A prospective cohort study characterising the role of anogenital warts in HIV acquisition among men who have sex with men: a study protocol

Incidence, psychosocial burden, and economic impact of genital warts in Mexico

OBJECTIVE

To estimate the burden of genital warts (GW)in Mexico.

MATERIALS AND METHODS

We estimated the annual incidence of GW based on data reported by specialist physicians. We also assessed GW treatment practices, the average cost of treatment, and the psychosocial burden of GW among patients.

RESULTS

The annual incidence of GW in Mexico was estimated to be 547 200 cases. Treatment procedures vary by specialist and patient gender. The estimated annual cost was $195 million USD. The psychosocial impact of GW was slightly greater in males than females.

CONCLUSIONS

This is the first evaluation of the burden of GW in Mexico. Our data suggest that GW are common, with significant health-related costs and psychosocial impact.

The relationship between anogenital HPV types and incident HIV infection among men who have sex with men and transgender women in Lima, Peru: Findings from a prospective cohort study

Although it is known that individuals living with HIV have a higher HPV prevalence, the impact of individual HPV types on HIV acquisition is less clear. In this prospective cohort study we investigated the relationship between HPV types and incident HIV infection among men who have sex with men (MSM) and transgender women (TW) in Lima, Peru. Six hundred HIV-negative Peruvian MSM and TW participated in a 2-year study with biannual visits. At baseline, participants completed a computerized, self-administered questionnaire on sexual behavior and HPV knowledge and underwent a physical exam including anogenital swabs for HPV DNA (37 genotypes via linear array testing) and HIV testing; follow-up visits included the questionnaire and HIV testing. Participant mean age was 25 years (range = 18-40), with 48.9% self-identifying as gay and 86.5% reporting having sex exclusively with men. At baseline, 530 participants had HPV DNA present (61.1% with high-risk HPV, 84.9% with low-risk HPV). Among 571 participants who returned for any study visit, 73 (12.8%) became infected with HIV during the 2-year follow-up (6% HIV incidence). Compared to those without HIV, more participants with HIV had any HPV type present (97.3% vs. 87.6%, respectively, p = .01), more than one HPV type (79.5% vs. 58.2%, p < .01), or high-risk HPV (72.6% vs. 51.4%, p < .01). Some participants lost to follow-up could have been HIV-positive, which would have affected the relationship of HPV and HIV infection. Our prospective study showed that participants with any HPV type, more than one HPV type, or high-risk HPV were more likely to test positive for HIV. Although most studies have shown HPV-HIV coinfection, our findings illustrate the strong relationship between individual HPV types and HIV infection. This further illustrates the potential utility of HPV vaccine for MSM and TW, not only for HPV prevention but also possibly for HIV prevention.

Individual-level characteristics associated with oral HIV test acceptability among Peruvian men who have sex with men and transgender women: a cross-sectional study

OBJECTIVES

Peruvian men who have sex with men (MSM) and transgender women (TGW) are highly vulnerable to HIV infection (HIV), but stigma, access issues and fear of venipuncture hamper testing. The oral HIV test-which uses oral fluids and provides results in 20 minutes-could reduce these barriers. The objective of this study was to determine the acceptability of the oral HIV test and the individual-level factors associated with its acceptability among MSM and TGW.

METHODS

We conducted a cross-sectional secondary analysis among Peruvian MSM and TGW attending a community-based health centre between February 2012 and February 2013 to determine the individual-level factors associated with oral HIV test acceptability.

RESULTS

Of 334 participants, 88% were MSM and 12% TGW. Overall, 85% of participants indicated their acceptability of the oral HIV test. Acceptability was higher in MSM than TGW (85.7% vs 80.0%) but this difference was not significant. Factors associated with acceptability in MSM were: tertiary or higher education (prevalence ratio (PR)=1.18, 95% CI 1.06 to 1.32 and PR=1.16, 95% CI 1.03 to 1.30, respectively); sex with drug use (PR=1.19, 95% CI 1.05 to 1.36); believing that HIV is transmitted by saliva (PR=1.20, 95% CI 1.08 to 1.33); and potential use of the oral test at home (PR=1.56, 95% CI 1.32 to 1.85). The only factor associated with lower acceptability was having had first anal intercourse between 14 and 19 years of age (PR=0.89, 95% CI 0.80 to 0.98).

CONCLUSIONS

We identified the individual factors associated with oral HIV test acceptability among Peruvian MSM and TGW. Expanded use of the oral HIV test to increase testing rates among Peruvian MSM and TGW is recommended.

TRIAL REGISTRATION NUMBER

NCT01387412, post-results.

HPV knowledge, burden and genital wart location among heterosexually identified versus homosexually identified men who have sex with men in Lima, Peru: cross-sectional results from a cohort study

OBJECTIVES

The relationship between sexual practices, identity and role among Latino men who have sex with men (MSM) and HIV risk is the subject of ongoing investigation but less is known about how these aspects of sexuality relate to human papilloma-virus (HPV), an independent risk factor for HIV. This observational study investigated the relationship between HPV and sexual practices, identity and role as well as other sexually transmitted infection (STI)/HIV risk factors among HIV-negative heterosexually and homosexually identified Peruvian MSM.

SETTING

Community-based clinic for MSM in Lima, Peru.

PARTICIPANTS

756 subjects were screened based on inclusion criteria of: born anatomically male; age ≥18 years; had any anal intercourse with a man during the previous 12 months; residing in metropolitan Lima; HIV negative; willing to commit to twice-yearly clinic visits for 24 months; had not participated in an HIV or HPV vaccine study. 600/756 participants met the inclusion criteria and were enrolled, of whom 48% (284) identified as homosexual and 10% (57) as heterosexual, the basis of the analyses performed.

RESULTS

Compared with homosexually identified MSM, heterosexually identified MSM had completed fewer years of formal education and were less likely to have: anogenital HPV or visible anal warts; given oral sex to a man; or used a condom with their most recent female sexual partner (all p<0.05). Conversely, heterosexually identified MSM were more likely to have: visible penile warts; used a condom during last anal intercourse; smoked cigarettes; had transactional sex; and used drugs during sex in the previous month (all p<0.01). There was no difference found between heterosexually and homosexually identified MSM by syphilis or high-risk HPV prevalence.

CONCLUSIONS

HPV burden, wart type (penile vs anal) and select HIV/STI risk behaviours differed between heterosexually and homosexually identified Peruvian MSM. Understanding the implications of these differences can lead to tailored HIV/STI prevention interventions for heterosexually identified MSM.

TRIAL REGISTRATION NUMBER

NCT01387412.

Rectal Douching Prevalence and Practices Among Peruvian Men Who have Sex with Men and Transwomen: Implications for Rectal Microbicides

Peruvian men who have sex with men (MSM) and transwomen (TW) could benefit from a rectal microbicide (RM) formulated as a rectal douche to prevent HIV infection. However, little is known about rectal douching practices among Peruvian MSM and TW, information necessary to inform RM douche development and future uptake. Using a self-administered interview, we examined the prevalence of and factors associated with rectal douching among a convenience sample of 415 Peruvian MSM and 68 TW. In the previous 6 months, 18 % of participants reported rectal douching using pre-filled commercial kits or plastic bottles or enema bags filled with water, water/soap or saltwater. Multivariate logistic analysis found that "equally insertive and receptive" or "exclusively/mainly receptive" sex roles were associated with douche use. Rectal douching among Peruvian MSM and TW is similar to reports from other studies and supports the potential uptake of a douche-formulated RM in these populations.

Anogenital Human Papillomavirus Infection and HIV Infection Outcomes Among Peruvian Transgender Women: Results from a Cohort Study

Latin American transgender women are highly vulnerable to HIV infection, and although much is known about factors associated with HIV infection in this population, little is known about the association of human papilloma virus (HPV) with HIV infection. We investigated anogenital HPV and cumulative HIV incidence among 68, initially HIV uninfected, Peruvian transgender women enrolled into a 2-year, prospective cohort study: 95.6% had at least one anogenital HPV genotype at baseline, 19.1% had visible anogenital warts, and 6.0% became infected with HIV over the course of the study. Due to the high anogenital HPV prevalence, this population would likely benefit from early immunization with the HPV vaccine.

Sociodemographic and behavioral correlates of anogenital warts and human papillomavirus-related knowledge among men who have sex with men and transwomen in Lima, Peru

BACKGROUND

Human papilloma virus (HPV) is the most common sexually transmitted infection (STI) globally, with a high burden of anogenital warts (AGW) among men who have sex with men (MSM) and transwomen (TW).

METHODS

Six-hundred HIV negative MSM and TW (300 with AGW, 300 without) were recruited for a prospective cohort study to examine HPV outcomes and HPV vaccine knowledge. Participants completed a self-administered online questionnaire. Logistic regression was used to assess the association between sociodemographic and behavioral characteristics with HPV vaccine knowledge.

RESULTS

The average participant age was 25.5 years. Most (67%) were single and 41.2% self-reported STI symptoms. The average age of first anal intercourse was 17 years, with self-reported sexual role as active (36%), passive (36%), and both (27%). Three quarters (77%) of participants reported engaging in condomless anal or oral sex up to six months prior to the study. Less than half (48%) of participants had heard of HPV. Participants with AGW were more likely to report that condoms helped prevent HPV (p=0.01) and that the absence of genital warts does not mean the absence of HPV (p < 0.01).

CONCLUSION

Study participants had low levels of HPV knowledge but likely high HPV exposure due to condomless anal sex. The HPV knowledge gap may be explained in part by the stigma of sex work, underreporting of STIs, the high cost of the HPV vaccine in Peru, and misinformation about HPV vaccine. More work is needed to educate MSM and TW on HPV and the HPV vaccine.

Prevalence, Incidence, and Clearance of Anogenital Warts in Kenyan Men Reporting High-Risk Sexual Behavior, Including Men Who Have Sex With Men

Background.  Human papillomavirus (HPV) causes a spectrum of disease, ranging from warts to cancer. Prevalence, incidence, and factors associated with anogenital warts in East African men are unknown. Methods.  Kenyan men reporting high-risk sexual behavior were inspected for anogenital warts at enrollment and follow-up visits. Logistic regression was performed to identify associations with anogenital warts at baseline. Cox regression was performed to analyze predictors of incident anogenital warts, and Kaplan-Meier curves were used to estimate clearance. Results.  Baseline anogenital wart prevalence in 1137 men was 2.9% (95% confidence interval [CI], 2.0%-4.0%) overall, 2.0% in human immunodeficiency virus (HIV)-uninfected men, and 9.4% in HIV-1-infected men (adjusted odds ratio, 5.43; 95% CI, 2.03-11.29). Over a median of 1.4 years, anogenital wart incidence among 1104 men was 5.3 (95% CI, 4.3-6.5) per 100 person-years. Having HIV-1 infection at baseline (adjusted hazard ratio [aHR], 1.66; 95% CI, 1.01-2.72) or a genital syndrome during follow-up (aHR, 4.78; 95% CI, 3.03-7.56) was associated with increased wart incidence. Wart clearance was lower in HIV-1-infected men (log-rank P<.001). Conclusions.  Anogenital wart prevalence and incidence were increased in HIV-1-infected men, and anogenital warts co-occurred with other genital syndromes. Quadrivalent HPV vaccination should be recommended for young men in settings with high HIV-1 prevalence.

Anal Human Papillomavirus Genotyping among HIV-Positive Men Who Have Sex with Men in Xi'an, China

Background

Anal human papillomavirus (HPV) infection and its related diseases are relatively common in men who have sex with men (MSM), especially in those HIV positive. In China, molecular epidemiology of anal HPV infection among HIV-positive MSM has been sparsely studied.

Methods

A cross-sectional study was conducted among HIV-positive MSM in Xi’an, China between April and July 2014. Anal swabs were collected for HPV genotyping.

Results

A total of 195 HIV-positive MSM were included in this study. HPV genotyping showed that 99.0% (191/193) of participants were positive for at least one of the targeted 37 HPV genotypes. 183 (94.8%) of them were infected with multiple high-risk types and 154 (79.8%) of them with low-risk HPV types. HPV 18 was the most frequently identified high-risk type, followed by HPV 16 and HPV 51. As for low-risk types, HPV11, HPV 6 and HPV 81 were most commonly observe. High-risk HPV infection was found to be associated with the status of antiretroviral therapy (ART), the distribution of low-risk types was observed to be varied by CD4⁺ T cell level.

Conclusion

Almost all HIV-positive MSM were anal HPV infected in our study. It is highly recommended to consider regular active screening and preventive intervention of HPV infection among this high risk population.