Near Elimination of Genital Warts in Australia Predicted With Extension of Human Papillomavirus Vaccination to Males

Estimation of mid-and long-term benefits and hypothetical risk of Guillain-Barre syndrome after human papillomavirus vaccination among boys in France: A simulation study

BACKGROUND

The burden of human papillomavirus (HPV) infection can be substantially reduced through vaccination of girls, and gender-neutral policies are being adopted in many countries to accelerate disease control among women and expand direct benefits to men. Clinical direct benefit of boys HPV vaccination has been established for ano-genital warts and anal cancer. HPV vaccines are considered safe, but an association with Guillain-Barre syndrome has been found in French reimbursement and hospital discharge data.

METHODS

We conducted a Monte-Carlo simulation assuming a stable French population of 11- to 14-year-old boys, adult men and men having sex with men. We modelled and quantified the mid-term benefits as the annually prevented ano-genital warts among the 8.72 M men aged 15-35 years and the long-term benefits as the annually prevented anal cancer cases among the 17.4 M men aged 25-65 years. We also estimated the number of Guillain-Barre syndrome cases hypothetically induced by vaccination.

RESULTS

With a vaccine coverage of 30%, an annual number of 9310 (95% uncertainty interval [7050-11,200]) first ano-genital warts episodes among the 8.72 M men aged 15-35 years are prevented. According to more or less optimistic hypotheses on the proportion of HPV cancers covered by the vaccine, between 15.1 [11.7-17.7] and 19.2 [15.0-22.6] cases of anal cancer among the 17.4 M men aged 25-65 years would be annually avoided. Among men having sex with men, the corresponding figures were 1907 (1944-2291) for ano-genital warts and between 2.0 [0.23-4.5] and 2.6 [0.29-5.7] for anal cancer. Among 11- to 14-year-old boys, 0.82 (0.15-2.3) Guillain-Barre syndrome cases would be induced annually.

INTERPRETATION

A long-term program of HPV vaccination among boys in France would avoid substantially more cancer cases than hypothetically induce Guillain-Barre syndrome cases, in the general and specifically the homosexual population. Additional benefits may arise with the possible vaccine protection against oro-laryngeal and -pharyngeal cancer.

Effect on genital warts in Australian female and heterosexual male individuals after introduction of the national human papillomavirus gender-neutral vaccination programme: an analysis of national sentinel surveillance data from 2004-18

BACKGROUND

In Australia, the government-funded human papillomavirus (HPV) vaccination programme was introduced in April, 2007, for girls and young women, and in February, 2013, for boys. As of Dec 31, 2018, all Australian-born female individuals younger than 38 years and male individuals younger than 21 years have been eligible for the free quadrivalent or nonavalent HPV vaccine. We aimed to examine the trends in genital wart diagnoses among Australian-born female and heterosexual male individuals who attended sexual health clinics throughout Australia before and after the introduction of the gender-neutral HPV vaccination programme in February, 2013.

METHODS

We did a serial cross-sectional analysis of genital wart diagnoses among Australian-born female and heterosexual male individuals attending a national surveillance network of 35 clinics between Jan 1, 2004, and Dec 31, 2018. We calculated prevalence ratios of genital warts, using log-binomial regression models, for the female-only vaccination period (July 1, 2007, to Feb 28, 2013), gender-neutral vaccination period (March 1, 2013, to Dec 31, 2018), and the whole vaccination period (July 1, 2007, to Dec 31, 2018) compared with the pre-vaccination period (Jan 1, 2004, to June 30, 2007).

FINDINGS

We included 121 038 men and 116 341 women in the analysis. Overall, we observed a 58% reduction (prevalence ratio 0·42, 95% CI 0·40-0·44) in genital wart diagnoses in female individuals and a 45% reduction (0·55, 0·53-0·57) in genital wart diagnoses in heterosexual male individuals after the introduction of the vaccination programme in 2007. The largest reduction in genital warts was observed in younger individuals, and there was a decreasing magnitude of reduction with increasing age (80%, 72%, 61%, 41%, and 16% reductions in female individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively; 70%, 61%, 49%, 37%, and 29% reductions in male individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively). Significant reductions observed in female individuals (0·32, 0·28-0·36) and male individuals (0·51, 0·43-0·61) aged 15-20 years in the female-only vaccination period were followed by a more substantial reduction in female individuals (0·07, 0·06-0·09) and male individuals (0·11, 0·08-0·15) aged 15-20 years in the gender-neutral vaccination period.

INTERPRETATION

The national gender-neutral HPV vaccination programme has led to substantial and ongoing reduction in genital warts among Australian female and heterosexual male individuals, with a marked reduction in young individuals who received the vaccine at school.

FUNDING

Seqirus Australia and the Australian Government Department of Health.

Population Impact of Girls-Only Human Papillomavirus 16/18 Vaccination in The Netherlands: Cross-Protective and Second-Order Herd Effects

Background

Human papillomavirus (HPV) vaccination programs achieve substantial population-level impact, with effects extending beyond protection of vaccinated individuals. We assessed trends in HPV prevalence up to 8 years postvaccination among men and women in the Netherlands, where bivalent HPV vaccination, targeting HPV types 16/18, has been offered to (pre)adolescent girls since 2009 with moderate vaccination coverage.

Methods

We used data from the PASSYON study, a survey initiated in 2009 (prevaccination) and repeated biennially among 16- to 24-year-old visitors of sexual health centers. We studied genital HPV positivity from 2009 to 2017 among women, heterosexual men, and unvaccinated women using Poisson generalized estimating equation models, adjusted for individual- and population-level confounders. Trends were studied for 25 HPV types detected by the SPF10-LiPA25 platform.

Results

A total of 6354 women (64.7% self-reported unvaccinated) and 2414 heterosexual men were included. Percentual declines in vaccine types HPV-16/18 were observed for all women (12.6% per year [95% confidence interval {CI}, 10.6–14.5]), heterosexual men (13.0% per year [95% CI, 8.3–17.5]), and unvaccinated women (5.4% per year [95% CI, 2.9–7.8]). We observed significant declines in HPV-31 (all women and heterosexual men), HPV-45 (all women), and in all high-risk HPV types pooled (all women and heterosexual men). Significant increases were observed for HPV-56 (all women) and HPV-52 (unvaccinated women).

Conclusions

Our results provide evidence for first-order herd effects among heterosexual men against HPV-16/18 and cross-protective types. Additionally, we show second-order herd effects against vaccine types among unvaccinated women. These results are promising regarding population-level and clinical impact of girls-only bivalent HPV vaccination in a country with moderate vaccine uptake.

Defining Elimination of Genital Warts-A Modified Delphi Study

Background: Substantial declines in genital warts (GW) have been observed in countries with quadrivalent HPV vaccination programmes, with Australia showing the highest reductions due to early commencement and high vaccination coverage. There is a real potential to achieve GW elimination; however, no GW elimination definition exists. Taking Australia as a case study, we aimed to reach expert consensus on a proposed GW elimination definition using a modified Delphi process. Method: We used modelling and epidemiological data to estimate the expected number of new GW cases, from pre-vaccination (baseline) in 2006 to the year 2060 in Australian heterosexuals, men who have sex with men (MSM), and newly arrived international travellers and migrants. We used these data and the literature, to develop a questionnaire containing ten elimination-related items, each with 9-point Likert scales (1-strongly disagree; 9-strongly agree). The survey was completed by 18 experts who participated in a full day face-to-face modified Delphi study, in which individuals and then small groups discussed and scored each item. The process was repeated online for items where consensus (≥70% agreement) was not initially achieved. Median and coefficient of variation (COV) were used to describe the central tendency and variability of responses, respectively. Findings: There was a 95% participation rate in the face-to-face session, and 84% response rate in the final online round. The median item score ranged between 7.0 and 9.0 and the COV was ≤0.30 on all items. Consensus was reached that at ≥80% HPV vaccination coverage, GW will be eliminated as a public health problem in Australia by 2060. During this time period there will be a 95% reduction in population-level incidence compared with baseline, equivalent to <1 GW case per 10,000 population. The reductions will occur most rapidly in Australian heterosexuals, with 73%, 90% and 97% relative reductions by years 2021, 2030 and 2060, respectively. The proportion of new GW cases attributable to importation will increase from 3.6% in 2006 to ~49% in 2060. Interpretation: Our results indicate that the vaccination programme will minimise new GW cases in the Australian population, but importation of cases will continue. This is the first study to define GW elimination at a national level. The framework developed could be used to define GW elimination in other countries, with thresholds particularly valuable for vaccination programme impact evaluation. Funding: LK supported through an Australian Government Research Training Programme Scholarship; unconditional funding from Seqirus to support the Delphi Workshop.

Recurrence patterns identify aggressive form of human papillomavirus-dependent vulvar cancer

BACKGROUND

Vulvar cancer is rare and, as a result, is understudied. Treatment is predominantly surgery, irrespective of the type of vulvar cancer, and is associated with physical, emotional and sexual complications. A cluster of human papillomavirus (HPV)-dependent vulvar cancer patients was identified in Arnhem Land Northern Territory (NT), Australia, in which young Indigenous women were diagnosed at 70 times the national incidence rate.

AIMS

To assess whether women from the Arnhem Land cluster differ from women with vulvar squamous cell carcinoma (VSCC) and vulvar intraepithelial neoplasia (VIN) resident elsewhere in the NT in recurrence after treatment, disease progression and mortality.

MATERIALS AND METHODS

A retrospective cohort study of NT-resident women diagnosed with VIN or invasive vulvar cancer (VSCC) between 1 January 1993 and 30 June 2015 was undertaken. Time to recurrence was assessed using cumulative incidence plots and Fine and Gray competing risk regression models. Mean cumulative count was used to estimate the burden of recurrent events.

RESULTS

Indigenous women from Arnhem Land experienced more recurrences after treatment than non-Indigenous women, the cancers recurred faster, and Indigenous women have worse survival at five years.

CONCLUSIONS

In characterising the epidemiological features of this cluster, we have identified a particularly aggressive form of vulvar cancer. This provides a unique opportunity for elucidating the aetiopathological pathways driving vulvar cancer development that may ultimately lead to preventive and therapeutic targets for this neglected malignancy. Further, these findings have important implications for clinical practice and HPV vaccination policy in the affected population.

Knowledge towards human papilloma virus (HPV) infection and attitude towards its vaccine in the Kingdom of Bahrain: cross-sectional study

OBJECTIVES

To determine the level of awareness of human papilloma virus (HPV) infection and to assess attitudes towards receiving the vaccine among men and women in Bahrain.

DESIGN

A cross-sectional study. An interview-based questionnaire was used to measure HPV knowledge and attitude towards HPV vaccine.

SETTING

Ten randomly selected primary health centres (PHCs) in the Kingdom of Bahrain.

PARTICIPANTS

408 PHC attendees, including 268 women and 140 men aged 18-65 years. Only residents from Bahrain and English or Arabic speakers were invited to participate.

PRIMARY AND SECONDARY OUTCOME MEASURES

Extent of awareness of HPV infection, acceptance of HPV vaccine and describing the results in association to gender, educational level and other demographics.

RESULTS

A response rate of 91.4% was achieved, with a majority being female responders as opposed to male responders (65.7% vs 34.3%, respectively). Only 13.5% of the participants had heard of HPV, with female gender and employment in the health sector (p<0.001 for both) having a significant association with awareness of HPV. The majority of the participants (76%) were willing to take the vaccine if recommended, with 84.8% believing that both genders should be vaccinated. However, 48.5% were concerned about possible side effects from the vaccine and 83.6% wanted reassurance that the vaccine will protect against HPV. More than 90% of the participants agreed on the need for educating the community about the HPV infection.

CONCLUSION

Despite the limited knowledge about HPV infection among the study's participants, there is a favourable attitude towards the HPV vaccine. These data can support the initiation of a nationwide HPV immunisation programme.

The impact of 10 years of human papillomavirus (HPV) vaccination in Australia: what additional disease burden will a nonavalent vaccine prevent?

Background: A National human papilloma virus (HPV) Vaccination Programme for the prevention of HPV infection and associated disease using the quadrivalent HPV vaccine (4vHPV) has been funded and implemented in Australia since 2007, initially for girls only and extended to boys in 2013, with uptake rates among the highest observed worldwide. Aim: We report on the impact of this national programme on HPV prevalence and associated disease burden and estimate the potential impact of adopting a nonavalent HPV (9vHPV) vaccine. Methods: We performed a non-systematic literature review of studies measuring the burden of HPV-associated disease and infection in Australia before and after introduction of HPV vaccination. We also included key national reports with estimates of HPV-related disease burden. Results: Substantial declines in high-grade cervical disease and genital warts among vaccine-eligible women have been observed. Reductions in genital warts incidence and HPV prevalence among heterosexual men of similar age were observed before introduction of the male vaccination programme, indicating a substantial herd effect. 9vHPV vaccine is expected to prevent up to 90% of cervical and 96% of anal cancers. Of an estimated 1,544 HPV-associated cancers in 2012, 1,242 would have been preventable by the 4vHPV vaccine and an additional 187 anogenital cancers by the 9vHPV vaccine. Conclusions: Vaccination using 4vHPV vaccine has had a large demonstrable impact on HPV-related disease in Australia. A switch to 9vHPV could further reduce the HPV-associated cancer burden. With continued high coverage among both males and females, elimination of vaccine-type HPV disease seems achievable in Australia.

Prevalence of human papillomavirus in teenage heterosexual males following the implementation of female and male school-based vaccination in Australia: 2014-2017

BACKGROUND

Australia introduced a school-based human papillomavirus (HPV) vaccination program for females aged 12-13 years in 2007, with a three-year catch-up to age 26; and for boys aged 12-13 from 2013, with a two-year catch-up to age 15. This study aimed to compare the prevalence of penile HPV between teenage heterosexual males in cohorts eligible or non-eligible for the school-based male vaccination program.

METHODS

Between 2014 and 2017, sexually active heterosexual males aged 17-19 were recruited from sexual health centres and community sources across Australia. Males provided a self-collected penile swab for 37 HPV genotypes using Roche Linear Array and completed a questionnaire. We calculated adjusted prevalence ratios (aPR) of HPV between males in two periods: 2014-2015 (preceding implementation of school-based male vaccination) and 2016-2017 (eligible for school-based male vaccination). Self-reported vaccine doses were confirmed with doses reported to the National HPV Vaccination Program Register.

RESULTS

Overall, 152 males were recruited in 2014-2015 and 146 in 2016-2017. Numbers of female sex partners and condom use did not differ between the two periods. The prevalence of quadrivalent vaccine-preventable [4vHPV] genotypes (6/11/16/18) was low in both periods (2.6% [2014-15] versus 0.7% [2016-17]; p = 0.371; aPR 0.28 [95% CI: 0.03-2.62]). Compared with men in 2014-2015, men in 2016-2017 had a lower prevalence of any of the 37 HPV genotypes tested (21.7% versus 11.6%; aPR 0.62 [95% CI: 0.36-1.07]) and any of the 13 high-risk genotypes tested (15.8% versus 7.5%; aPR 0.59 [95% CI: 0.30-1.19]). Prevalence of low-risk HPV genotypes did not differ between the two periods. Of the males recruited in 2016-2017, 55% had received ≥1 vaccine dose.

CONCLUSION

The prevalence of 4vHPV genotypes among teenage heterosexual males in both cohorts was low, presumably due to herd protection from the female-only vaccination program. Further studies are required to determine the impact of universal HPV vaccination on HPV prevalence in males.

As through a glass, darkly: the future of sexually transmissible infections among gay, bisexual and other men who have sex with men

The trajectory of sexually transmissible infection (STI) incidence among gay and other men who have sex with men (MSM) suggests that incidence will likely remain high in the near future. STIs were hyperendemic globally among MSM in the decades preceding the HIV epidemic. Significant changes among MSM as a response to the HIV epidemic, caused STI incidence to decline, reaching historical nadirs in the mid-1990s. With the advent of antiretroviral treatment (ART), HIV-related mortality and morbidity declined significantly in that decade. Concurrently, STI incidence resurged among MSM and increased in scope and geographic magnitude. By 2000, bacterial STIs were universally resurgent among MSM, reaching or exceeding pre-HIV levels. While the evidence base necessary for assessing the burden STIs among MSM, both across time and across regions, continues to be lacking, recent progress has been made in this respect. Current epidemiology indicates a continuing and increasing trajectory of STI incidence among MSM. Yet increased reported case incidence of gonorrhoea is likely confounded by additional screening and identification of an existing burden of infection. Conversely, more MSM may be diagnosed and treated in the context of HIV care or as part of routine management of pre-exposure prophylaxis (PrEP), potentially reducing transmission. Optimistically, uptake of human papillomavirus (HPV) vaccination may lead to a near-elimination of genital warts and reductions in HPV-related cancers. Moreover, structural changes are occurring with respect to sexual minorities in social and civic life that may offer new opportunities, as well as exacerbate existing challenges, for STI prevention among MSM.

Human Papillomavirus Research: Where Should We Place Our Bets?

BACKGROUND

Massive strides have been made with respect to primary and secondary prevention of human papillomavirus (HPV)-associated disease as a result of prophylactic vaccination and cervical screening based on molecular HPV testing. However, cervical cancer continues to be an important clinical and societal burden. Additionally, other HPV-associated cancers, for which there are no screening programmes, are rising. Finally, the optimal combination of vaccination and screening strategies will require careful thinking. Considering this unprecedented and important time, we were keen to solicit the views of the expert community to determine what they perceived were the key priorities for HPV research. Our objective was to identify consensus and key priorities for HPV-based research through provision of a questionnaire disseminated to a multidisciplinary group of key opinion leaders (KOLs).

SUMMARY

A structured survey composed of 46 HPV research "categories" was sent to 73 KOLs who were invited to "rank" the categories according to priority. The invitees represented clinical and public health disciplines as well as basic scientists. Scores were weighted according to the number of responses. Invitees also had the opportunity to comment on barriers to the research and suggest other research areas that required attention not reflected in the survey. We received 29 responses in total; overall, the 3 highest-ranked categories were "optimal cervical screening in low and middle-income countries (LMICs)," "primary disease prevention in LMICs" and "impact of vaccine on HPV infection and associated disease." "HPV and the microbiome" and "mechanisms of transformation" were the highest-ranked categories with respect to basic research. Consistent barriers to research were around governance on the use of samples and data and funding, particularly in an era of vaccination. Key Messages: Research to support the management of disease in LMICs is clearly perceived as a priority in the international community in addition to other diverse areas which necessitate an improved basic understanding of viral mechanisms and interactions. International, multidisciplinary efforts which articulate the broader HPV research agenda will be important when seeking funding in addition to international endeavours to support the efficient use of existing samples and cohorts to facilitate such research.

High-Risk Human Papillomaviral Oncogenes E6 and E7 Target Key Cellular Pathways to Achieve Oncogenesis

Infection with high-risk human papillomavirus (HPV) has been linked to several human cancers, the most prominent of which is cervical cancer. The integration of the viral genome into the host genome is one of the manners in which the viral oncogenes E6 and E7 achieve persistent expression. The most well-studied cellular targets of the viral oncogenes E6 and E7 are p53 and pRb, respectively. However, recent research has demonstrated the ability of these two viral factors to target many more cellular factors, including proteins which regulate epigenetic marks and splicing changes in the cell. These have the ability to exert a global change, which eventually culminates to uncontrolled proliferation and carcinogenesis.

Human papillomavirus vaccination and the role of herd effects in future cancer control planning: a review

INTRODUCTION

Vaccine herd effects are the indirect protection that vaccinated persons provide to those who remain susceptible to infection, due to the reduced transmission of infections. Herd effects have been an important part of the discourse on how to best implement human papillomavirus (HPV) vaccines and prevent HPV-related diseases.

AREAS COVERED

In this paper, we review the theory of HPV vaccine herd effects derived from mathematical models, give an account of observed HPV vaccine herd effects worldwide, and examine the implications of vaccine herd effects for future cervical cancer screening efforts.

EXPERT COMMENTARY

HPV vaccine herd effects improve the cost-effectiveness of vaccinating preadolescent girls, but contribute to making gender-neutral vaccination less economically efficient. Vaccination coverage and sexual mixing patterns by age are strong determinants of herd effects. Many countries worldwide are starting to observe reductions in HPV-related outcomes likely attributable to herd effects, most notably declining anogenital warts in young men, and declining HPV-16/18 infection prevalence in young unvaccinated women. Policy makers making recommendations for cervical cancer screening will have to consider HPV vaccination coverage and herd effects, as these will affect the positive predictive value of screening and the risk of cervical cancer in unvaccinated women.

Strengthening the case for gender-neutral and the nonavalent HPV vaccine

PURPOSE

The purpose of this review is to highlight the benefits of gender-neutral and the nonavalent human papillomavirus vaccination. Human papillomavirus infection is the most commonly sexually transmitted disease and is known to cause several types of cancers, including cervical, vulvar, vaginal, penile, oropharyngeal, anal, and rectal. 5% of cancers every year are attributable to human papillomavirus infection, with cervical cancer the most common and oropharyngeal cancer estimated to surpass the incidence of cervical cancer by 2020.

METHODS

PubMed and MEDLINE were searched using the following search terms: [(human papillomavirus OR HPV) AND (vaccine OR vaccination)] AND [(gardasil OR gardasil9 OR cervarix OR quadrivalent OR nonavalent OR ninevalent) OR (gender neutral OR male)].

RESULTS

There are currently three different types of human papillomavirus vaccinations and range in cover from four to nine different strains known to cause human disease. Most countries currently only supply vaccination to females; however, recent data point towards both a personal benefit as well as a cost-effective population-based benefit with gender-neutral vaccination. Data from female vaccination only have shown the vaccine to be effective in preventing premalignant cervical lesions, and are believed to have the same effect for other human papillomavirus cancers. Male vaccination not only provides personal benefit but also has a "herd effect" for females by preventing the propagation of the virus.

CONCLUSION

Gender-neutral vaccination provides significant cost-effective benefits for preventing human papillomavirus-related diseases, and this effect is further enhanced by the use of the nonavalent vaccine.

Declines in Anogenital Warts Among Age Groups Most Likely to Be Impacted by Human Papillomavirus Vaccination, United States, 2006-2014

OBJECTIVES

To detect decreases in anogenital warts (AGW) among sex and age groups likely to be affected by human papillomavirus vaccination.

METHODS

We estimated annual AGW prevalence during 2006 to 2014 using health care claims among US private health insurance enrollees aged 15 to 39 years. We derived AGW diagnoses using 1 of the following: (1) condylomata acuminata diagnosis, (2) viral wart diagnosis combined with a benign anogenital neoplasm diagnosis or destruction or excision of an anogenital lesion, or (3) AGW medication combined with a benign anogenital neoplasm diagnosis or destruction or excision of an anogenital lesion.

RESULTS

Prevalence decreased during 2008 to 2014 among females aged 15 to 19 years (annual percentage change [APC] = -14.1%; P < .001) and during 2009 to 2014 among women aged 20 to 24 years (APC = -12.9%; P < .001) and among women aged 25 to 29 years (APC = -6.0%; P = .001). We observed significant declines among men aged 20 to 24 years (APC = -6.5%; P = .005). Prevalence increased or was stable in all other sex and age groups.

CONCLUSIONS

We observed AGW decreases among females in the age groups most likely to be affected by human papillomavirus vaccination and decreases in men aged 20 to 24 years. Decreased prevalence in young men is likely attributable to herd protection from vaccination among females.

Impact of HPV vaccination on anogenital warts and respiratory papillomatosis

Human papillomavirus (HPV), the most common sexually transmitted infection in the US and worldwide, can cause cancers, anogenital warts (AGW), and recurrent respiratory papillomatosis (RRP) in men, women, and children. Global incidence of AGW ranges from 160-289 cases per 100,000 person-years and peaks in young men and women in the third decade of life. RRP has an estimated incidence of 3 per 1 million person-years in children. Pre-licensure trial efficacy, modeling and time-trend ecological studies have shown a significant short-term impact of 4vHPV vaccine. In girls aged 15-19 years, a previously published meta-analysis indicated that genital warts decreased significantly by 31%; stratified analysis revealed more substantial reductions in populations with high (≥50 %) vs. low (<50 % ) vaccination coverage (61% vs. 14%). Longer-term monitoring will reveal whether this impact continues under 9vHPV programs, and whether current declines in AGW are mirrored by declines in RRP.

[HPV-induced anal lesions]

Human papillomavirus (HPV) infections belong to the most common sexually transmitted infections. To date, more than 200 completely classified HPV-types have been reported, and those belonging to the genus alpha predominantly infect the anogenital region. Condylomata acuminata are caused by the two low-risk types HPV6 and HPV11 in more than 90 % of cases. Treatment of genital warts might be either ablative (e.g. electrocautery, surgical excision, or laser therapy) or topical (e.g. podophyllotoxine, trichloroacetic acid, or imiquimod), and depends on the size, location, morphology and anatomical region. Recurrences after treatment are frequent. Therefore, combination therapies (e.g. topical and ablative) play an important role in daily routine. HIV-infected individuals, especially HIV-positive MSM, have a strongly increased risk for anal dysplasia and anal cancer. Condylomata acuminata and a large proportion of anal dysplasia and anal carcinoma are preventable by prophylactic HPV-vaccination.

Public health value of universal HPV vaccination

BACKGROUND

The story of Human Papillomavirus vaccination demands reflection not only for its public health impact on the prophylactic management of HPV disease, but also for its relevant economic and social outcomes. Greater than ever data confirm the efficacy and support the urge for effective vaccination plans for both genders before sexual debut.

METHODS

A review of previous experience in gender-restricted vaccination programs has demonstrated a lower effectiveness. Limiting vaccination to women might increase the psychological burden on women by confirming a perceived inequality between genders; and even if all women were immunized, the HPV chain of transmission would still be maintained through men.

RESULTS

The cost-effectiveness of including boys into HPV vaccination programs should be re-assessed in view of the progressive drop of the economic burden of HPV-related diseases in men and women due to universal vaccination. The cost of the remarkable increase in anal and oropharyngeal HPV driven cancers in both sexes has been grossly underestimated or ignored.

CONCLUSIONS

Steps must be taken by relevant bodies to achieve the target of universal vaccination. The analysis of HPV vaccination's clinical effectiveness vs. economic efficacy are supportive of the economic sustainability of vaccination programs both in women and men. In Europe, these achievements demand urgent attention to the social equity for both genders in healthcare. There is sufficient ethical, scientific, strategic and economic evidence to urge the European Community to develop and implement a coordinated and comprehensive strategy aimed at both genders and geographically balanced, to eradicate cervical cancer and other diseases caused by HPV in Europe. Policymakers must take into consideration effective vaccination programs in the prevention of cancers.

Human papillomavirus in young women with Chlamydia trachomatis infection 7 years after the Australian human papillomavirus vaccination programme: a cross-sectional study

BACKGROUND

The national quadrivalent human papillomavirus (4vHPV) vaccination programme was launched in Australia in April, 2007. In this study, we aimed to explore the prevalence of vaccine-targeted human papillomavirus (HPV) types contained in the 4vHPV and nine-valent HPV (9vHPV) vaccines detected in young women diagnosed with chlamydia.

METHODS

In this cross-sectional study, we identified specimens from women aged 25 years or younger who attended the Melbourne Sexual Health Centre (Melbourne, VIC, Australia) diagnosed with chlamydia. We calculated the prevalence of 4vHPV types (6, 11, 16, and 18) and the extra five 9vHPV types (31, 33, 45, 52, and 58 alone) excluding 4vHPV types, stratified by Australian financial year (and according to the prevaccination and postvaccination periods) and self-reported vaccination status, for all women, Australian-born women, Australian-born women aged 21 years and younger, and overseas-born women. We calculated adjusted prevalence ratios using binomial log linear regression.

FINDINGS

Between July 1, 2004, and June 30, 2014, we included 1202 women. The prevalence of 4vHPV types in Australian-born women decreased during this period (HPV 6 and 11: 2004-05 nine [16%, 95% CI 8-28] of 56 vs 2013-14 one [2%, 0-9] of 57, p<0·0001; HPV 16 and 18: 17 [30%, 19-44] vs two [4%, 0-12], p<0·0001). In Australian-born women aged 21 years and younger, HPV 6 and 11 prevalence remained at 0% for all years after 2008-09, and we detected HPV 16 and 18 in 5% or less of samples for the same period. In unvaccinated Australian-born women, we noted a significant decrease in 4vHPV types from 66 (41%, 95% CI 34-49) of 160 in the prevaccination period (from July 1, 2004, to June 30, 2007) to five (19%, 6-38) of 27 in the postvaccination period (July 1, 2007, to June 30, 2014; p=0·031), but not in the 9vHPV types, excluding 4vHPV (36 [23%, 95% CI 16-30] vs seven [26%, 11-46]; p=0·805).

INTERPRETATION

The three-dose vaccination coverage was sufficient for the 4vHPV types to almost disappear in Australian-born women aged 21 years or younger within 3 years of introduction of the national HPV vaccination programme. We noted strong herd protection, with a significant decrease in the prevalence of 4vHPV in unvaccinated women. The 4vHPV vaccination programme in Australia has been successful at protecting women against 4vHPV types.

FUNDING

Australian National Health and Medical Research Council.

Quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine (gardasil(®)): a review of its use in the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts

Quadrivalent human papillomavirus (HPV) [types 6, 11, 16, 18] recombinant vaccine (Gardasil(®); Silgard(®)) is composed of virus-like particles formed by self-assembly of recombinant L1 capsid protein from each of HPV types 6, 11, 16 and 18. It is indicated for use from the age of 9 years as a two- or three-dose vaccination course over 6 months for the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts caused by the vaccine HPV types. In placebo-controlled trials, quadrivalent HPV vaccine provided high-level protection against infection or disease caused by the vaccine HPV types over 2-4 years in females aged 15-45 years who were negative for the vaccine HPV types, and provided a degree of cross-protection against certain non-vaccine HPV types. The vaccine also provided high-level protection against persistent infection, anogenital precancerous lesions and genital warts caused by the vaccine HPV types over 3 years in susceptible males aged 16-26 years. Protection has been demonstrated for up to 8 years. In subjects who were negative for the vaccine HPV types, high seroconversion rates and high levels of anti-HPV antibodies were observed in females of all age ranges from 9 to 45 years and in males aged 9-26 years. The vaccine was generally well tolerated and was usually predicted to be cost effective in girls and young women. Therefore, quadrivalent HPV vaccine offers an effective means to substantially reduce the burden of HPV-related anogenital disease in females and males, particularly cervical cancer and genital warts.

High HIV, HPV, and STI prevalence among young Western Cape, South African women: EVRI HIV prevention preparedness trial

BACKGROUND

This study sought to assess the feasibility of conducting a phase III HIV prevention trial using a multivalent human papillomavirus (HPV) vaccine (Gardasil; Merck, Whitehouse Station, NJ).

METHODS

A total of 479 sexually active women aged 16-24 years in the Western Cape, South Africa, were enrolled in the Efficacy of HPV Vaccine to Reduce HIV Infection (EVRI) Trial. Of these, 402 were HIV negative, nonpregnant, and randomized 1:1 to receive Gardasil or a saline placebo vaccine. Vaccine doses were administered at enrollment, month 2, and month 6, and participants were followed for 1 month after the third dose. Enrollment HIV, HPV, other sexually transmitted infections (STIs), and cervical cytology were evaluated. Rates of accrual, vaccine compliance, and adherence to protocol were monitored.

RESULTS

High rates of accrual of eligible females to study (93%) and completion of the 3-dose vaccine series (91%) were noted, with few protocol violations. Ineligibility due to reported HIV positivity was 19%, and another 12% of those enrolled tested HIV positive. STI prevalence was high, with 6.2%, 10.9%, and 32.8% testing positive for syphilis, gonorrhea, and chlamydia, respectively. Cervical prevalence of ≥1 of 37 HPV types was 71%. STI and HPV prevalence was highest among the youngest women (<19 years).

CONCLUSIONS

Feasibility (successful accrual, retention, and vaccination) of conducting randomized placebo-controlled trials of HPV vaccines among HIV high-risk women in South Africa was demonstrated. This work demonstrates that phase III HIV prevention trials need to intervene at young ages and screen and treat multiple STIs concurrently to have a measurable impact on HIV acquisition.

The next steps in cervical screening

Cervical cancer is fourth most common cancer among women with four-fifths of the global burden in low- and middle-income countries (LMICs). Persistent infection with one of the high-risk types of human papillomaviruses (HPV), particularly HPV 16/18, is the central cause of cervical neoplasia. Progress in developing feasible, alternative screening methods in LMICs and HPV vaccines have further improved cervical cancer prevention prospects. While existing screening programs in high-income countries should be re-organized, in view of the downstream effects of national HPV vaccination programs, LMICs should introduce national programs to vaccinate single year cohorts of girls aged 9-13 years with two or three doses and screen 30-35-year-old women with HPV testing to pragmatically decrease their high disease burden.

Ongoing decline in genital warts among young heterosexuals 7 years after the Australian human papillomavirus (HPV) vaccination programme

BACKGROUND

Australia has provided free quadrivalent human papillomavirus (HPV) vaccines to school girls since mid-2007 and a catch-up programme in the community to women aged up to 26 years in 2007-2009. We describe the temporal trend of genital warts in different populations in Melbourne.

METHODS

We analysed the proportion diagnosed with genital warts for all new patients attending Melbourne Sexual Health Centre from July 2004 to June 2014, stratified by different risk groups and age. Adjusted ORs were calculated to compare the annual trend in the proportion of patients with genital warts in different risk groups in the prevaccination period (before June 2007) and the vaccination period (after July 2007).

RESULTS

The proportion with genital warts decreased in women aged <21 years, from 18.4% in 2004/2005 to 1.1% in 2013/2014 (p<0.001), but increased in women aged >32 years, from 4.0% to 8.5% (p=0.037). The odds per year for diagnosis of genital warts adjusted for number of sexual partners in the vaccination period were 0.55 (95% CI 0.47 to 0.65) and 0.63 (95% CI 0.54 to 0.74) in women and heterosexual men aged <21 years, respectively. There was no change in adjusted odds of genital warts in both women and men aged >32 years. A small annual decline in genital warts was observed in men who have sex with men (aOR=0.92; 95% CI 0.88 to 0.97).

CONCLUSIONS

Genital warts have now become rare in young Australian women and heterosexual men 7 years after the launch of the national HPV vaccination programme but in stark contrast, remain common in men who have sex with men.

Impact of genital warts on emotional and sexual well-being differs by gender

To assess gender-specific impact of genital warts on health-related quality of life (HRQoL), and to explore to what extent sexual characteristics and clinical symptoms influenced the impact on emotional and sexual well-being of both sexes. We conducted a survey of sexual and clinical characteristics from persons diagnosed with genital warts at STI clinics. HRQoL was measured using two measurement tools: 1) the generic EQ-5D; and 2) the genital warts-specific CECA-10 including an emotional well-being and a sexual activity dimension. The EQ-5D scores were compared with scores of the general population. Descriptive analyses were used to explore characteristics associated with HRQoL scores stratified for gender. The HRQoL-measurement tools showed that genital warts have especially an emotional impact. The impact of genital warts on HRQoL was greater for women than for men. In addition, the CECA-10 showed that in women the impact of genital warts on sexual activity was influenced by age, relationship status and number of warts. No related factors were seen in men. Genital warts have a greater impact on women than on men. In women, sexual and clinical factors influenced the impact of genital warts on well-being, whereas in men no such factors were found.

Number of external anogenital warts is associated with the occurrence of abnormal cervical cytology

BACKGROUND

Anogenital warts (AGWs) are common results of sexually transmitted infection (STI). Human papillomavirus (HPV) types 6 and 11, which are non-oncogenic types, account for 90% of the clinical manifestations. Although the quadrivalent HPV vaccine has been launched, AGW remains prevalent in some countries and shows association with abnormal cervical cytology.

OBJECTIVES

To study the prevalence of abnormal cervical cytology (low grade squamous intraepithelial lesions or worse; LSIL+) in immunocompetent Thai women newly presenting with external AGWs.

MATERIALS AND METHODS

Medical charts of all women attending Siriraj STI clinic during 2007-2011 were reviewed. Only women presenting with external AGWs who were not immunocompromised (pregnant, human immunodeficiency virus positive or being on immunosuppressant drugs) and had not been diagnosed with cervical cancer were included into the study. Multivariate analysis was used to determine the association between the characteristics of the patients and those of AGWs and LSIL+.

RESULTS

A total of 191 women were eligible, with a mean age of 27.0±8.9 years; and a mean body mass index of 20.6±8.9 kg/m2. Half of them finished university. The most common type of AGWs was exophytic (80.1%). The posterior fourchette appeared to be the most common affected site of the warts (31.9%), followed by labia minora (26.6%) and mons pubis (19.9%). The median number of lesions was 3 (range 1-20). Around 40% of them had recurrent warts within 6 months after completing the treatment. The prevalence of LSIL+ at the first visit was 16.3% (LSIL 12.6%, ASC-H 1.1%, HSIL 2.6%). After adjusting for age, parity and miscarriage, number of warts ≥ 5 was the only factor associated with LSIL+ (aOR 2.65, 95%CI 1.11-6.29, p 0.027).

CONCLUSIONS

LSIL+ is prevalent among immunocompetent Thai women presenting with external AGWs, especially those with multiple lesions.

HPV vaccination in boys and men

Human papillomaviruses are DNA viruses that infect skin or mucosal cells. In the genital tract HPV (especially types 6 and 11) cause genital warts, the commonest viral sexually transmitted disease. At least 13 of the more than 100 known HPV genotypes are oncogenic "high-risk" genotypes. The 2 most common of these (genotypes 16 and 18) cause approximately 70% of all cervical cancers. Oncogenic HPVs particularly HPV 16 are associated with other anogenital cancers, anus, vagina, vulva and penis, and cancers of the head and neck and current estimates are that 5.2% of all cancers are HPV associated. In industrialised countries cervical cancer is controlled by secondary intervention other HPV associated malignancies are increasing in incidence and the burden of HPV associated disease in men is now comparable to that in women in economically developed countries. Randomized control trials with the quadrivalent HPV VLP vaccine demonstrate robust antibody responses and high efficacy against genital warts anal precancers in men. Few countries have recommended male vaccination on the basis that this is not cost effective. However gender-neutral vaccination has been recommended in the USA, Canada, Austria, and Australia. Careful cost effective modeling has preceded these decisions showing that when the burden of disease in men is included in the models then, depending upon coverage, vaccine price, and other factors male vaccination can become cost effective.