Spectrum of genital human papillomavirus infection in a female adolescent population

Human papilloma virus: Apprehending the link with carcinogenesis and unveiling new research avenues (Review)

Human papilloma viruses (HPV) are a small group of non‑enveloped viruses belonging to the Papillomaviridae family with strong similarities to polyoma viruses. The viral particles consist of a genome in the form of a circular double‑stranded DNA, encompassing eight open reading frames, as well as a non‑enveloped icosahedral capsid. HPV infection is considered the most common sexually transmitted disease in both sexes and is strongly implicated in the pathogenesis of different types of cancer. 'High‑risk' mucosal HPV types, predominantly types 16, 18, 31, 33 and 35, are associated with most cervical, penile, vulvar, vaginal, anal, oropharyngeal cancers and pre‑cancers. Screening for HPV is necessary for the prognosis and for determining treatment strategies for cancer. Novel HPV markers, including proteomic and genomic markers, as well as anti‑papillomavirus vaccines are currently available. The aim of this comprehensive review was to thoroughly present the updated information on virus development, cancer occurrence, treatment and prevention strategies, in an attempt to shed further light into the field, including novel research avenues.

Prevalence of sexually transmitted infections in at-risk adolescent females at a comprehensive, stand-alone adolescent health center in New York City

BACKGROUND

Sexually transmitted infections (STIs) are common among adolescents, and multiple STIs over one's lifetime can increase health risks. Few studies have assessed lifetime STI prevalence. This study evaluates minority, underserved adolescents' self-reported lifetime STI history and objective STI rates.

METHODS

Lifetime STI rates of female patients at an urban adolescent health center were obtained from self-administered questionnaires. Additionally, STI test results were retrieved from electronic medical records.

RESULTS

Patients reported a high lifetime prevalence of STIs. By comparing self-report and objective data, underreporting was identified for chlamydia, gonorrhea, and herpes.

CONCLUSIONS

STI rates in at-risk adolescent females are higher than in the general population and remain elevated over time. Lifetime STI reports could expand our understanding of sexual health and should be further studied. Underreporting, which may increase health risks and hinder health care delivery, requires further investigation. Improvements in STI screening and prevention targeting at-risk populations are warranted.

Ethical considerations of universal vaccination against human papilloma virus

BACKGROUND

From an epidemiological perspective, the practice of universal vaccination of girls and young women in order to prevent human papilloma virus (HPV) infection and potential development of cervical cancer is widely accepted even though it may lead to the neglect of other preventive strategies against cervical cancer.

DISCUSSION

It is argued that removing the deterrent effect--the fear of developing cancer--could encourage teenage sex. This paper reflects on the ethical legitimacy of the universal vaccination of girls and young women against HPV infection, especially regarding safety issues, the need to vaccinate people who have opted to abstain from sex, the presumption of early onset of sexual relations, the commercial interests of the companies that manufacture the vaccine, and the recommendation of universal vaccination in males.

SUMMARY

Based on the aforementioned information, we believe that the universal vaccination against HPV in young women is acceptable from an ethical point of view, given the medical advantages it presents.

The association of HPV-16 seropositivity and natural immunity to reinfection: insights from compartmental models

BACKGROUND

Seroreactivity, processes of seroconversion and seroreversion, in the context of HPV infection has been investigated in numerous studies. However, the data resulting from these studies are usually not accounted for in mathematical transmission models of various HPV types due to gaps in our understanding of the nature of seroreactivity and its implications for HPV natural history.

METHODS

In this study we selected a number of simple but plausible compartmental transmission models of HPV-16, differing in assumptions regarding the relation between seropositivity and immunity, and attempted to calibrate them to Australian HPV seroprevalence data for females and males, as well as DNA prevalence data for females, using a Bayesian model comparison procedure. We ranked the models according to both their simplicity and ability to be fitted to the data.

RESULTS

Our results demonstrate that models with seroreversion where seropositivity indicates only a partial or very short-term full protection against re-infection generate age-specific HPV DNA prevalence most consistent with the observed data when compared with other models.

CONCLUSIONS

Models supporting the notion that seropositive individuals are fully immune to reinfection demonstrated consistently inferior fits to the data than other models making no such assumption.

Human papillomavirus infection among young adolescents in India: impact of vaccination

High-risk human papillomaviruses (HR-HPVs) are the causative agents of cervical cancer and prophylactic HPV vaccination has been recommended for adolescents but no data are available on the prevalence of HPV infection among adolescents in India. Self-collected midstream urine samples from 940 healthy school children, aged 8-17 years, from 12 different schools in and around Noida and Delhi, India, were collected for HPV detection by PCR. Of 458 girls, 15 (3.2%) were positive for HPV and 10 (66.6%) were positive for high-risk human papillomavirus (HR-HPV) type16 and 2 (13.3%) for HPV 18. Of 342 boys, 7 (2.1%) were HPV positive, of which 5 (71.4%) had HPV type 6 but interestingly, none were positive for HR-HPV types 16 or 18. Among HPV positive girls, 13 (66.6%) were >13 years and the rest were <13 years (P = 0.004), while all seven HPV positive boys were >13 years (P = 0.007). The majority of HPV positive adolescents (80-86%) belonged to the Hindu and related communities, whereas only about 14-20% belonged to the Muslim community. A significant association (P < 0.001) was observed between the parent's education and the awareness of cervical cancer, which was significantly higher among adolescent girls from India, thereby exerting an immense psychosocial impact on vaccination programs. A lower prevalence of HR-HPV infection among adolescent girls will have significant positive effect on HPV vaccination and cancer control programs in India where education and awareness should go hand in hand.

Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study

OBJECTIVES

To characterize the epidemiology of genital human papillomavirus (HPV) infection in children without previous consensual sexual activity, comparing HPV prevalence by certainty of child sexual abuse (CSA).

PATIENTS AND METHODS

Patients presenting for evaluation of CSA in 8 sites in Atlanta, Houston, Harrisburg, and New York City were recruited along with patients presenting for unrelated health visits. CSA certainty was classified as definite, probable, possible, or no evidence following published guidelines and the results of history, physical examination, and laboratory tests. Urine and swabs of external genitalia were tested for HPV using L1 consensus polymerase chain reaction.

RESULTS

The study included 576 participants (89.9% female) aged 6 months to 13 years (mean: 7.9); 534 of whom were evaluated for CSA and 42 for unrelated reasons. Of those evaluated for CSA, 14 had genital warts. One or more HPV types were detected in 11.8% (61 of 517) of participants with adequate samples. HPV detection was more likely among abused participants (definite, probable, or possible) than among participants without evidence of CSA (13.7% and 1.3%, respectively; P < .0001) and increased with certainty of abuse (8.4%, 15.6%, and 14.5% in participants with possible, probable, and definite CSA, respectively; P < .0001). Participants aged 10 years or older had a higher prevalence of HPV (20.6%) than others (5.6%) (P < .0001). CSA, anogenital warts, and age were independently associated with HPV detection.

CONCLUSIONS

HPV detection was associated with CSA and increased with CSA certainty. In this population, genital HPV seemed to behave as a sexually transmitted infection.

Women's knowledge of Pap smear test and human papillomavirus: acceptance of HPV vaccination to themselves and their daughters in an Islamic society

OBJECTIVE

Cancer of cervix uteri is the second most common cancer among women, and it has been shown to be caused by human papillomavirus (HPV) infection in more than 99% of cases. We surveyed Muslim Turkish women, who mostly accept talking about sex as a taboo, to examine their knowledge about Papanicolaou (Pap) smear test, HPV, HPV vaccine, and their attitude toward vaccination to themselves and their daughters.

METHODS

We surveyed 525 women aged between 19 and 53 years to examine their knowledge about cervical cancer screening Pap smear test, HPV, HPV vaccine, and their attitude toward vaccination to themselves and their daughters with a questionnaire that is consisted of 5 parts with a total of 31 items.

RESULTS

The knowledge of cervical screening was high (70%), and 51% of the subjects were at least once had a Pap smear test, but most respondents (56%) had never heard of HPV. For most women, recommendations from health workers (67%) were the major influences in deciding to get vaccinated.

CONCLUSIONS

The importance of successful introduction on the vaccine by the drug providers and health care professionals in Turkey was shown in this present study with a high rate of awareness of cervical cancer vaccine. "Early-age vaccination knowledge" before any sexual contact is probably due to the correct education of mothers by health care professionals. The professionals should be educated and trained about HPV, vaccination, and its relation with cervical cancer to increase the knowledge about it.

Human papillomavirus infection and risk factors in a cohort of Tuscan women aged 18-24: results at recruitment

Background

There is conclusive evidence that human papillomavirus (HPV) infections of the cervix are a necessary cause of cervical cancer. In Italy there are consistent data of HPV prevalence in women aged 25 - 64 years, but there is limited data for younger women. The objective of this on-going 3-year prospective cohort study is to investigate the prevalence, acquisition, clearance and persistence of HPV infections in young Tuscan women and the risk factors correlated with such events.

Methods

One thousand and sixty-six women aged between 18 and 24 years were enrolled and received an initial HPV test. They were asked to return to the clinic over the study period for further tests every 12 months, if their HPV HR result was negative, or every 6 months, if positive. Additionally, women with an HPV positive result were given a cytological examination and if the cytological diagnosis was ASC-US or more severe, only women with HPV HR, were referred for colposcopy.

Results

We present here data for the enrolment phase of the study. At baseline, within the study sample, just under 30% of women were infected by HPV and 19.3% of women were infected with oncogenic types. A relationship was highlighted between HPV infection, number of sexual partners (in particularly in the last 3 years) and the lifetime number of partner's partners. Condom use showed a slight protective effect in univariate analysis but these data were not statistically significant in multivariate analysis. The association between HPV infection and demographic and behavioural variables were tested by crude odds ratio (OR). Multivariate logistic regression was applied to compute the adjusted odds ratios.

Conclusions

The prevalence of oncogenic HPV types was high in young Tuscan women. The 3-year follow-up of this cohort may provide a better understanding of the processes of acquisition, clearance and persistence of infection and the correlated risk factors.

An audit of Colposcopy referrals from a GU/STD clinic

BACKGROUND

Cervical cancer is increasing at 1.5% per year in Ireland with 50% mortality giving 2.2% of all cancer deaths. In the Mid-West region a pilot screening programme has begun to screen all women 25-60 years. 66% of Genitourinary/Sexually transmitted disease (GU/STD) clinics' abnormal smears are <25 years. Requests to abandon "opportunistic" screening prompted this GU/STD clinic audit.

METHODS

221(8.4%) patients referred to colposcopy over 4 years were audited. Retrospective analysis was carried out on GU/STD clinic files, hospital files and computer records for biopsy reports. Ethical approval was prospectively granted.

RESULTS

2637 smears were carried out from November 1999 - September 2003.221 patients referred to colposcopy were audited.1%, 3%, 5% had severe, moderate and, mild dyskaryosis, respectively, on cervical screening while 0.8%, 1.2%, 1.5% had CIN3, CIN2, CIN1 abnormalities, respectively, on biopsy with 3.5% having no abnormality (Cervical Intraepithelial Neoplasia = CIN).53% referred to colposcopy were <25 years.

CONCLUSION

2% had high grade lesions. 37% of high grade lesions are <25 years.Of the high grade lesions 13% had Chlamydia trachomatis (27% of CIN3) and 44% had HPV despite Relative Risks (RR) being 0.75 and 1.09 respectively. Older women had higher grade changes. No statistical difference was found for progression, regression and persistence in those over and under 25.

Human papillomavirus and HPV vaccines: a review

Cervical cancer, the most common cancer affecting women in developing countries, is caused by persistent infection with "high-risk" genotypes of human papillomaviruses (HPV). The most common oncogenic HPV genotypes are 16 and 18, causing approximately 70% of all cervical cancers. Types 6 and 11 do not contribute to the incidence of high-grade dysplasias (precancerous lesions) or cervical cancer, but do cause laryngeal papillomas and most genital warts. HPV is highly transmissible, with peak incidence soon after the onset of sexual activity. A quadrivalent (types 6, 11, 16 and 18) HPV vaccine has recently been licensed in several countries following the determination that it has an acceptable benefit/risk profile. In large phase III trials, the vaccine prevented 100% of moderate and severe precancerous cervical lesions associated with types 16 or 18 among women with no previous infection with these types. A bivalent (types 16 and 18) vaccine has also undergone extensive evaluation and been licensed in at least one country. Both vaccines are prepared from non-infectious, DNA-free virus-like particles produced by recombinant technology and combined with an adjuvant. With three doses administered, they induce high levels of serum antibodies in virtually all vaccinated individuals. In women who have no evidence of past or current infection with the HPV genotypes in the vaccine, both vaccines show > 90% protection against persistent HPV infection for up to 5 years after vaccination, which is the longest reported follow-up so far. Vaccinating at an age before females are exposed to HPV would have the greatest impact. Since HPV vaccines do not eliminate the risk of cervical cancer, cervical screening will still be required to minimize cancer incidence. Tiered pricing for HPV vaccines, innovative financing mechanisms and multidisciplinary partnerships will be essential in order for the vaccines to reach populations in greatest need.

Cervical screening in the 21st century: the case for human papillomavirus testing of self-collected specimens

Cervical screening by Pap smear involves a high rate of false negatives, necessitating frequent testing. Because women do not like the sampling procedure, many avoid being screened. Testing for the causative high-risk human papillomavirus (HPV) types, by PCR or other technologies, on self-collected (tampon) samples permits women to be monitored non-invasively. The high negative predictive value of HPV testing means a greater interval between tests, and thus reduces costs. HPV testing lends itself to primary screening. A kit for self-collection and return to a testing laboratory, followed by practitioner notification and follow-up if required, should result in wider participation. The higher accuracy of HPV testing should lead to improved cervical cancer prevention.

Predictors of timely initiation of gynecologic care among urban adolescent girls

PURPOSE

To determine whether or not critical sexual health services are delivered to low-income girls, and to identify predictors of timely initiation of gynecologic care for sexually active adolescent girls. Few studies have addressed the interval between sexual debut and risk-appropriate primary care services.

METHODS

We conducted an anonymous, cross-sectional, laptop-based, self-administered branching survey of 9th-12th grade girls in three Bronx public high schools (n = 819).

RESULTS

Over half (60.0%) had an opportunity for confidential care at last clinical visit. Only 27% of sexually active girls had informed any clinician that they had been sexually active; 45% had ever had a pelvic exam. The mean interval between sexual debut and initial pelvic exam (our proxy for gynecologic care) was 13.3 months (range = 0-70 months, SD = 11.8 months). Cox proportional hazard modeling identified four predictors of time to first pelvic exam: experience of sexually transmitted infection (STI) or pregnancy (hazard ratio [HR] = 1.9), having disclosed sexual activity to any clinician (HR = 1.7), access to confidential care (HR = 3.1), and high self-efficacy for accessing confidential care (HR = 2.1).

CONCLUSIONS

Most sexually active girls have not told a clinician that they are sexually active and many have not had counseling related to sexual health. Delay between sexual debut and initial pelvic exam is substantial for low-income urban girls, and often occurs in reaction to pregnancy or STI. Setting of usual care does not predict timely gynecologic care, but access to confidential care does.

Condom use and the risk of genital human papillomavirus infection in young women

BACKGROUND

To evaluate whether the use of male condoms reduces the risk of male-to-female transmission of human papillomavirus (HPV) infection, longitudinal studies explicitly designed to evaluate the temporal relationship between condom use and HPV infection are needed.

METHODS

We followed 82 female university students who reported their first intercourse with a male partner either during the study period or within two weeks before enrollment. Cervical and vulvovaginal samples for HPV DNA testing and Papanicolaou testing were collected at gynecologic examinations every four months. Every two weeks, women used electronic diaries to record information about their daily sexual behavior. Cox proportional-hazards models were used to evaluate risk factors for HPV infection.

RESULTS

The incidence of genital HPV infection was 37.8 per 100 patient-years at risk among women whose partners used condoms for all instances of intercourse during the eight months before testing, as compared with 89.3 per 100 patient-years at risk in women whose partners used condoms less than 5 percent of the time (adjusted hazard ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the number of new partners and the number of previous partners of the male partner). Similar associations were observed when the analysis was restricted to high-risk and low-risk types of HPV and HPV types 6, 11, 16, and 18. In women reporting 100 percent condom use by their partners, no cervical squamous intraepithelial lesions were detected in 32 patient-years at risk, whereas 14 incident lesions were detected during 97 patient-years at risk among women whose partners did not use condoms or used them less consistently.

CONCLUSIONS

Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection.

Sexual behavior, condom use, and human papillomavirus: pooled analysis of the IARC human papillomavirus prevalence surveys

Human papillomavirus (HPV) is a sexually transmitted infection but it is unclear whether differences in transmission efficacy exist between individual HPV types. Information on sexual behavior was collected from 11 areas in four continents among population-based, age-stratified random samples of women of ages > or = 15 years. HPV testing was done using PCR-based enzyme immunoassay. Unconditional logistic regression was used to estimate odds ratios (OR) of being HPV positive and corresponding 95% confidence intervals (95% CI). Variables were analyzed categorically. When more than two groups were compared, floating confidence intervals were estimated by treating ORs as floating absolute risks. A total of 11,337 women (mean age, 41.9 years) were available. We confirmed that lifetime number of sexual partners is associated with HPV positivity (OR for > or = 2 versus 1, 1.86; 95% CI, 1.63-2.11) but the association was not a linear one for HPV18, 31, and 33 (i.e., no clear increase for > or = 3 versus 2 sexual partners). Women who had multiple-type infection and high-risk HPV type infection reported a statistically nonsignificant higher number of sexual partners than women who had single-type and low-risk type infections, respectively. Early age at sexual debut was not significantly related to HPV positivity. Husband's extramarital sexual relationships were associated with an OR of 1.45 (95% CI, 1.24-1.70) for HPV positivity in their wives after adjustment for age and lifetime number of women's sexual partners. We did not observe a significant association with condom use. Our study showed an effect of both women's and their husbands' sexual behavior on HPV positivity. Furthermore, it suggests some differences in the pattern of the association between sexual behavior and different HPV types.

Immunohistochemical analysis of CD4+ and CD8+ T-cell subsets in high risk human papillomavirus-associated pre-malignant and malignant lesions of the uterine cervix

OBJECTIVES

Humoral and cellular immune responses are likely to play a key role for the clearance or persistence and progression of high risk (HR) HPV-associated cervical lesions. Although there are many studies describing the systemic T-cell responses to HPV16 and 18 proteins, few data are available regarding the cellular mucosal immune responses. We used immunohistochemistry to characterize populations of T-immune cells (CD4+, CD8+, CD45RO+) in HR-HPV-infected precancerous and cancerous lesions of the uterine cervix.

METHODS

Four biopsies from normal cervix, 9 CIN1 which have regressed (rCIN), 5 CIN1 which have progressed (pCIN) to high grade lesions, 13 CIN3 and 11 invasive carcinomas were included. All dysplasias and carcinomas were HR-HPV-positive and low-risk-HPV-negative. They were stained with monoclonal antibodies specific for CD4, CD8 and CD45RO and examined by microscopy.

STATISTICAL ANALYSIS

The Kruskal-Wallis test and the Siegel's and Castelan's method were used. RESULTS.: CD4+ cells predominated in regressing CIN1 both within the stroma and the epithelium with the highest CD4+/CD8+ ratio compared with pCIN1, CIN3 and invasive carcinoma. At the exception of CD45RO+ cells, T cells were detected with similar frequencies in both pCIN1 and CIN3. However, in 7 out of 10 CIN3, CD4+ and CD8+ cells were visible as organized lymphoid follicle structure. The CD8+ and CD45RO+ cells far exceeded the CD4+ cells in invasive cancers.

CONCLUSIONS

Density and distribution of immune T cells depend on the malignant potential of HR-HPV lesions. These results suggest that the studied lymphocyte subsets have an important role to fulfil during the natural history of HR-HPV-associated lesions.

The epidemiology of sexually transmitted infections in adolescents

This article addresses the epidemiology of several common sexually transmitted infections (STIs) in adolescents. Chlamydia is a common occurrence in adolescents, more so than is gonorrhea, but both are of particular concern because they may cause pelvic inflammatory disease. Many experts recommend screening for chlamydia in sexually active adolescents, particularly females. Trichomonas vaginalis is significant as a marker for risk of contracting other STIs and because of its association with pregnancy complications and with increased risk of transmission of HIV. Genital herpes simplex virus (HSV) infection, which usually has been caused by HSV-2, is a common finding in adolescents, and it now is caused also by HSV-1 in some populations. Human papillomavirus (HPV), though widespread in adolescents, usually is a self-limited infection, and malignancy resulting from HPV is a rare occurrence in this age group. The least common of the diseases discussed below is syphilis, but a recent sharp increase in incidence has occurred in men who have sex with men.

Is There an Association Between Alcohol Consumption and Sexually Transmitted Diseases? A Systematic Review

OBJECTIVE/GOAL

The objective of this study was to conduct a systematic review of published literature on the association between problematic alcohol consumption and sexually transmitted diseases (STDs).

DESIGN

Using a MEDLINE search (1995-2003) and article references, we identified articles that described measures of alcohol consumption and STDs and presented data on their association. For each eligible study, we classified the alcohol consumption measure as specific (problem drinking) or general, and examined study designs, study populations, STD measures, and results.

RESULTS

Of 42 eligible studies, 11 included specific measures of problem drinking, of which 8 found a significant association between alcohol consumption and at least 1 STD. The relationship did not appear to vary according to gender or pattern of alcohol consumption assessed.

CONCLUSIONS

The literature supports an overall association between problematic alcohol consumption and STDs, although their causal relationship cannot be determined with certainty from these observational studies. The findings have implications for prevention planners, clinicians, and individual patients at risk of STDs.

Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic

BACKGROUND AND OBJECTIVES

Human papillomavirus (HPV) is the primary cause of cervical, anal, and other anogenital cancers, but risk factors for penile HPV detection in men have not been well-characterized.

GOAL

The goal of this study was to identify correlates of penile HPV detection in ethnically diverse men attending a sexually transmitted disease clinic.

STUDY

A cross-sectional investigation was conducted among 393 men. Participants completed a risk-factor questionnaire and underwent testing for penile HPV DNA. Presence of HPV DNA was assessed using polymerase chain reaction with PGMY primers and reverse line blot genotyping. Logistic regression analyses were conducted to identify variables associated with any-type, oncogenic, and nononcogenic HPV.

RESULTS

Circumcision was associated with reduced risk for oncogenic, nononcogenic, and overall HPV. Regular condom use was associated with reduced risk for oncogenic and overall HPV.

CONCLUSION

These findings, if confirmed by other studies, could impact public health practices and messages regarding HPV.

Recent trends in the epidemiology of sexually transmitted infections in the European Union

Sexually transmitted infections (STIs) are a major public health problem in Europe. We review recent trends in the epidemiology of the major acute STIs in the European Union and Norway, their key determinants, and opportunities for enhancing STI prevention interventions in the region.

Atypical Squamous Cells of Undetermined Significance in Girls and Women

OBJECTIVE

To estimate the outcome of adolescents with atypical squamous cells of undetermined significance (ASC-US) on cytology.

METHODS

A review of ASC-US cytology in girls and women aged 10-19 years between 1995 and 1999 was performed. The cytologic and histologic follow-up of each patient was evaluated. The outcome was recorded as the most significant (highest grade) subsequent cervical smear or biopsy.

RESULTS

Overall, 535 of 7897 (6.8%) cervical cytologic specimens were reported as ASC-US. The study group consisted of 398 patients for whom pathologic follow-up was available. The mean duration of follow-up was 19 months. Follow-up consisted of repeat cytology in 251 (63%) patients and colposcopy with cervical biopsies and/or endocervical curettage in 147 (37%) of the adolescents. Two hundred fifty-three (64%) adolescents had no pathologic abnormalities on follow-up. Persistent ASC-US was identified in 65 (16%), low-grade squamous intraepithelial lesions/cervical intraepithelial neoplasia (CIN) 1 was found in 44 (11%) and high-grade squamous intraepithelial lesions/CIN 2 or 3 occurred in 36 (9%) of the adolescents. No cases of invasive carcinoma were found.

CONCLUSIONS

Among adolescents with ASC-US, the rate of squamous intraepithelial lesions/CIN is similar to that of adults. Although the optimal management of ASC-US in adolescents is unknown, these patients warrant close follow-up.

LEVEL OF EVIDENCE

III

Genital and perianal warts: new treatment opportunities for human papillomavirus infection

Human papillomaviruses are among the most common sexually transmitted diseases in the United States. Genital warts are a common phenotypic expression of human papillomaviruses, affecting 1% of the population; therefore, the obstetrician/gynecologist will invariably be required to advise and treat patients with this clinical manifestation. Issues essential in the diagnosis, counseling, and management of patients with genital warts will be examined, including epidemiology, transmission, molecular biology, and host immune response. This review will also provide the health care professional with a thorough examination of the new patient-applied treatment opportunities for anogenital condyloma, in addition to an overview of current provider-administered therapies, to assist in patient management.

Do condoms prevent genital HPV infection, external genital warts, or cervical neoplasia? A meta-analysis

BACKGROUND

Although condoms most likely prevent HIV infection, evidence of their effectiveness against other sexually transmitted diseases is mixed.

GOAL

The goal of the study was to determine whether condom use prevents genital human papillomavirus (HPV) infection and HPV-related conditions.

STUDY DESIGN

We conducted a literature review and meta-analysis of the effect of condom use on the prevention of genital warts, subclinical HPV infection, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer (ICC).

RESULTS

Among 27 estimates from 20 studies, there was no consistent evidence that condom use reduces the risk of becoming HPV DNA-positive. However, risk for genital warts, CIN of grade II or III (CIN II or III), and ICC was somewhat reduced.

CONCLUSIONS

Available data are too inconsistent to provide precise estimates. However, they suggest that while condoms may not prevent HPV infection, they may protect against genital warts, CIN II or III, and ICC.

External genital warts: diagnosis, treatment, and prevention

External genital warts (EGWs) are visible warts that occur in the perigenital and perianal regions. They are due primarily to non-oncogenic human papillomavirus (HPV) types, usually types 6 and 11. Physical examination assisted by bright light and magnification is the recommended approach for primary diagnosis. Biopsy is indicated when EGWs are fixed to underlying structures or discolored or when standard therapies are not effective. Recurrences are common, and there is no single treatment that is superior to others. Among women with atypical squamous cells, molecular HPV testing may be useful in determining who should be referred for colposcopy. Condoms may provide some protection against HPV-related diseases and thus are recommended in new sexual relationships and when partnerships are not mutually monogamous. Because the efficacy of cesarean section in preventing vertical transmission of HPV infection from women with EGWs to their progeny has not been proved, it is not recommended.

Characterization of genital human papillomavirus infection in women who have or who are at risk of having HIV infection

OBJECTIVE

The purpose of this study was to describe the prevalence of human papillomavirus infection and the likelihood of human papillomavirus expression and Papanicolaou test abnormalities among women who have and who are at risk of having human immunodeficiency virus infection.

STUDY DESIGN

Cross-sectional analysis of 767 women who had human immunodeficiency virus infection and 390 women who were at risk of having human immunodeficiency virus infection in 4 cities in the United States.

RESULTS

Women who were infected with human immunodeficiency virus were more likely than women who were not infected to have human papillomavirus infection (prevalence ratio, 2.3; 95% CI, 2.0-2.8) but had similar human papillomavirus types. Among women who tested positive for human papillomavirus by polymerase chain reaction, human immunodeficiency virus infection was associated with a high level of human papillomavirus expression (prevalence ratio, 1.3-1.6) and multiple human papillomavirus infections (prevalence ratio, 1.9). However, among women with a high level of human papillomavirus expression or infection with multiple types, there was no association between human immunodeficiency virus serostatus and risk of cervical dysplasia.

CONCLUSION

Through its association with a high level of expression and multiple human papillomavirus infections, human immunodeficiency virus infection may increase the risk of cervical dysplasia in women who are infected with human papillomavirus.

Condylomata acuminata (genital warts): patient demographics and treating physicians

BACKGROUND

Condylomata acuminata (genital warts), caused by the human papillomavirus, are common and sexually transmitted. However, the use of healthcare services for condylomata has never been characterized from a national probability sample study.

GOAL

To understand better the demographics of patients seen by physicians for this disorder.

STUDY DESIGN

Data from office visits for warts, both condylomata and noncondylomatous types, were obtained from the 1994 to 1998 National Ambulatory Medical Care Survey.

RESULTS

The age distribution of those treated for condylomata peaked in 20- to 39-year-olds, with more than 70% of patients in this age category. A younger and wider age distribution was seen in patients with noncondylomatous warts. Women accounted for 67% of the population seen for condylomata, whereas a more equal number of women and men were seen for noncondylomatous warts. Per capita healthcare use for condylomata was equal between blacks and whites, and whites had almost five times more per capita healthcare use than blacks for noncondylomatous warts. Obstetrician/gynecologists were the most commonly consulted physicians for condylomata. Per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists, and lower for all other physicians.

CONCLUSIONS

The difference in age distribution between condylomata and noncondylomatous visits likely results from differing modes of transmission and age at first sexual contact. Females are more likely than males to use health care for condylomata, which may be attributable to increased prevalence, differences in treatment efficacy, differences in the gender frequency of genital health screenings, or psychosocial causes. Healthcare use for condylomata appears equal between blacks and whites. Patients with condylomata acuminata were most often seen by obstetrician/gynecologists, whereas patients with noncondylomatous warts most often consulted dermatologists. The fact that per capita condylomata visits per physician were highest for obstetrician/gynecologists, dermatologists, and urologists may imply that specialists in these fields have expertise in treating these patients.

Condom use by adolescents

The use of condoms as part of the prevention of unintended pregnancies and sexually transmitted diseases (STDs) in adolescents is evaluated in this policy statement. Sexual activity and pregnancies decreased slightly among adolescents in the 1990s, reversing trends that were present in the 1970s and 1980s, while condom use among adolescents increased significantly. These trends likely reflect initial success of primary and secondary prevention messages aimed at adolescents. Rates of acquisition of STDs and human immunodeficiency virus (HIV) among adolescents remain unacceptably high, highlighting the need for continued prevention efforts and reflecting the fact that improved condom use can decrease, but never eliminate, the risk of acquisition of STDs and HIV as well as unintended pregnancies. While many condom education and availability programs have been shown to have modest effects on condom use, there is no evidence that these programs contribute to increased sexual activity among adolescents. These trends highlight the progress that has been made and the large amount that still needs to be accomplished.

Progression of cervical lesions in HIV-seropositive women: a cytological study

It has been reported that cervical intraepithelial lesions have a more aggressive course in HIV-seropositive than in HIV-seronegative women. In the present investigation, the progression of these cervical lesions was studied in a group of HIV-seropositive women. Of 1,587 patients, 200 (12.6%) had a cytological diagnosis of squamous intraepithelial lesion (SIL) or invasive carcinoma. In 409 patients, more than one cytological smear was collected in 3(1/2) years. Progression occurred in 39 cases. In 24 (61.5%), the first diagnosis was benign cellular changes (BCC) and the second was low-grade SIL (LSIL) (1-yr interval in 21 cases); in 11 (28.2%), the first was BCC, and the second, high-grade SIL (HSIL) (1-yr interval in 9 cases); in 2 (5.0%), the first diagnosis was LSIL. and the second, HSIL (1-yr interval); in 2 (5.0%), the first was HSIL, and the second, invasive carcinoma (2-yr interval). These results point to the importance of cervical cytologic surveillance in HIV-seropositive patients.

Female genital warts: global trends and treatments

The increasing incidence of human papillomavirus (HPV) infection and HPV-associated conditions such as genital warts in women is a global concern. Genital warts are a clinical manifestation of HPV types 6 and 11, and are estimated to affect 1% of sexually active adults aged between 15 and 49. HPV infection is also strongly associated with cervical cancer, and is prevalent in as many as 99% of cases. The psychological stress of having genital warts is often greater than the morbidity of the disease, and therefore successful treatment is crucial. Current treatments are patient-applied and provider-administered therapies. Imiquimod 5% cream, a patient-applied therapy, is an efficacious treatment with tolerable side-effects and a low recurrence rate, and has the potential to be an effective strategy for the management of genital warts.

Concordance of human papillomavirus in the cervix and urine among inner city adolescents

OBJECTIVES

To evaluate concordance for human papillomaviruses (HPVs) between cervix and urine in sexually active adolescents.

METHODS

Cervical swabs and urine were collected from 80 adolescents in Baltimore, MD. Specimens were tested for 34 HPVs by PCR and for cancer-associated HPVs by Hybrid Capture (HC II) Probe B. Cervical vs. urine prevalence was evaluated by logistic regression with general estimating equations. Risk factors for prevalence and viral burden were evaluated by Fisher's exact and Kruskal-Wallis tests, respectively.

RESULTS

HPV prevalence by PCR, for any HPV, was very high in the cervix (90.0%) and somewhat lower in urine (75.0%) (odds ratio, 1.07; 95% confidence interval 1.07 to 1.34). Only one adolescent was HPV-positive in urine alone. Among HPV-PCR positives at either or both sites, concordance was 82% for presence of any HPV and 40% for specific HPV types. Multiple infections were common at both sites. On an average, HC II viral burden (relative light unit ratio) was 9-fold higher in cervix than in urine (median, 47.3 vs. 4.9; P = 0.005) but correlated poorly between the two sites of the same individual (r = 0.14). Compared with normal adolescents, those with squamous intraepithelial lesions had a much higher prevalence of HPV by HC II in cervix (100% vs. 28.6, P<0.0001) as well as in urine (86.7% vs. 35.4%, P = 0.002) and a significantly higher viral burden in the cervix (median, 141.8 vs. 7.3, P = 0.0045) but not in urine (median, 22.7 vs. 4.38; P = 0.13).

CONCLUSION

There was a very high prevalence of HPV in cervix and urine of sexually active adolescents. Testing urine for HPV may be useful in epidemiologic investigations and in monitoring of infected women.

Pap smear follow-up of possible role of mucopurulent exudate as a prognosticator of a negative pregnancy outcome

Our objective was to study a cohort of women by various means to detect sexually transmitted diseases (STD) and to correlate the presence of mucopurulent exudate (PEX) on Papanicolaou (Pap) smears with pregnancy outcome. Bacteriologic cultures taken from swabs for chlamydia and gonorrhea were correlated with Gen-Probe results. Smears were examined for trichomonas, yeast, HPV, obscuring mucopurulent exudate, and squamous intraepithelial abnormalities. There was no positive correlation between STD and negative pregnancy outcome. Mucopurulent exudate on Pap smears was very high in this population. Continuing study of this population of women is needed to see if larger cohorts will demonstrate any positive correlations between PEX and pregnancy outcome. Placing women with obscuring mucopurulent exudate in a "high-risk" category for complications may prevent adverse side effects to the birth product. The Pap smear works as well as the Gram stain for detection of bacterial vaginosis and cervicitis. Eliminating the Gram stain from routine pelvic exam results in cost savings.

Adolescent sexuality and sexually transmitted diseases: attitudes, beliefs, knowledge, and values

This study described rural adolescents' attitudes, beliefs, knowledge, and values with regard to sexuality and sexually transmitted diseases (STDs). Rotter's Social Learning Theory (1954) provided the theoretical framework for this descriptive, correlational design. The convenience sample consisted of 170 students from one rural high school. Consistent with past studies, results included the following: participants had more correct than incorrect knowledge related to sexual intercourse and STDs; the majority had positive attitudes toward condom use and believed it was OK for peers to have sex with a "steady;" the value of an exciting life correlated positively with attitudes toward sex; knowledge of sexual intercourse correlated positively with attitudes toward condom use; and the value health correlated positively with knowledge of sex and attitudes toward condom use, and negatively with attitudes toward sex. The findings in this study suggest the need for ongoing research with adolescents in the area of sexuality and STDs. Additionally, the findings support past studies, which revealed that knowledge of sexual intercourse and STDs has little impact on attitudes toward sexual intercourse. With the serious nature of some of the undesired consequences of adolescent sexual behavior, current and accurate information on this population is needed to assist health educators in developing interventions in this area.

A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern New England

OBJECTIVE

This study analyzes pediatric and adolescent Papanicolaou (Pap) smear diagnoses to determine the prevalence rates of squamous intraepithelial lesion (SIL) as well as infectious and reactive processes in this age group.

DESIGN

A total of 10 296 Pap smear diagnoses from patients 10 to 19 years of age collected over a 1-year period and classified according to the Bethesda system were reviewed. This population was almost exclusively white, the majority residing in rural or suburban areas of Maine, New Hampshire, and Vermont. The percentage of abnormal smear results was then compared with data generated for older age subsets.

RESULTS

The following diagnoses were made on 10 296 Pap smears from patients 10 to 19 years of age: 7208 (70.01%) normal; 1689 (16.4%) benign cellular change; 1004 (9.75%) atypical squamous cells of undetermined significance; 388 (3.77%) squamous intraepithelial lesion (SIL); and 7 (0.06%) atypical glandular cells of undetermined significance. A total of 1503 (14.6%) of smears showed infectious processes. Compared with the results of adult Pap smears collected over the same time period, the age 20 to 29 subset with 27 067 Pap smears and the age 30+ subset with 42 617 Pap smears showed 11.79% and 8.43% infectious processes and 3.49% and 1.27% SIL, respectively. Therefore, the highest rate of infectious processes and SIL was found in the subset of patients age 10 to 19 years.

CONCLUSIONS

Because the development of SIL and hence cervical cancer is causally related to sexually transmitted human papilloma virus (HPV) infection, this high rate of abnormal Pap smear results of both an infectious and precancerous nature in this population may reflect a high level of sexual activity among adolescent girls. These data reinforce the importance of implementing early cervical Pap smear screening in the sexually active pediatric and adolescent population.

Squamous intraepithelial lesions in cervical smears of human immunodeficiency virus-seropositive adolescents

Various authors have reported a high rate of human papillomavirus (HPV) infection and HPV-related neoplasias in human immunodeficiency virus (HIV)-seropositive women. On the other hand, young women are most susceptible to cervical infection because of immaturity of the cervix, as it appears that HPV has more access to the basal cells of the differentiating epithelium. The purpose of the present work was to study cervical smears of 82 adolescent HIV-seropositive women (13-21 years of age) to search for cytological evidence of cervical intraepithelial neoplasias. Twenty-one cases showed characteristic features of HPV infection and squamous intraepithelial lesions (SIL; 25.6%). Sixteen cases aged from 17 to 21 years (mean age 19.5 years) had low-grade SIL (LSIL; 19.5%) and five cases aged from 18 to 21 years (mean age 20.2 years) had high-grade SIL (HSIL; 6.1%). There was no significant difference between the mean age of patients with LSIL and HSIL. Two cases had atypical squamous cells of undetermined significance (ASCUS). In the present work it was found that HIV-seropositive adolescents have a high risk for preneoplastic lesions of the cervix (25.6%) as well as a high incidence of more aggressive lesions (6.1% of HSIL) when compared to the general population of adolescents. As it can be assumed that, if the age of acquisition of the infection in both groups (in the general population and HIV-seropositive women) is the same, it is probable that HIV infection in adolescents not only increases the frequency of HPV infections but also facilitates the evolution to more aggressive preneoplastic lesions of the cervix due to HPV.

History of genital warts in 10,838 women 20 to 29 years of age from the general population. Risk factors and association with Papanicolaou smear history

BACKGROUND AND OBJECTIVES

The most important risk factor for cervical neoplasia is genital infection with certain types of human papillomavirus (HPV). Genital warts (GW) are an easily recognizable condition caused by HPV. Although only a fraction of HPV infections are clinical, a history of ever having had GW could serve as a marker for exposure to HPV.

GOALS

To study the risk factors for ever having had GW. The association of GW with abnormal Papanicolaou (Pap) smear and relation to cervical neoplasia is also discussed.

STUDY DESIGN

A case-control study among 10,838 women aged 20 to 29 years and reporting at least one lifetime sexual partner. The women were participants in a prospective cohort study on the relationship between HPV and cervical neoplasia in Copenhagen, Denmark. Data were obtained by means of personal interviews using structured questionnaires.

RESULTS

In all, 1,820 women (17%) reported ever having had GW. The most important risk factor was the number of lifetime of sexual partners (adjusted odds ratio 5.2; 95% confidence interval: 3.4-8.0) for at least 40 partners vs. 1 to 2 partners). The number of regular partners, sexually active years, a history of chlamydial infection, and smoking were also associated with the risk of ever having had GW. Women who had had GW were 1.9 times more likely than other women to report an abnormal Pap smear.

CONCLUSIONS

The study confirms the sexual transmission of the infection. There is also good concordance between risk factors for ever having had GW and cervical neoplasia. A close relationship between having had GW and an abnormal Pap smear was observed.

The role of vaccines in the control of STDs: HPV vaccines

Prophylactic vaccines for genital human papillomavirus (HPV) infection have been shown to be feasible in animal models, and suitable vaccine material based on virus-like particles can be produced in bulk at reasonable cost. Initiation of phase III clinical trials will follow definition of trial outcome measures through further epidemiological studies, and development of assays of host protective immunity. Vaccines could in principle eliminate HPV-related disease, as the human race is the only natural host for the relevant papillomaviruses (PVs). Therapeutic vaccines for genital HPV infection are also possible, but have not yet been demonstrated as feasible in practice because the choice of vaccine antigens is difficult, the method of their optimal delivery is uncertain, and the nature of the relevant antiviral immunity is unknown. PV species specificity will require trials to be conducted in man, which will slow definition of an ideal vaccine.