HPV infection in men

Co-infection with human papillomavirus and sexually transmitted infections among Chinese individuals

OBJECTIVES

This study aimed to investigate the prevalence of Human Papillomavirus (HPV), Sexually Transmitted Infections (STIs) and their co-infections on different genders and ages.

METHODS

Different samples of secretions from the reproductive system were collected from 459 males and 494 females for HPV and STI detection.

RESULTS

Total HPV infection rate was 49.46 % for males and 48.99 % for females, and the distribution of HPV subtypes varied significantly between different genders. The infection rate of HR-HPV 52 and 31 in females was higher than that in males (p = 0.002 and 0.039, respectively). In contrast, the infection rate of LR-HPV 6 and 11 in males was higher than that in females (p = 0.01 and 0.001, respectively). Females had a significantly higher infection rate of Ureaplasma urealyticum (UU). Besides, these STIs were stratified based on age and the results indicated that the highest incidence of STIs was observed in younger patients (<20 years old). Patients with HPV infections had a higher incidence of Chlamydia trachomatis (CT) in both males and females.

CONCLUSIONS

There is a need to perform HPV, CT and UU screening among patients, and more thorough health education for younger patients is of great clinical significance to improve treatment and prognosis.

Integration of human papillomavirus associated anal cancer screening into HIV care and treatment program in Pakistan: perceptions of policymakers, managers, and care providers

BACKGROUND

The incidence of anal cancer, largely associated with anal human papillomavirus (HPV) infection, is increasing among men who have sex with men (MSM), and transgender women living with or without HIV. Screening for anal cancer to detect anal precancerous lesions in high-risk groups is an important opportunity for prevention but still lacking in many low-and-middle-income countries. The aim of this study was to explore the readiness of Pakistan's healthcare system to integrate anal cancer and HPV screening into a national HIV program, as perceived by policymakers, health managers, and healthcare providers.

DESIGN

This qualitative study using key-informant interviews with participants influence in policy making, implementation and advocacy from public and private sector were conducted between March 2021 to August 2021 in Karachi Pakistan.

METHODS

Key informants were purposely selected from different domains of the healthcare system responsible for the target group of interest, MSM and transgender-women in general and people living with HIV in particular. A total of 18 key informants, at different levels of seniority were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives. Qualitative content analysis was used to identify the manifest and latent themes, based on socioecological framework.

RESULTS

The results were grouped into five major themes; (1) The policy context and priorities, (2) Health systems factors, (3) Community environment, (4) Healthcare setting & providers and (5) Individual-level obstacles. The policy actors expressed their concerns about their limited voice in country's health and health related priority setting. Informants reported a lack of political will and suggested that government should bring a change in the paradigm of healthcare service delivery from reactive to proactive approach. Although, participants unanimously favored integration of HPV preventive services into existing HIV program, they also identified several service delivery barriers including trained workforce shortage, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet key-populations needs. Participants also predicted other implementation challenges such as stigma, social victimization, and systemic discrimination against at-risk groups at healthcare facilities.

CONCLUSION

Although policy makers and health providers in Pakistan saw a clear need to scale-up and integrate anal cancer screening for key populations, the feasibility of this is dependent on political will, financing, anti-stigma and discrimination interventions and health system efficiency.

Proteases and HPV-Induced Carcinogenesis

Simple Summary

Human papillomavirus (HPV) infection is a sexually transmitted disease with high prevalence worldwide. Although most HPV infections do not lead to cancer, some HPV types are correlated with the majority of cervical cancers, and with some anogenital and oropharyngeal cancers. Moreover, enzymes known as proteases play an essential role in the pathogenic process in HPV-induced carcinogenesis. This review highlights the role of proteases and recent epidemiological data regarding HPV-dependent carcinogenesis.

Abstract

Persistent infection with Human papillomavirus (HPV) is the main etiologic factor for pre-malignant and malignant cervical lesions. Moreover, HPV is also associated with oropharynx and other anogenital carcinomas. Cancer-causing HPV viruses classified as group 1 carcinogens include 12 HPV types, with HPV 16 and 18 being the most prevalent. High-risk HPVs express two oncoproteins, E6 and E7, the products of which are responsible for the inhibition of p53 and pRB proteins, respectively, in human keratinocytes and cellular immortalization. p53 and pRB are pleiotropic proteins that regulate the activity of several signaling pathways and gene expression. Among the important factors that are augmented in HPV-mediated carcinogenesis, proteases not only control processes involved in cellular carcinogenesis but also control the microenvironment. For instance, genetic polymorphisms of matrix metalloproteinase 1 (MMP-1) are associated with carcinoma invasiveness. Similarly, the serine protease inhibitors hepatocyte growth factor activator inhibitor-1 (HAI-1) and -2 (HAI-2) have been identified as prognostic markers for HPV-dependent cervical carcinomas. This review highlights the most crucial mechanisms involved in HPV-dependent carcinogenesis, and includes a section on the proteolytic cascades that are important for the progression of this disease and their impact on patient health, treatment, and survival.

Could the human papillomavirus vaccine prevent recurrence of ano-genital warts?: a systematic review and meta-analysis

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and ano-genital warts (AGWs) are highly infectious. This virus is transmitted through sexual, anal, or oral contact as well as skin-to-skin contacts. Treatment for this condition has significant morbidity and it can be frustrating in certain cases. The HPV vaccination has been demonstrated as a promising strategy of secondary prevention in HPV-related diseases such as head and neck cancers, cervical diseases, and recurrent respiratory papillomatosis. Regarding AGWs, it is unclear whether vaccination can provide analogous clinical benefit. The aim of this work is to systematically review the literature regarding HPV vaccination for secondary disease prevention after treatment of AGWs. From October to December 2018, a systematic search for clinical trials was conducted in five databases: PubMed, MEDLINE, EMBASE, Cochrane, and clinicaltrials.gov using a combination of the following descriptors: 'gardasil' OR 'cervarix' OR 'nine-valent' OR '9-valent' OR 'vaccine' AND 'recurrence' OR 'relapse' AND 'hpv' OR 'papillomavirus' AND 'warts' OR 'condyloma.' Data were synthetized and entered in the Review Manager software (RevMan 5.3.5) to perform the meta-analysis. The search yielded 824 potentially relevant studies. Two studies fulfilled the eligibility criteria involving 656 participants. The meta-analysis estimated the rate of recurrence of AGWs was similar between the vaccine group and the control group. The overall effect estimate was 1.02 (0.75-1.38). This is the first meta-analysis exploring the effect of HPV vaccine in preventing the relapse of AGWs. These results suggest that HPV vaccination does not provide secondary benefit in patients with previous AGWs. However, these results cannot be generalized due to the scarce number of RCTs currently available in the literature. The outcomes from future randomized controlled trials (RCTs) are warranted to further clarify the precise effect of the vaccine.

Human Papillomavirus Vaccine Effectiveness and Herd Protection in Young Women

BACKGROUND

Clinical trials of the 4-valent human papillomavirus (HPV) vaccine demonstrate high efficacy, but surveillance studies are essential to examine the long-term impact of vaccine introduction on HPV prevalence in community settings. The aims of this study were to determine during the 11 years after vaccine introduction the prevalence of (1) vaccine-type HPV in adolescent and young adult women who were vaccinated (to assess vaccine effectiveness) and (2) vaccine-type HPV in women who were unvaccinated (to assess herd protection).

METHODS

Young women 13 to 26 years of age were recruited from hospital-based and community health clinics for 4 surveillance studies from 2006 to 2017. We determined the proportion of vaccinated and unvaccinated women who were positive for vaccine-type HPV across the studies, and the odds of positivity for vaccine-type HPV using logistic regression; all analyses were propensity score-adjusted to control for between-wave differences in participant characteristics.

RESULTS

Vaccination rates increased from 0% to 84.3% (97% of study participants received the 4-valent vaccine). Among women who were vaccinated, 4-valent vaccine-type HPV detection decreased from 35% to 6.7% (80.9% decline; odds ratio 0.13, 95% confidence interval 0.08 to 0.22). Among women who were unvaccinated, 4-valent vaccine-type HPV detection decreased from 32.4% to 19.4% (40% decline; odds ratio 0.50, 95% confidence interval 0.26 to 0.97). Estimated vaccine effectiveness was 90.6% in wave 3 and 80.1% in wave 4.

CONCLUSIONS

In this study in which trends in HPV in a US community >10 years after 4-valent HPV vaccine introduction and after 9-valent vaccine introduction were examined, we found evidence of vaccine effectiveness and herd protection. Further research is needed to examine trends in 9-valent vaccine-type HPV after higher rates of vaccination are achieved.

Association between Human Papillomavirus and Non-cervical Genital Cancers in Brazil: A Systematic Review and Meta-Analysis

Background: Human papillomavirus (HPV) infection is associated with cervical cancer; however, it is controversial whether it is involved in non-cervical genital cancers. Objective: This study aimed to evaluate articles on the prevalence of HPV in penile cancer, vulvar cancer, colorectal cancer, prostate cancer and anal canal cancer in studies conducted in Brazil. Methods: The study was conducted in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analysis Statement. Comprehensive searches for HPV and cancer for the years 2006 to 2016 were conducted in two databases (PubMed and Web of Knowledge) and Google Scholar system. We also tracked the references of all eligible articles to identify additional non-captured publications through online surveys. Results: Eighteen studies, with a combined sample size of 1,552 patients were analyzed. The overall prevalence of HPV was 43% (95% CI: 36–51%; p < 0.001). The pooled prevalence of HPV in penile cancer was 42% (95% CI: 32–55%; p < 0.001), in colorectal cancer it was 67% (95% CI: 64–70%; p < 0.001) and in vulvar cancer 43% (95% CI: 34–55%; p < 0.001). HPV 16 was the most prevalent in all sites evaluated, with prevalence estimated at 54% (95% CI: 44–66%; p < 0.001), followed by genotypes 33 (21%; 95% CI: 17–28; p < 0.001), 6 (15%; 95% CI: 8–26%; p < 0.001), 11 (13%; 95% CI: 5–32%; p < 0.001) and 18 (12%; 95% CI: 7–22%; p < 0.001), respectively. The pooled prevalence of single infection was 82% and infection by multiple genotypes of HPV was 22%. Conclusion: Our study demonstrated a high prevalence of HPV in non-cervical genital cancers in Brazil, with predominance of genotype 16, providing evidence for the need for preventive and control measures to avoid future harm to the population.

An Examination of HPV16 Natural Immunity in Men Who Have Sex with Men (MSM) in the HPV in Men (HIM) Study

Background: Evidence suggests that natural antibodies developed after HPV16 infection may protect some women but not men against subsequent HPV16 reacquisition. Less is known whether antibodies developed following HPV16 infection are protective among men who have sex with men (MSM).Methods: Four hundred seventy-five MSM from the Human Papillomavirus Infection in Men (HIM) study were tested for serum antibodies to HPV16 L1 using enzyme-linked immunosorbent assays, and for anal and genital HPV16 DNA using PCR consensus primer system (PGMY 09/11). Adjusted Cox regression was used to evaluate whether baseline HPV16 seropositivity impacts subsequent genital or anal HPV16 DNA.Results: The risk of subsequent genital HPV16 [aHR = 1.05, 95% confidence interval (CI) = 0.66-1.68] and anal HPV16 infections among MSM (aHR = 2.34, 95% CI = 0.92-5.98) was similar or nonsignificantly higher in HPV16-seropositive than HPV16-seronegative MSM. The risk of genital HPV16 was also similar between HPV16-seronegative and HPV16-seropositive MSM in the highest tertile of HPV16 antibody levels and when restricting to those with new sex partners during follow-up (P > 0.20). Among the 118 MSM who were HPV16 seropositive, 90% remained HPV16 seropositive up to 4 years later. When tested together, MSM with the highest antibody titers (top tertile) had similar levels to females (mean = 130.3 vs. 134.5 EU/mL, P = 0.84).Conclusions: Despite years of HPV16 seropositivity persistence and antibody titers comparable with females, this study suggested no evidence of HPV16 natural antibodies protecting against subsequent genital or anal HPV16 infection in MSM.Impact: This could help partially explain the high incidence of genital and anal HPV16 infection and related anal cancer seen in middle-aged and older MSM. Cancer Epidemiol Biomarkers Prev; 27(4); 496-502. ©2018 AACR.

Genital HPV infection among heterosexual and homosexual male attendees of sexually transmitted diseases clinic in Beijing, China

Human papillomavirus (HPV) has been identified as etiologic agent of various cancers for both men and women. However, HPV vaccine has not been recommended for men in China by far. To provide more evidences to promote HPV vaccination among males at high-risk of infection, this study investigated genital HPV genotypes among male attendees of sexually transmitted disease (STD) clinic. Male attendees (⩾18 years old) were recruited from STD clinic of Beijing Ditan Hospital. Data on sociodemographic characteristics and self-reported sexual behaviors were collected based on questionnaire. Genital swab specimens were collected for HPV genotypes. Finally, a total of 198 eligible participants were included in the study. Nearly half of them were infected with at least one type of HPV. The prevalence of genital infection among participants with only heterosexual behaviors (50·91%, 56/110) was significantly higher than those with only homosexual behaviors (36·36%, 32/88) (P < 0·001). However, the distribution pattern of the most frequently observed HPV subtypes were found to be similar between these two subgroups. HPV31, HPV18, HPV16 and HPV58 were the most frequently identified high-risk types and HPV11, HPV6, HPV81 and HPV61 were the most frequently observed low-risk types. Our results, although need further verification by larger sample size, suggested that currently available HPV vaccines covered most prevalent HPV types observed in Chinese men. As HPV vaccine has been approved for application in females in China, molecular epidemiological studies and intervention studies among high-risk males should be promoted as well.

A review of the infection-associated cancers in North African countries

Cancer is typically classified as a leading non-communicable disease; however, infectious agents, such as Helicobacter pylori (H. pylori), hepatitis B virus (HBV), hepatitis C virus (HCV) and human papilloma virus (HPV), contribute significantly to the pathogenesis of various cancers. Less developed countries, including countries of the North African (NA) region, endure the highest burden of infection-related cancers. The five most common infection-associated cancers in NA in order of incidence are bladder cancer, cervical cancer, liver cancer, stomach cancer, and nasopharyngeal carcinoma. This review aims to outline the epidemiologic pattern of infection-associated cancers in five NA countries (namely: Morocco, Algeria, Tunisia, Libya and Egypt) highlighting the similarities and differences across the region. The present study employed an initial literature review of peer-reviewed articles selected from PubMed, ScienceDirect and World Health Organization (WHO) databases based on key word searches without restriction on publication dates. Original research articles and reports written in French, as well as data from institutional reports and regional meeting abstracts were also included in this extensive review. Egypt, Libya, Tunisia, Algeria and Morocco were selected to be the focus of this review.

Human papillomavirus and anal carcinoma knowledge in men who have sex with men in Belgrade, Serbia

BACKGROUND

To evaluate the level of knowledge among men who have sex with men regarding human papillomavirus (HPV), anal cancer screening, and HPV vaccine.

METHODS

A cross-sectional study was conducted in 2013 in Belgrade, Serbia, comprising 142 HIV-positive and 128 HIV-negative persons.

RESULTS

Of all participants, 34.8% had never heard of HPV infection; 43.3% of participants were informed that HPV infection might be asymptomatic, while 30.4% knew that HPV is not transmitted by towels/cloth. Furthermore, 45.9% answered that HPV is a cause of genital warts, while 28.9%, 14.4%, and 17.4%, respectively, answered that it can cause anal, penile, and oral cancers. Only one-fourth of participants knew that anal cancer is more frequent in homosexual men. More than 50% had not heard of anal Papanicolaou (Pap) smears, and less than 3% had ever had it. Almost 90% of participants did not know which physicians provide anal Pap smears. Less than one-third knew that regular anal Pap smears might prevent consequences of anal HPV infection. The majority of participants did not know that there is a vaccine against HPV and anal cancer. Less than 50% reported willingness to receive HPV vaccine. Knowledge was slightly better in HIV-positive men in comparison with HIV-negative ones.

CONCLUSIONS

Results point out the need for community efforts to promote knowledge about HPV, anal carcinoma, and anal Pap screening among men who have sex with men and their healthcare providers, and to increase the acceptance of HPV vaccine by the population.

Safety of human papillomavirus vaccines: a review

INTRODUCTION

Between 2006 and 2009, two different human papillomavirus virus (HPV) vaccines were licensed for use: a quadrivalent (qHPVv) and a bivalent (bHPVv) vaccine. Since 2008, HPV vaccination programmes have been implemented in the majority of the industrialized countries. Since 2013, HPV vaccination has been part of the national programs of 66 countries including almost all countries in North America and Western Europe. Despite all the efforts made by individual countries, coverage rates are lower than expected. Vaccine safety represents one of the main concerns associated with the lack of acceptance of HPV vaccination both in the European Union/European Economic Area and elsewhere.

AREAS COVERED

Safety data published on bivalent and quadrivalent HPV vaccines, both in pre-licensure and post-licensure phase, are reviewed.

EXPERT OPINION

Based on the latest scientific evidence, both HPV vaccines seem to be safe. Nevertheless, public concern and rumors about adverse events (AE) represent an important barrier to overcome in order to increase vaccine coverage. Passive surveillance of AEs is an important tool for detecting safety signals, but it should be complemented by activities aimed at assessing the real cause of all suspect AEs. Improved vaccine safety surveillance is the first step for effective communication based on scientific evidence.

Prevalence of genital human papillomavirus among men in Europe: systematic review and meta-analysis

INTRODUCTION

Human papillomavirus (HPV) is the commonest sexually transmitted infection worldwide and causes substantial morbidity in both sexes. Most European countries offer HPV vaccination for girls, but vaccine recommendations for boys are warranted.

AIMS

The aims of this study were to investigate the prevalence of genital HPV, identify parameters that affect the prevalence, and describe the type-specific prevalence among men in Europe.

METHODS

A systematic review and meta-analysis of the published literature in PubMed and Embase.

MAIN OUTCOME MEASURES

Genital HPV prevalence and factors influencing prevalence in general and high-risk male populations in Europe.

RESULTS

We included 31 articles that gave the prevalence of genital HPV DNA among men in northern, southern and western Europe; no studies from eastern Europe were identified. The pooled HPV prevalence among 1,863 men representing the general population (nine studies) was 12.4%, with large heterogeneity between studies (I(2)  = 96.3%, P < 0.0001). The pooled HPV prevalence among 6,428 men in the high-risk population (22 studies) was 30.9%, also with substantial heterogeneity (I(2)  = 95.6%, P < 0.0001). In unadjusted meta-regression analysis, the HPV prevalence in the general population was significantly higher in studies published after 2000 (28.5%) than in earlier studies (8.8%) (P = 0.0179). In the meta-regression analysis adjusted by publication year, the heterogeneity in the two population groups could not be explained by geographical region, anatomical sampling site, or HPV detection method. HPV16 was the most prevalent high-risk type in both populations.

CONCLUSIONS

HPV prevalence differs in male general and high-risk populations, but HPV16 and HPV18 are among the most common HPV types detected in both groups. Our findings contribute knowledge that may be useful as a baseline measure before the introduction of HPV vaccination for boys in Europe, and add to understanding of the epidemiology of HPV infection in men.

The role of Human Papilloma Virus (HPV) vaccination in the prevention of anal cancer in individuals with Human Immunodeficiency Virus-1 (HIV-1) infection

The incidence of anal cancer is increasing in the general population and especially in high-risk groups. A total of 90% of anal cancers are caused by human papilloma virus (HPV) infection of the anal canal. Similar to cervical cancer, anal cancer progresses through a predictable series of premalignant stages before resulting in invasive cancer; this process begins with persistent HPV infection. The HPV vaccine represents a promising strategy to combat the increasing incidence of anal cancer. Human Immunodeficiency Virus (HIV) predisposes people to persistent HPV infection, dysplasia, and subsequent anal cancer. Patients infected with HIV should be targeted for vaccination against HPV. There are difficulties in targeting this population, the most notable being that the optimal age for vaccination is prior to identification with any high-risk groups. Universal vaccination against HPV represents the best strategy to achieve maximum protection against anal cancer in high-risk groups.

Increased HIV-1 activity in anal high-grade squamous intraepithelial lesions compared with unaffected anal mucosa in men who have sex with men

We studied 3 patients with focal intra-anal tissue high-grade squamous intraepithelial lesions (HSILs). All had increased human immunodeficiency virus type 1 (HIV-1) RNA and DNA in lesions compared with that in healthy mucosa. HIV-1 RNA and HIV-1 episomal DNA were indicative of ongoing viral replication, more so in anal HSILs.

Human papillomavirus infections in women with clinical gynaecological diseases in southwest China

The aim of this study was to determine the prevalence of human papillomavirus (HPV) infections in women with different gynaecological diseases (GDs) and ages in southwest China. With the assay of reverse dot blot, a total of 5544 cervical samples, including 1008 normal and 4536 abnormal specimens from women with GDs, were assayed for HPV detection. For the normal group, 20.2% (204/1008) tested positive for HPV, of which 40.2% (82/204) were high-risk (HR-HPV) genotypes. In the 4536 abnormal samples, 1569 women (34.6%) tested positive for HPV: 73.5% (1153/1569) had a single infection, 17.7% (277/1569) dual infection and 8.8% (138/1569) multiple HPV infection. Of 1569 HPV-positive specimens, 58.7% (921/1569) were infected with only HR-HPV genotypes. Significant differences in HPV infections were found among women of different ages (P < 0.01), number of pregnancies (P < 0.01), GDs (P < 0.01) and age at first sex (P < 0.01). In the present study, we found a high prevalence of HPV infection in women with GDs in southwest China. In addition to HPV types 16 and 18, a significant proportion of other HR-HPV genotypes were detected in this population.

Male circumcision is associated with a lower prevalence of human papillomavirus-associated penile lesions among Kenyan men

Human papillomavirus (HPV)-associated penile lesions in men may increase the risk of HPV transmission to their female partners. Risk factor data on HPV-associated penile lesions are needed from regions with a high burden of cervical cancer. Visual inspection of the penis was conducted using a colposcope at the 24-month visit among participants in a randomized controlled trial of male circumcision in Kenya, from May 2006 to October 2007. All photos were read independently by two observers for quality control. Penile exfoliated cells sampled from the glans/coronal sulcus and the shaft were tested for HPV DNA using GP5+/6+ PCR and for HPV16, 18 and 31 viral loads using a real time PCR assay. Of 275 men, 151 were circumcised and 124 uncircumcised. The median age was 22 years. Circumcised men had a lower prevalence of flat penile lesions (0.7%) versus uncircumcised (26.0%); adjusted odds ratio (OR) = 0.02; 95% confidence interval (CI) = 0.003-0.1. Compared to men who were HPV negative, men who were HPV DNA positive (OR = 6.5; 95% CI = 2.4-17.5) or who had high HPV16/18/31 viral load (OR = 5.2; 95% CI = 1.1-24.4) had higher odds of flat penile lesions. Among men with flat penile lesions, HPV56 (29.0%) and 16 (25.8%) were the most common types within single or multiple infections. Flat penile lesions are much more frequent in uncircumcised men and associated with higher prevalence of HPV and higher viral loads. This study suggests that circumcision reduces the prevalence of HPV-associated flat lesions and may ultimately reduce male-to-female HPV transmission.

Characterization of the human papillomavirus (HPV) integration sites into genital cancers

Oncogenic HPVs have been found frequently integrated into human genome of invasive cancers and chromosomal localization has been extensively investigated in cervical carcinoma. Few studies have analyzed the HPV integration loci in other genital cancers. We have characterized the integration sites of HPV16 in invasive penile carcinoma by means of Alu-HPV-based PCR. Nucleotide sequence analysis of viral-human DNA junctions showed that HPV integration occurred in one case within the chromosome 8q21.3 region, in which the FAM92A1 gene is mapped, and in the second case inside the chromosome 16p13.3, within the intronic region of TRAP1 gene. These results confirm previous observations, summarized in a systematic review of the literature, on the HPV integration events in gene loci relevant to cancer pathogenesis.

CD4+ cell count and HIV load as predictors of size of anal warts over time in HIV-infected women

BACKGROUND

Little is known about the associations between CD4(+) cell counts, human immunodeficiency virus (HIV) load, and human papillomavirus "low-risk" types in noncancerous clinical outcomes. This study examined whether CD4(+) count and HIV load predict the size of the largest anal warts in 976 HIV-infected women in an ongoing cohort.

METHODS

A linear mixed model was used to determine the association between size of anal wart and CD4(+) count and HIV load.

RESULTS

The incidence of anal warts was 4.15 cases per 100 person-years (95% confidence interval [CI], 3.83-4.77) and 1.30 cases per 100 person-years (95% CI, 1.00-1.58) in HIV-infected and HIV-uninfected women, respectively. There appeared to be an inverse association between size of the largest anal warts and CD4(+) count at baseline; however, this was not statistically significant. There was no association between size of the largest anal warts and CD4(+) count or HIV load over time.

CONCLUSIONS

There was no evidence for an association between size of the largest anal warts and CD4(+) count or HIV load over time. Further exploration on the role of immune response on the development of anal warts is warranted in a larger study.

Immunogenicity of the quadrivalent human papillomavirus (type 6/11/16/18) vaccine in males 16 to 26 years old

Human papillomavirus (HPV) infection can lead to significant disease in males, including anogenital warts, intraepithelial neoplasias, and several types of oral and anogenital cancers. The quadrivalent HPV (type 6/11/16/18) L1 virus-like particle (VLP) vaccine (qHPV vaccine; Gardasil) has recently been demonstrated to prevent persistent infection and associated disease related to vaccine HPV types in males. We report the overall immunogenicity results from a trial of the quadrivalent HPV vaccine in males. Overall, 3,463 heterosexual men and 602 men who had sex with men were enrolled into a randomized, placebo-controlled, double-blind safety, immunogenicity, and efficacy study. Serum samples were collected prior to vaccination at day 1 and at months 7, 24, and 36 postvaccination. Immunogenicity was evaluated with a multiplex, competitive Luminex immunoassay. Almost all subjects (97.4 to 99.2%) seroconverted for vaccine HPV types by month 7. At month 36, 88.9%, 94.0%, 97.9%, and 57.0% of subjects were still seropositive for HPV-6, -11, -16, and -18, respectively. For all vaccine HPV types, black subjects had significantly higher antibody titers at month 7 than did both Caucasian and Asian subjects. An anamnestic antibody response was seen in men seropositive before vaccination. The vaccine was highly immunogenic in males 16 to 23 years of age; responses were comparable to those observed in women. Furthermore, the immune responses were consistent with the established efficacy of the vaccine in the prevention of incident and persistent HPV infection, anogenital warts, and anal intraepithelial neoplasia.

Economic burden of HPV-related cancers in France

Human papillomavirus (HPV) infection is associated with a range of diseases and cancers at different anatomical sites. In addition to its role as a necessary cause of cervical cancer, HPV is also associated with cancers of the vulva, vagina, anus, penis, head and neck. With the exception of cervical cancer, however, very few data are available on the economic burden of HPV-associated cancers. We assessed the annual costs associated with management of HPV-related cancers in France from the healthcare payers' perspective. We used data from studies that employed similar methodologies to estimate the costs during 2006 for cervical cancer, vulvar and vaginal cancers, anal cancer, and penile cancer, and during 2007 for head and neck cancers. Data on hospital-management costs for cancer were derived from the French national hospital database. The costs of outpatient care and daily allowance costs were estimated using data from the French National Institute of Cancer report for 2007. The costs for HPV-related cancers were estimated according to the percentage of each cancer type attributable to HPV infection. The estimated total costs associated with HPV-related cancers in France were €239.7 million. The overall costs in men were €107.2 million, driven mainly by head and neck cancers (€94.6 million). The total costs in women were €132.5 million, due mainly to invasive cervical cancer (€83.9 million). The costs associated with HPV-related cancers are important to consider when evaluating the overall benefits of HPV vaccination in males and females.

Efficacy of quadrivalent HPV vaccine against HPV Infection and disease in males

BACKGROUND

Infection with human papillomavirus (HPV) and diseases caused by HPV are common in boys and men. We report on the safety of a quadrivalent vaccine (active against HPV types 6, 11, 16, and 18) and on its efficacy in preventing the development of external genital lesions and anogenital HPV infection in boys and men.

METHODS

We enrolled 4065 healthy boys and men 16 to 26 years of age, from 18 countries in a randomized, placebo-controlled, double-blind trial. The primary efficacy objective was to show that the quadrivalent HPV vaccine reduced the incidence of external genital lesions related to HPV-6, 11, 16, or 18. Efficacy analyses were conducted in a per-protocol population, in which subjects received all three vaccinations and were negative for relevant HPV types at enrollment, and in an intention-to-treat population, in which subjects received vaccine or placebo, regardless of baseline HPV status.

RESULTS

In the intention-to-treat population, 36 external genital lesions were seen in the vaccine group as compared with 89 in the placebo group, for an observed efficacy of 60.2% (95% confidence interval [CI], 40.8 to 73.8); the efficacy was 65.5% (95% CI, 45.8 to 78.6) for lesions related to HPV-6, 11, 16, or 18. In the per-protocol population, efficacy against lesions related to HPV-6, 11, 16, or 18 was 90.4% (95% CI, 69.2 to 98.1). Efficacy with respect to persistent infection with HPV-6, 11, 16, or 18 and detection of related DNA at any time was 47.8% (95% CI, 36.0 to 57.6) and 27.1% (95% CI, 16.6 to 36.3), respectively, in the intention-to-treat population and 85.6% (97.5% CI, 73.4 to 92.9) and 44.7% (95% CI, 31.5 to 55.6) in the per-protocol population. Injection-site pain was significantly more frequent among subjects receiving quadrivalent HPV vaccine than among those receiving placebo (57% vs. 51%, P<0.001).

CONCLUSIONS

Quadrivalent HPV vaccine prevents infection with HPV-6, 11, 16, and 18 and the development of related external genital lesions in males 16 to 26 years of age. (Funded by Merck and others; ClinicalTrials.gov number, NCT00090285.).

Quality of life of homosexual males with genital warts: a qualitative study

BACKGROUND

A recent qualitative study in Denmark showed that genital warts (GWs) can considerably lower the quality of life of heterosexual patients. In this follow-up study, we interviewed men having sex with men (MSM) suffering from GWs to obtain an in-depth understanding of their perception of GWs and determine the extent to which minority (homosexual) cultural issues affect these patients' experiences. Qualitative interviews with six MSM were performed using a semi-structured interview guide. Questions were formulated on the basis of the earlier qualitative study in heterosexual patients with GWs along with a literature review. Data were analysed using a medical anthropological approach.

FINDINGS

Many MSM worried about being stigmatised and excluded from the small homosexual 'scene', their key social group, thereby lowering their chances of finding sex and love. Most participants had suffered from GWs for several years which added to the negative psycho-sexual and social effects of the disease. Participants' fears of developing anal cancer were similar to those expressed about cervical cancer by females with GWs.

CONCLUSIONS

Ano-genital human papillomavirus (HPV) infection is common and has a serious psychological and sexual impact among MSM. However, they do not benefit to the same extent as heterosexual men from the herd immunity effect of HPV vaccination of girls. The pathological profile and concerns specific to MSM should be addressed when communicating with these patients, and should be taken into account when considering HPV vaccination of boys.

Burden of human papillomavirus infection and related comorbidities in men: implications for research, disease prevention and health promotion among Hispanic men

Genital human papillomavirus (HPV) infection is one of the most commonly diagnosed sexually transmitted infections world-wide. Over the last two decades, research has established a strong causal link between specific types of HPV infection and cancer, particularly cervical, anal, vulvar/vaginal, penile, and oropharyngeal cancer. Limited epidemiological studies of anogenital HPV infection have been conducted in Hispanic populations (including Puerto Rico), and population-based incidence and prevalence estimates of HPV infection among Hispanics are limited. Studies that evaluate knowledge and awareness of HPV among men are also scarce. With the world-wide introduction of two new prophylactic vaccines against high-risk HPVs causing cervical cancer, and the recent FDA approval of the quadrivalent vaccine in preventing genital warts in men, there is an urgency to determine the burden of HPV in Hispanic populations before vaccine programs are implemented on a widespread basis. Knowledge and acceptability of the vaccine prior to implementation of these programs are also necessary to allow a targeted assessment. This review article summarizes existing research on HPV infection and HPV-related morbidities in men, with a particular emphasis on Hispanic men in the United States and Puerto Rico. Three major areas are discussed: (1) genital warts, (2) HPV and related cancers and (3) biobehavioral and psychosocial factors related to HPV infection and vaccination. Specific recommendations for advancing HPV research and knowledge among Hispanic populations also are suggested.

The EVER proteins as a natural barrier against papillomaviruses: a new insight into the pathogenesis of human papillomavirus infections

Infections by human papillomaviruses (HPVs) are the most frequently occurring sexually transmitted diseases. The crucial role of genital oncogenic HPV in cervical carcinoma development is now well established. In contrast, the role of cutaneous HPV in skin cancer development remains a matter of debate. Cutaneous beta-HPV strains show an amazing ubiquity. The fact that a few oncogenic genotypes cause cancers in patients suffering from epidermodysplasia verruciformis is in sharp contrast to the unapparent course of infection in the general population. Our recent investigations revealed that a natural barrier exists in humans, which protects them against infection with these papillomaviruses. A central role in the function of this HPV-specific barrier is played by a complex of the zinc-transporting proteins EVER1, EVER2, and ZnT-1, which maintain cellular zinc homeostasis. Apparently, the deregulation of the cellular zinc balance emerges as an important step in the life cycles not only of cutaneous but also of genital HPVs, although the latter viruses have developed a mechanism by which they can break the barrier and impose a zinc imbalance. Herein, we present a previously unpublished list of the cellular partners of EVER proteins, which points to future directions concerning investigations of the mechanisms of action of the EVER/ZnT-1 complex. We also present a general overview of the pathogenesis of HPV infections, taking into account the latest discoveries regarding the role of cellular zinc homeostasis in the HPV life cycle. We propose a potential model for the mechanism of function of the anti-HPV barrier.

Prevalence and type distribution of human papillomavirus in carcinoma and intraepithelial neoplasia of the vulva, vagina and anus: a meta-analysis

This meta-analysis investigated human papillomavirus (HPV) prevalence in vulvar, vaginal and anal intraepithelial neoplasia (VIN, VAIN, AIN) grades 1-3 and carcinoma from 93 studies conducted in 4 continents and using PCR assays. Overall HPV prevalence was 67.8%, 85.3% and 40.4% among 90 VIN1, 1,061 VIN2/3 and 1,873 vulvar carcinomas; 100%, 90.1% and 69.9% among 107 VAIN1, 191 VAIN2/3 and 136 vaginal carcinomas; and 91.5%, 93.9% and 84.3% among 671 AIN1, 609 AIN2/3 and 955 anal carcinomas, respectively. HPV16 was found more frequently (>75%) and HPV18 less frequently (<10%) in HPV-positive vulvar, vaginal and anal carcinomas than in cervical carcinoma. HPV6 and 11 were common in VIN1 and AIN1, but not in VAIN1. HPV prevalence in vulvar carcinoma varied most by histological type (69.4% in warty-basaloid and 13.2% in keratinized type) and was also higher in women 60 years or younger and in studies carried out in North America. HPV prevalence in anal carcinoma was higher among women (90.8%) than men (74.9%), but no difference by gender emerged in North America. The majority of AIN2/3 derived from studies of HIV-positive individuals and/or men who have sex with men. Among AIN2/3, HIV infection was associated with higher HPV prevalence, more multiple-type infections and a relative under-representation of HPV16. In conclusion, approximately 40% of vulvar, 60% of vaginal and 80% of anal carcinoma may be avoided by prophylactic vaccines against HPV16/18. This proportion would be similar for the corresponding high-grade lesions of the vagina and anus, but higher for VIN2/3 (75%) than for vulvar carcinoma.

Distribution of human papillomavirus types in anogenital warts of men

BACKGROUND

A wide spectrum of human papillomavirus (HPV) types can infect the male genitalia. An HPV vaccine covering HPV6 and 11 is now available. Detailed data on the distribution of these two types in anogenital warts is needed to assess the potential benefits of the vaccine.

STUDY DESIGN

Anogenital wart specimens collected from 130 Chinese men were examined for HPV-type distribution by a method that covers a broad spectrum of high- and low-risk HPVs, and able to reveal multiple types from a single specimen.

RESULTS

Forty-four (33.8%) of the 130 specimens had a coinfection with multiple HPV types. In 63.1% of cases, only HPV6 and/or HPV11 were/was found. In 26.2% of cases, HPV6 and/or HPV11 were/was found together with one or more other HPV types. In 10.8% of specimens, only non-6/11 HPV types were found. HPV16 and/or 18 were/was found in 12 (9.2%) specimens, with majority (8/12, 66.7%) of which existed as coinfections with HPV6/11. Other HPV types found included HPV39, 51, 52, 55, 59, 61, 62, 68, 58, 72, 81, 83, 84 and CP6108.

CONCLUSIONS

A substantial proportion of HPV6/11-positive male anogenital warts are coinfected with other HPV types. The efficacy of HPV6/11 vaccine for preventing these lesions needs to be defined before the benefits of vaccinating men can be precisely assessed.

Systematic review of human papillomavirus prevalence in invasive penile cancer

OBJECTIVE

Type-specific prevalence data of human papillomavirus (HPV) DNA in penile carcinoma are needed to determine the potential impact of HPV prophylactic vaccines, assuming demonstrated efficacy in men.

METHODS

A review was conducted using search terms including HPV and penile cancer. Studies using polymerase chain reaction (PCR) assays for HPV DNA detection in invasive penile carcinoma were included.

RESULTS

A total of 1,266 squamous cell carcinoma (SCC) cases contributed data from 30 studies. The number of SCC was similar in Europe (28.2%), North America (27.6%), South America (23.9%) and Asia (20.4%). All SCC were histologically confirmed with biopsies for DNA detection. Most commonly used PCR primers were type-specific (35.2%), and combination PCR (18.2%). HPV prevalence was 47.9%, ranging from 22.4% in verrucous SCC to 66.3% for the basaloid/warty subtypes. HPV16 (30.8%), HPV6 (6.7%) and HPV18 (6.6%) were the most prevalent types. HPV16 and/or HPV 18 prevalence was 36.7%.

CONCLUSIONS

HPV DNA was detected in half of SCC, with HPV16 being the most common type. If proven efficacious in men, prophylactic vaccines targeting carcinogenic types HPV16 and 18 could potentially reduce approximately one-third of incident SCC.

Human papillomavirus-16 and -18 in penile carcinomas: DNA methylation, chromosomal recombination and genomic variation

Penile carcinomas are frequently associated with high risk human papillomavirus (HPV) types. Because little is known about the molecular biology of this association, we investigated three properties of HPV genomes in penile carcinomas from Brazilian patients: (i) HPV DNA methylation, (ii) junctions between HPV and cellular DNA and (iii) genomic variation. In cervical carcinogenesis, recombination between HPV and chromosomal DNA is frequent and likely necessary for progression, and DNA hypermethylation-specifically of the L1 gene-is a biomarker for cancerous progression. The same mechanisms apparently occur during penile carcinogenesis, because 95 HPV-16 molecules derived from 19 penile lesions had 58% of the CpGs in L1 and 22% in the 5' part of the long control region methylated, more than the percentages found in cervical carcinomas. In addition, 2 out of 3 HPV-18 infections, all present in double infections with HPV-16, showed L1 specific methylation typical of malignant cervical lesions. In 11 out of 15 HPV-16 lesions, we confirmed chromosomal integration by reverse ligation inverted PCR, while 4 samples had concatemeric integrations or episomes. Nine of 17 penile carcinomas contained HPV-16 AA variants, and 8 E variants. As AA variants are relatively rare in Brazilian cohorts of asymptomatic women, the high prevalence in penile carcinomas may indicate a higher risk of progression of AA lesions, as suspected for cervical infections. Our observations of frequent viral DNA methylation, chromosomal integration and the prevalence of high risk variants suggest that HPV-dependent carcinogenesis of the penis and cervix follows similar etiological and epidemiological parameters.

Anal intraepithelial neoplasia in HIV infection

Human papillomavirus (HPV) infections belong to the most common sexually transmitted infections worldwide. While the immune system eliminates most HPV infections over time in immunocompetent individuals, HPV infections tend to persist in immunodeficient individuals. In HIV-infected men who have sex with men (MSM), anal HPV prevalence is more than 90% and infections with multiple HPV types are common. Consequently, HPV-associated anogenital malignancies occur with high frequency in patients with HIV infection. Anal intraepithelial neoplasia (AIN) is a potential precursor lesion of squamous cell carcinoma of the anus. Like its cervical counterpart, cervical intraepithelial neoplasia (CIN), AIN is causally linked to persistent infections with high-risk HPV types such as HPV16 or HPV18. As AIN and CIN share distinct biological similar-ities, AIN screenings analogous to Pap smear programs for CIN have been recommended in high-risk populations to reduce the incidence of anal carcinoma. These screenings include cytological analysis followed by high resolution anoscopy in case of anal dysplasia. Treatment guidelines for AIN are not yet available. Therapeutic strategies can be divided into topical (e.g. trichloroacetic acid, podophyllotoxin, imiquimod, photodynamic therapy) and ablative (e. g. surgical excision, laser ablation, infrared coagulation, electrocautery) measures. However, controlled studies on AIN treatment have not been performed. The impact of HPV vaccination on AIN development will also need to be assessed. Long-term follow-up of these patients is essential to gain more insight into the natural history of anogenital HPV infection in HIV-positive MSM.

HPV vaccines: are they the answer?

BACKGROUND

The burden of human papillomavirus (HPV)-associated ano-genital disease is significant but the ability to generate HPV virus-like particles by the synthesis and self-assembly in vitro of the major virus coat protein L1 has transformed our prospects for preventing benign and malignant ano-genital disease caused by the common genital HPV types.

SOURCES OF DATA

Peer reviewed journals.

AREAS OF AGREEMENT

Two HPV L1 vaccines have been developed, a quadrivalent HPV 6/11/16/18, and a bivalent HPV 16/18 product. Both vaccines are very immunogenic and well tolerated. They have been shown in the various randomized Control trials to be very effective at preventing infection and premalignant disease related to the vaccine HPV genotypes in women who were DNA negative and sero negative for the vaccine HPV types at base line. The protection against disease generated by the vaccines persists for at least 5 years. HPV vaccines containing HPV 6/11 will reduce the incidence of genital warts by 80-90% in the medium term. The vaccines will reduce but not eliminate the risk of cervical cancer since at the present they only target two of the oncogenic genital types. Cervical cancer screening programmes will remain as important secondary interventions for cervical cancer even in vaccinated populations.

AREAS OF CONTROVERSY

The duration of protection remains unknown but there is evidence of good immune memory, it is possible that protection will be long lasting. The primary target group for cost effective immunization with HPV vaccines are peri-pubertal females. There may be benefit in vaccinating other groups (men, sexually active women of all ages) but the cost effectiveness of these interventions will need to be evaluated. In societies in which organized screening programmes are not available, HPV vaccines are probably the most realistic intervention against HPV-associated disease.

AREAS TIMELY FOR DEVELOPING RESEARCH

Second generation vaccines that offer protection against additional types, are thermostable and delivered by non-injection methods are an important area of investigation.