPV infection was lifetime number of male sexual partners, and with anal oncogenic HPV infection was age.
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Affiliation(s)
- Chang Hun Lee
- Department of Pathology, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sun Hee Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
- * E-mail:
| | - Shinwon Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Heerim Cho
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kye-Hyung Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jung Eun Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Eun ju Jung
- Department of Internal Medicine, Pusan National University School of Medicine, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Su jin Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan Pusan National University Hospital, Geongsangnam-do, Korea
| | - Eun Jung Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan Pusan National University Hospital, Geongsangnam-do, Korea
| | - Ki Hyung Kim
- Department of Obstetrics & Gynecology, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Eunsoo Moon
- Department of Psychiatry, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
| | - Hong Je Cho
- Department of Surgery, Pusan National University School of Medicine, Pusan National University Hospital, Busan, Korea
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