Human papillomavirus infection in sexually active adolescent females: prevalence and risk factors

Prevalence of oncogenic human papillomavirus in pregnant adolescents, association with colpocytological changes, risk factors and obstetric outcomes

PURPOSE

The authors aim to carry out an investigation on the impact of cervical oncogenic Human Papillomavirus (HPV) detection in pregnant adolescents, to clarify the prevalence and risk factors, considering the importance and lack of data on this topic in Brazil.

METHODS

A cross-sectional study was conducted with adolescents receiving prenatal care in a tertiary hospital in São Paulo, Brazil, with routine Pap smear and oncogenic HPV detection test in the uterine cervix. The authors sought to associate the results of these tests with demographic and obstetric variables.

RESULTS

A total of 303 pregnant adolescents whose mean age was 15.30 ± 1.22 years comprised the study subjects. The frequency of high-risk HPV cervical detection was 50.50%. Multivariate analysis revealed that a large number of partners in their lifetime (OR = 1.27) and having a religion (OR = 2.05) were risk factors for cervical detection of oncogenic HPV, while schooling appeared as a protective factor (OR = 0.85). There was an association between this detection and colpocytological alterations, reaching almost 30% of patients, but without association with obstetric and neonatal outcomes.

CONCLUSION

The prevalence found is one of the highest in Brazil and worldwide. A greater number of partners during their lifetime and having religion were detected as possible factors associated with cervical HPV detection. Detection of cervical HPV-DNA did not influence obstetric and neonatal outcomes. The findings of this study reinforce the need to implement educational measures capable of modifying the incidence of sexually transmitted infections in this population and capable of promoting adherence to HPV vaccination programs.

Incidence and clearance of oral and cervicogenital HPV infection: longitudinal analysis of the MHOC cohort study

OBJECTIVES

The Michigan HPV and Oropharyngeal Cancer study aimed to evaluate patterns of oral and cervicogenital human papillomavirus (HPV) infection prevalence, incidence, and clearance as well as their relationship to sexual behaviours.

DESIGN

Cohort SETTING: General public in and around Ann Arbor, Michigan.

PARTICIPANTS

394 college-age and older-adult participants of both sexes provided oral samples, and 325 completed at least 2 visits. 130 who provided a cervicogenital samples, and 127 completed at least 2 visits.

OUTCOMES

Incidence and clearance rates as well as HRs for oral and cervicogenital HPV.

RESULTS

Oral HPV infections were transient, with only 16% of genotypes persisting to the next visit. The mean time to clearance of a genotype was 46 days (95% CI 37 to 58). In contrast, cervicogenital infections were more persistent, with 56% of genotypes persisting to the next visit. The mean time to clearance of a genotype was 87 days (95% CI 74 to 102). HPV vaccination was associated with reduced incidence of cervicogenital HPV infection (HR 0.63; 95% CI 0.47 to 0.83) but not oral HPV infection. Incidence of oral HPV infection was associated with 2+ recent deep kissing partners (HR 2.00; 95% CI 1.13 to 3.56). Incidence of both oral (HR: 1.70; 95% CI 1.08 to 2.68) and cervicogenital (HR 2.46; 95% CI 1.69 to 3.59) was associated with 2+ recent sexual partners.

CONCLUSIONS

Detection of oral HPV was highly transient, but incidence was associated with recent deep kissing and sexual partners. Detection of cervicogenital HPV was more persistent, and incidence was positively associated with recent sexual partners and negatively associated with HPV vaccination.

Evaluating Risk-Stratified HPV Catch-up Vaccination Strategies: Should We Go beyond Age 26?

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV can cause genital warts and multiple types of cancers in females. HPV vaccination is recommended to youth age 11 or 12 years before sexual initiation to prevent onset of HPV-related diseases. For females who have not been vaccinated previously, catch-up vaccines are recommended through age 26. The extent to which catch-up vaccines are beneficial in terms of disease prevention and cost-effectiveness is questionable given that some women may have been exposed to HPV before receiving the catch-up vaccination. This study aims to examine whether the cutoff age of catch-up vaccination should be determined based on an individual woman's risk characteristic instead of a one-size-fits-all age 26.

METHODS

We developed a microsimulation model to evaluate multiple clinical outcomes of HPV vaccination for different women based on a number of personal attributes. We modeled the impact of HPV vaccination at different ages on every woman and tracked her course of life to estimate the clinical outcomes that resulted from receiving vaccines. As the simulation model is risk stratified, we used extreme gradient boosting to build an HPV risk model estimating every woman's dynamic HPV risk over time for the lifetime simulation model.

RESULTS

Our study shows that catch-up vaccines still benefit all women after age 26 from the perspective of clinical outcomes. Women facing high risk of HPV infection are expected to gain more health benefits compared with women with low HPV risk.

CONCLUSIONS

From a cancer prevention perspective, this study suggests that the catch-up vaccine after age 26 should be deliberately considered.

Does the vaginal microbiota play a role in the development of cervical cancer?

Persistent infection with oncogenic human papillomavirus (HPV) is necessary but not sufficient for the development of cervical cancer. The factors promoting persistence as well those triggering carcinogenetic pathways are incompletely understood. Rapidly evolving evidence indicates that the vaginal microbiome (VM) may play a functional role (both protective and harmful) in the acquisition and persistence of HPV, and subsequent development of cervical cancer. The first studies examining the VM and the presence of an HPV infection using next-generation sequencing techniques identified higher microbial diversity in HPV-positive as opposed to HPV-negative women. Furthermore, there appears to be a temporal relationship between the VM and HPV infection in that specific community state types may be correlated with a higher chance of progression or regression of the infection. Studies describing the VM in women with preinvasive disease (squamous intraepithelial neoplasia [SIL]) consistently demonstrate a dysbiosis in women with the more severe disease. Although it is plausible that the composition of the VM may influence the host's innate immune response, susceptibility to infection, and the development of cervical disease, the studies to date do not prove causality. Future studies should explore the causal link between the VM and the clinical outcome in longitudinal samples from existing biobanks.

Vaginal high-risk human papillomavirus infection in a cross-sectional study among women of six different ethnicities in Amsterdam, the Netherlands: the HELIUS study

OBJECTIVE

In the Netherlands the incidence of cervical cancer is higher among ethnic minority populations compared with the general Dutch population. We investigated the prevalence of, and risk factors associated with, vaginal high-risk human papillomavirus (hrHPV) infection in women of six different ethnicities living in Amsterdam.

METHODS

For this cross-sectional study we selected women aged 18-34 years old of six ethnicities from the large-scale multiethnic HEalthy LIfe in an Urban Setting study. Self-collected vaginal swabs were tested for HPV DNA and genotyped using a highly sensitive PCR and reverse line blot assay (short PCR fragment (SPF)10-PCR DNA enzyme immunoassay/LiPA25-system version-1, delft diagnostic laboratory (DDL)). Participants completed a questionnaire regarding demographics and sexual behaviour. Logistic regression using generalised estimating equations was used to assess risk factors of hrHPV, and to investigate whether prevalence of hrHPV differed among ethnicities.

RESULTS

The study population consisted of 592 women with a median age of 27 (IQR: 23-31) years. Dutch and African Surinamese women reported the highest sexual risk behaviour. HrHPV prevalence was highest in the Dutch (40%) followed by the African Surinamese (32%), Turkish (29%), Ghanaian (26%), Moroccan (26%) and South-Asian Surinamese (18%). When correcting for sexual risk behaviour, the odds to be hrHPV-positive were similar for all non-Dutch groups when compared with that of the Dutch group.

CONCLUSIONS

We found an overall higher hrHPV prevalence and higher sexual risk behaviour in the native Dutch population. Further research is needed to unravel the complex problem concerning cervical cancer disparities, such as differences in participation in the cervical cancer screening programme, or differences in clearance and persistence of hrHPV.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of smoking on HPV infection and the development of anogenital warts

PURPOSE

The worldwide prevalence of human papillomavirus (HPV) infection is estimated at 9-13 %. Persistent infection can lead to the development of malignant and nonmalignant diseases. Low-risk HPV types are mostly associated with benign lesions such as anogenital warts. In the present systematic review, we examined the impact of smoking on HPV infection and the development of anogenital warts, respectively.

METHODS

A systematic literature search was performed using MEDLINE database for peer-reviewed articles published from January 01, 1985 to November 30, 2013. Pooled rates of HPV prevalence were compared using the χ (2) test.

RESULTS

In both genders, smoking is associated with higher incidence and prevalence rates for HPV infection, whereas the latter responds to a dose-effect relationship. The overall HPV prevalence for smoking patients was 48.2 versus 37. 5 % for nonsmoking patients (p < 0.001) (odds ratio (OR) = 1.5, 95 % confidence interval (CI) 1.4-1.7). Smoking does also increase persistence rates for high-risk HPV infection, while this correlation is debatable for low-risk HPV. The incidence and recurrence rates of anogenital warts are significantly increased in smokers.

CONCLUSIONS

Most current data demonstrate an association between smoking, increased anogenital HPV infection, and development of anogenital warts. These data add to the long list of reasons for making smoking cessation a keystone of patient health.

Determinants of newly detected human papillomavirus infection in HIV-infected and HIV-uninfected injection drug using women

BACKGROUND

We sought to identify factors associated with newly detected human papillomavirus (HPV) infection in a high-risk cohort of injection drug using women in Baltimore, MD.

METHODS

We studied 146 HIV-infected and 73 HIV-uninfected female participants in a 5-year prospective HIV natural history study. We examined the association of sexual and nonsexual risk factors and newly detected type-specific HPV infection as determined by consensus PCR between consecutive visits.

RESULTS

Newly detected HPV was more common among HIV-infected versus HIV-uninfected women (30% and 6%, respectively; P <0.01). Among the entire cohort, recent crack use (OR, 1.7; 95% CI, 1.1-2.6) and HIV infection/CD4 cell count were independent predictors for new HPV detection (HIV-uninfected as reference, OR, 4.6; 95% CI, 2.3-8.9, OR, 5.4; 95% CI, 2.8-10.3, and OR, 10.9; 95% CI, 5.5-21.7 for HIV-infected CD4 >500, 200-500, and <200, respectively). Among HIV-uninfected women, recent marijuana use was an independent predictor of newly detected HPV infection (OR, 3.5; 95% CI, 1.3-9.5).

CONCLUSIONS

Newly detected HPV clearly increased with greater immunosuppression in HIV-infected injection drug users. Larger studies of HIV-uninfected and infected high-risk individuals are needed to clarify the independent associations of crack and marijuana use with new (or reactivated) HPV infection.

Oncogenic HPV Types Infection in Adolescents and University Women from North Portugal: From Self-Sampling to Cancer Prevention

This study aimed to characterize the HPV infection status in adolescents and young university women in Portugal. The distribution of HPV genotypes was evaluated by PCR DNA genotyping after self-sampling collection from 435 women of exfoliated cervical cells using a commercial kit. We observed an overall frequency of HPV infection of 11.5%. Furthermore, HPV DNA prevalence was 16.6% in those young women that self-declared as sexually active. The more frequently detected HPV types were 31, 16, 53, and 61. Statistical analysis identified median age (OR = 3.56; P = 0.001), the number of lifetime sexual partners (OR = 4.50; P < 0.001), and years of sexual activity (OR = 2.36; P = 0.008) as risk factors for HPV acquisition. Hence, our study revealed that oncogenic HPV infection is common in young asymptomatic women Portuguese women, with a history of 2-5 sexual partners and over 2 year of sexual activity. Moreover, these results demonstrate that HPV detection performed in self-collected samples may be important to appraise better preventive strategies and to monitorize the influence of vaccination programmes within different populations.

Role and uptake of human papillomavirus vaccine in adolescent health in the United States

Both the prophylactic human papillomavirus (HPV) vaccines, Gardasil^® and Cervarix^®, are licensed for the prevention of cervical cancer in females, and Gardasil is also licensed for the prevention of genital warts and anal cancer in both males and females. This review focuses on the uptake of these vaccines in adolescent males and females in the USA and the barriers associated with vaccine initiation and completion. In the USA in 2009, approximately 44.3% of adolescent females aged 13-17 years had received at least one dose of the HPV vaccine, but only 26.7% had received all three doses. In general, the Northeast and Midwest regions of the USA have the highest rates of HPV vaccine initiation in adolescent females, while the Southeast has the lowest rates of vaccine initiation. Uptake of the first dose of the HPV vaccine in adolescent females did not vary by race/ethnicity; however, completion of all three doses is lower among African Americans (23.1%) and Latinos (23.4%) compared with Caucasians (29.3%). At present, vaccination rates among adolescent females are lower than expected, and thus vaccine models suggest that it is more cost-effective to vaccinate both adolescent males and females. Current guidelines for HPV vaccination in adolescent males is recommended only for "permissive use," which leaves this population out of routine vaccination for HPV. The uptake of the vaccine is challenged by the high cost, feasibility, and logistics of three-dose deliveries. The biggest impact on acceptability of the vaccine is by adolescents, physicians, parents, and the community. Future efforts need to focus on HPV vaccine education among adolescents and decreasing the barriers associated with poor vaccine uptake and completion in adolescents before their sexual debut, but Papanicolau screening should remain routine among adults and those already infected until a therapeutic vaccine can be developed.

Human papillomavirus concordance in heterosexual couples

PURPOSE

Few studies have examined the relationships between sexual or hygienic behaviors and human papillomavirus (HPV) transmission. Our objectives were to (1) describe HPV concordance between the anogenital, oral, and palmar areas of monogamous heterosexual couples; and (2) determine sexual behaviors, hygienic practices, sexual histories, and subject characteristics associated with HPV anogenital concordance.

METHODS

Couples were recruited from women who developed an incident HPV infection while being enrolled in a longitudinal HPV natural history study that recruited from two family-planning clinics. Men were their monogamous partners of at least 3 months. Samples were tested for HPV-DNA of 37 high- and low-risk genotypes. Questionnaires completed privately assessed health, sexual, hygienic history, and behaviors.

RESULTS

A total of 25 couples enrolled between February 2006 and July 2007; none had received HPV vaccine. The average age was 25 years (SD, 6) for men and 23 years (SD, 3) for women. HPV-84 was the most commonly shared HPV type in the anogenital and palmar areas. HPV-16 was the only shared oral-HPV type. Sixty-eight percent of couples had type-specific anogenital concordance. Receiving finger-anal sex (p = .05), sharing towels (p = .04), longer time since last intercourse (women: p = .03, men: p = .02 men), and men washing their genitals after sex (p = .03) were associated with decreased likelihood of concordance. Persistence of incident HPV types in women was associated with HPV in men (p = .002).

CONCLUSIONS

Our findings show that certain hygienic and sexual behaviors are associated with anogenital concordance between healthy, monogamous, heterosexual couples. Future studies are needed to see whether these detections reflect contamination, transient, or established infections.

Sexually transmitted and other genital infections in women with cervical human papillomavirus infection

Objective: We investigated possible correlations between latent cervical human papillomavirus infection (CHPI) and other sexually transmitted diseases (STDs).

Methods: Of 972 randomly selected women attending 2 family planning clinics and a youth clinic who had agreed to participate in a study concerning STDs, 66 (6.8%) had latent CHPI.

Results: An association was found between latent CHPI on one hand and a history of genital chlamydial infection, gonorrhea, recurrent vaginal candidiasis, cervicitis, or pelvic inflammatory disease (PID) on the other, while no correlation between latent CHPI and coexistent STDs was found. No correlation of latent CHPI to either current or past genital warts was noted. In multifactorial analyses, which included the lifetime number of sexual partners and age at first intercourse, we found that all significant associations except a history of gonorrhea vanished.

Conclusions: In this study population, screening for other current STDs in women with latent CHPI would be of limited value.

Marijuana use is not associated with cervical human papillomavirus natural history or cervical neoplasia in HIV-seropositive or HIV-seronegative women

Marijuana use was recently reported to have a positive cross-sectional association with human papillomavirus (HPV)-related head and neck cancer. Laboratory data suggest that marijuana could have an immunomodulatory effect. Little is known, however, regarding the effects of marijuana use on cervical HPV or neoplasia. Therefore, we studied the natural history (i.e., prevalence, incident detection, clearance/persistence) of cervical HPV and cervical neoplasia (i.e., squamous intraepithelial lesions; SIL) in a large prospective cohort of 2,584 HIV-seropositive and 915 HIV-seronegative women. Marijuana use was classified as ever/never, current/not current, and by frequency and duration of use. No positive associations were observed between use of marijuana, and either cervical HPV infection or SIL. The findings were similar among HIV-seropositive and HIV-seronegative women, and in tobacco smokers and nonsmokers. These data suggest that marijuana use does not increase the burden of cervical HPV infection or SIL.

Diagnosing Cervical Biopsies in Adolescents

OBJECTIVE

To increase the specificity in diagnosing cervical biopsies in adolescents, we evaluated the use of p16 immunohistochemistry (IHC) as an adjuvant test in addition to hematoxylin and eosin (H&E).

MATERIALS AND METHODS

One hundred cervical histological tissues from adolescents were stained with routine H&E and monoclonal p16 (clone E6H4; dilution, 1:25; Dako). One gynecologic pathologist and 3 pediatric pathologists independently reviewed the cases, rendered diagnoses first by using H&E alone, and then added p16 IHC as an adjuvant marker. The interobserver agreement between the gynecologic pathologist and the pediatric pathologists was calculated using kappa statistics.

RESULTS

The agreement rates between the gynecologic pathologist and all 3 pediatric pathologists were fair (kappa = 0.39, 0.36, and 0.37) when only H&E sections were used, and were improved to moderate (kappa = 0.53, 0.44, and 0.50) after using p16 IHC in addition to H&E.

CONCLUSIONS

The evaluation of cervical intraepithelial neoplasia based solely on H&E-stained biopsies may lack interobserver reproducibility. The p16 IHC reduces the number of discrepancies and improves the rate of agreement among pathologists in diagnosing adolescent's cervical lesions. The improvement in the diagnosis of cervical biopsies has important implications in the treatment and follow-up of adolescent girls with abnormal cervical cytological diagnoses.

Human papillomavirus detection in self-collected vaginal specimens and matched clinician-collected cervical specimens

Human papillomavirus (HPV) detection is an integral part of cervical cancer screening, and a range of specimen collection procedures are being tested. Preliminary studies have found that the majority of women prefer self-collection of vaginal specimens instead of clinician-collected specimens of the cervix. The purposes of the current study were to explore the social and behavioral predictors of acceptance of self-collection of vaginal specimens among patients and to assess concordance in detection of HPV between clinician-collected cervical specimens and self-collected vaginal specimens. The study was conducted at a university family medicine clinic using a cross-sectional study design, and enrollment of women presenting for routine gynecological examination consecutively in a period of 1 year, self-administered questionnaires, collection of paired vaginal and cervical specimens for HPV DNA using Hybrid Capture 2, and cytologic analysis. Most women (79.8% [398/499]) agreed to collect vaginal specimens. In our study, 76.6% (216/282) African American women (AA), 88.1% (156/176) white non-Hispanic (WNH) women, and 63.4% (26/41) women of other races (P < 0.0001) agreed to self-collect vaginal specimens. HPV was detected in 16.0% (80/499) of clinician-collected cervical specimens and 26.1% (104/398) of self-collected vaginal specimens (P < 0.001). HPV detection was concordant in 13.4% (53/398) women in both cervical and vaginal specimens. Self-collection of vaginal specimens for HPV DNA detection is acceptable to most women presenting for routine gynecological examination. WNH women were more likely to obtain self-collected specimens than AA women. Vaginal specimens were more likely to be positive for HPV than were cervical specimens.

Human papillomavirus triage for young women with atypical squamous cells of undetermined significance

OBJECTIVE

Human papillomavirus testing is a cost-effective strategy for the management of atypical squamous cells of undetermined significance. Young women have a high prevalence of transient human papillomavirus infections and low incidence high-grade cervical lesions, which may limit the usefulness of human papillomavirus testing in this cohort. We sought to estimate the usefulness of human papillomavirus testing for young women with atypical squamous cells of undetermined significance.

METHODS

A retrospective study of women with atypical squamous cells of undetermined significance was undertaken. Reflex human papillomavirus results and pathologic follow-up were evaluated. Age-stratified rates of human papillomavirus positivity, rates of high-grade dysplasia, and sensitivity and specificity were estimated.

RESULTS

A total of 1,290 women with atypical squamous cells of undetermined significance cytology were identified. The rate of human papillomavirus positivity decreased with age from 55% for those aged 25 years or younger to 12% for women aged older than 50 years (P < .001). The cumulative rate of high-grade lesions increased with age; 12% for patients aged 25 years or younger compared with 24% for women aged older than 50 years (P = .05). A negative human papillomavirus test more effectively excluded high-grade disease in the young women. No high-grade lesions were detected in the human papillomavirus negative women aged 25 years or younger compared with 3.8% of those aged older than 50 years (P = .04). The sensitivity for detection of high-grade disease was higher in women aged younger than 25 years compared with those aged older than 50 years (100% compared with 50%), whereas specificity was lower (14% compared with 44%).

CONCLUSION

Given the high prevalence of human papillomavirus and low occurrence of high-grade lesions in young women with atypical squamous cells of undetermined significance, a human papillomavirus-based triage strategy will result in the referral of a large number of women for colposcopy and may limit its cost-effectiveness.

LEVEL OF EVIDENCE

III.

Determinants of genital wart case detection rates among STD clinic attendees in Athens, Greece

BACKGROUND AND OBJECTIVE

To report significant sociodemographic and behavioral outpatient characteristics associated with the diagnosis of genital warts.

METHODS

Cross-sectional hospital-based study (1990-96).

RESULTS

Genital warts (n = 2988, 51.2%) represent the leading sexually transmitted disease (STD) among 5831 consecutive symptomatic Greek and foreign immigrant STD outpatients. In Greek heterosexuals a low rate of partner change was the main patient characteristic at diagnosis (median: one partner in the past 6 months). Lower detection rate and riskier behavior characterized immigrants. Although associated with risky behavior, homo/bisexual orientation in males and injecting drug use were not significantly associated with condyloma diagnosis in the context of STDs.

CONCLUSION

Broader health education and secondary prevention are needed to control this infection, whereas low-risk behavior in Greek heterosexuals with condylomata facilitates further preventive interventions.

Cervical cytology testing in teens

PURPOSE OF REVIEW

Although cervical cytology screening programs have dramatically decreased rates of invasive cancer in developed countries, most guidelines in the USA were overaggressive in their management of abnormal cytology in adolescents and young women. These management strategies resulted in costly over-treatment. The purpose of this article is to review the evidence for the new guidelines in cytology screening in youth.

RECENT FINDINGS

Natural history studies of human papillomavirus (the cause of abnormal cytology and cervical cancer) suggest there is little risk of a significant pre-cancerous lesion going undetected within the first 3-5 years after the onset of sexual activity. The American Cancer Society now recommends that screening be initiated within 3 years of the onset of vaginal intercourse but no later than 21 years of age. The American Society for Colposcopy and Cervical Pathology allows for follow-up of low-grade squamous intra-epithelial lesions with repeat cytology or human papillomavirus DNA testing rather than immediate referral to colposcopy.

SUMMARY

The new recommendations appear to be safe and will decrease the current over-referral and over-treatment of adolescents and young women with HPV infections.

The epidemiology of sexually transmitted infections in adolescents

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

Genital infection with human papillomavirus in adolescents

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections in adolescents. Such infection is associated with substantial health risks and is unpredictable in its resolution. Genital warts are the most common clinical manifestations of genital HPV infections. Most genital warts are caused by low risk HPV types (notably HPV-6 and -11). The majority of genital HPV infections are latent or subclinical. Although the outcome of a genital HPV infection is variable, the infection is usually transient and complete resolution is common. However, persistent infections with high-risk HPV types (notably HPV-16 and -18) are associated with the development of cervical intraepithelial dysplasia (CIN), which may progress to cervical cancer. Genital warts, generally diagnosed in the clinic, can be treated with imiquimod, podofilox, podophyllin, liquid nitrogen, bichloroacetic or trichloroacetic acid, or surgery. Cervical cytology screening is an ideal screening test for subclinical HPV infection with resultant CIN. Annual cervical cytology screening should begin approximately 3 years after initiation of sexual intercourse but no later than age 21 years. Because of the high rate of regression of low-grade squamous intraepithelial lesions (LSIL) in adolescents, the cytologic study should be repeated within 6 to 12 months. Colposcopy should be reserved for persistent LSIL. Patients with high-grade squamous intraepithelial lesions (HSIL) should be referred for colposcopy and biopsy. Confirmed HSIL should be treated with cryotherapy, laser therapy, or loop electrosurgical excisional procedure. The use of therapeutic vaccines is still experimental. HPV infection can be prevented, to a certain extent, by delaying the initiation of sexual activity, limiting the number of sexual partners, and using latex condoms. Several viruslike particle candidate vaccines are under development for the prevention of HPV. These vaccines have been proven safe, well tolerated, highly immunogenic, and highly efficacious. Such vaccines are urgently needed and ultimately may be an important preventive measure.

Impact of transforming viruses on cellular mutagenesis, genome stability, and cellular transformation

It is estimated that 15% of all cancers are etiologically linked to viral infection. Specific cancers including adult T-cell leukemia, hepatocellular carcinoma, and uterine cervical cancer are associated with infection by human T-cell leukemia virus type I, hepatitis B virus, and high-risk human papilloma virus, respectively. In these cancers, genomic instability, a hallmark of multistep cancers, has been explicitly linked to the expression of oncoproteins encoded by these viruses. This review discusses mechanisms utilized by these viral oncoproteins, Tax, HBx, and E6/E7, to mediate genomic instability and cellular transformation.

Atypical Squamous Cells of Undetermined Significance in Girls and Women

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III

Polymer-based enzyme-linked immunosorbent assay using human papillomavirus type 16 (HPV16) virus-like particles detects HPV16 clade-specific serologic responses

Human papillomavirus type 16 (HPV16) virus-like particles (VLP) were used as antigen in a polymer enzyme-linked immunosorbent assay (ELISA) to measure antibodies to HPV capsid proteins. Serum samples from 575 college women, previously tested for the presence of cervicovaginal HPV DNA, were analyzed. The prevalences of anti-HPV16 VLP antibodies at baseline were 14.1% for immunoglobulin G (IgG) and 6.4% for IgA. The seroprevalences of IgG in women with cervicovaginal HPV16, HPV16-related types, and other HPV types were 55, 33, and 19%, respectively (P < 0.001), compared to the prevalence in women without an HPV infection (10%). HPV VLP IgA seropositivity was associated with high HPV16 VLP IgG optical density values. The seropositivity of IgG antibodies was independently associated with infection with HPV16 or HPV16-related types, increased number of lifetime male partners for vaginal sex, having sex with men >/= 5 years older, history of abnormal PAP smear, older age, and living separately from parents. Use of HPV16 VLP polymer ELISA detects clade-specific responses and suggests an HPV16 VLP vaccine may have broader protection that initially anticipated.

Human papillomavirus infection and abnormal cytology of the anus in HIV-infected and uninfected adolescents

OBJECTIVE

To examine the prevalence of and risk for anal human papillomavirus (HPV) infection and abnormal anal cytology in sexually active adolescents.

DESIGN

Prevalence data from adolescents aged 13-18 years with and without HIV infection and with a history of high-risk sexual behavior.

METHODS

HPV DNA was detected using amplification techniques. Abnormal anal cytology was defined as atypical squamous cell of undetermined significance or worse.

RESULTS

Prevalence of anal HPV infection was similar in HIV-infected [28/58 (48%)] and uninfected [9/25 (36%)] boys (P = 0.3). but greater in HIV-infected [59/183 (59%)] than in uninfected [11/82 (13%)] girls (P < 0.001). Perianal warts were a risk for anal HPV in both boys [odds ratio (OR), 15.5; 95% confidence interval (CI), 1.6-149] and girls (OR, 9.9; 95% CI, 1.9-51.3). In subjects without anal warts, HIV infection was significant for girls (OR, 2.3; 95% CI, 1.1-4.9) and homosexual/bisexual orientation was significant for boys (OR, 5.2; 95% CI, 1.3-20.6). Abnormal anal cytology was more common among boys [32/77 (41.6%)] than girls [38/230 (16.5%)] (P < 0.001) and in addition to anal HPV, independent risk factors were positive HIV status in boys (OR, 6.5; 95% CI, 1.5-11.9) and number of partners within the past 3 months in girls (OR, 4.2; 95% CI, 1.5-11.9).

CONCLUSIONS

Strong risk factors for abnormal anal cytology were HIV infection and anal HPV in boys and anal HPV and higher number of sexual partners for girls. The results suggest that anal cytology screening should be considered in HIV infected homosexual/bisexual males.

High- and intermediate-risk human papillomavirus infection in sexually active adolescent females

STUDY OBJECTIVE

To determine the prevalence of high- and intermediate-risk type human papillomavirus (HPV) infection and cervical dysplasia in an urban Swiss adolescent population attending the local Adolescent Clinic, using a liquid-based Pap test combined with risk type HPV DNA testing. To determine the prevalence of Chlamydia trachomatis in the same study population.

DESIGN

Observational study.

SETTING

The Adolescent Clinic of the Department of Obstetrics and Gynaecology at the University Clinic, Geneva, Switzerland.

PARTICIPANTS

134 women between 14 and 20 years of age were enrolled in the study.

MAIN OUTCOME MEASURES

A standardized patient file on demographic and sexual history information was compiled and completed by physical examination, including a Pap test with adjunct high- and intermediate-risk type HPV DNA detection.

RESULTS

Of the 134 specimens analyzed for HPV, 115 patients were negative and 19 (14.2%) were positive for HPV types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, or 68. A significant association between HPV infection and having had more than one lifetime sexual partner was found (P <.05). Six (31.6%) of the HPV-positive and three (2.6%) of the HPV-negative specimens had a low-grade squamous intraepithelial lesion (SIL) by cytology. Abnormal Pap test was related to HPV infection (odds ratio, 46.2; 95% confidence interval, 7.4 to 287.4) and, inversely, to age at first sexual intercourse (odds ratio, 0.98; 95% confidence interval,.97 to 1.0).

CONCLUSION

High- and intermediate-risk type HPV infection is a frequent finding in our study group and is linked to having had more than one lifetime sexual partner. No association was found between HPV infection and other potential risk factors such as patient's age, age at first intercourse, frequency of intercourse during the three months prior to the investigation, smoking habits, or alcohol consumption.

Adolescents with ASCUS: are they a high risk group?

Population demographics, risk behaviors, and compliance rates for the management of an ASCUS (atypical squamous cells of undetermined significance) diagnosis are not well studied in the adolescent population. From June 1994 to December 1996, 1,175 Papanicalou (pap) smears were performed in an urban adolescent clinic on patients age 12 to 18. Of these, 124 (10.5%) were diagnosed with ASCUS or ASCUS with a qualifying statement. A retrospective chart review (n=83) and telephone interview was performed on patients with ASCUS. Ninety-nine percent of enrollees were African American. Comparisons were made between those patients with normal pap smears and those with ASCUS. No statistically significant difference existed pertaining to age at pap smear, age at menarche, age at first coitus, and education level. A positive association was found in the ASCUS group for the presence of sexually transmitted diseases (P < 0.001), number of sexual partners (P < 0.0007), and pregnancy (P < 0.001). Of the 80% of patients who had an ASCUS diagnosis and were referred for colposcopy (n = 62), only 61% attended their appointment (n = 38). Thirty-nine percent of these patients were aware of an abnormal diagnosis after colposcopy. For those that attended colposcopy, 56% were accompanied by a parent. For those who were not compliant with attendance, none cited parental consent for the procedure as a barrier to obtaining treatment. Adolescent females in an urban setting with multiple sexual partners, history of sexually transmitted diseases, and prior pregnancy are at a greater risk for ASCUS on cervicovaginal smear when compared to their age-matched controls. In addition, the adolescent compliance rate for colposcopy is low. We, therefore, recommend that these adolescent females be observed diligently.

Colposcopically directed biopsy findings in the young female

STUDY OBJECTIVE

To evaluate the colposcopic findings of cervical alterations in the young sexually active female.

DESIGN, SETTING, PARTICIPANTS

Colposcopic examination and follow-up of 51 young sexually active females aged 15-20 yr was conducted due to abnormal cytology or a suspicious abnormality of the cervix. The study was conducted at the Colposcopy Units of the 1(st) and 2(nd) Departments of Obstetrics and Gynecology, University of Athens, Greece. ONTERVENTIONS: Colposcopic examination, LEEP, conization.

MEAN OUTCOME MEASURES

Biopsy, human papillomavirus (HPV) typing.

RESULTS

Colposcopic examinations were within normal limits in 8 of 51 (15.7%) cases. Cervical alterations were related to HPV infection in 14 cases (27.4%), to cervical intraepithelial neoplasia (CIN) I in 15 (29.4%) cases, to CIN II in 13 (25.5%) cases, and to CIN III in 1 (2.0%) case. Of all CIN I cases, 8 of 15 (53.3%) were HPV positive, and HPV type 11, 16, 18, 31, 33, and 11& 16 were found. In CIN II cases, 5 of 13 (38.4%) were HPV positive, and HPV type 11, 16, 18, and 11 & 31 were found. In the CIN III case, only HPV type 16 was found.

CONCLUSIONS

Our findings strongly confirm the necessity of obtaining cervicovaginal smears on all sexually active gynecologic and obstetric teenage patients. Colposcopy plays a major role in the evaluation of the cervix and in the treatment that should be given for any individual CIN lesion.

Induction of CD8 T cells by vaccination with recombinant adenovirus expressing human papillomavirus type 16 E5 gene reduces tumor growth

The potential of the E5 protein as a tumor vaccine candidate has not been explored yet. In this study, we evaluate the human papillomavirus type 16 (HPV-16) E5 protein delivered by an adenovirus vector as a tumor vaccine for cervical lesions. The results demonstrate that a single intramuscular injection of a recombinant adenovirus carrying the HPV-16 E5 gene into syngeneic animals can reduce the growth of tumors which contain E5 gene expression. Moreover, the E5 vaccine-induced tumor protection occurs through CD8 T cells but not through CD4 T cells in in vitro assays. In addition, our studies using knockout mice with distinct T-cell deficiencies confirm that cytotoxic T-lymphocyte-induced tumor protection is CD8 dependent but CD4 independent. Hence, HPV-16 E5 can be regarded as a tumor rejection antigen.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adolescents' knowledge of human papillomavirus and cervical dysplasia

STUDY OBJECTIVE

This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified.

DESIGN

Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed.

SETTING

The study was conducted at a university-based adolescent dysplasia clinic.

PARTICIPANTS

Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian.

RESULTS

On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests.

CONCLUSIONS

Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Knowledge of human papillomavirus infection among young adult men and women: implications for health education and research

Human papillomavirus (HPV) infection of the genital tract is one of the most common sexually transmitted diseases (STDs), and a subset of genital tract HPVs are etiologically associated with cervical cancer. The prevalence of HPV infection is highest among adolescents and young adults. This study was undertaken to explore first year college students' knowledge about HPVs and to determine whether there were gender differences in this knowledge. An anonymous survey was distributed to all first year students at a private university. The results were analyzed by gender. We found that 96.2% of males and 95.4% of females had heard of genital warts, although only 4.2% of males and 11.6% of females knew that HPV caused genital warts. Although there was a greater awareness of genital warts than HPV in this population, students were uncertain about modes of transmission of both genital warts and HPVs, and unclear about the importance of HPV infection relative to other STDs. For both men and women (87% and 87.4%, respectively), health education classes were the major source of information about STDs. We conclude that health education should be reconceptualized to incorporate a better understanding of STDs, including HPV infection, by engaging adolescents and young adults in exploring the biological and social context of STDs, their public health importance, strategies for prevention, and the uncertainty of our scientific knowledge.

Comparison of human papillomavirus genotypes in archival cervical cancer specimens from Alaska natives, Greenland natives and Danish Caucasians

Archival, formalin-fixed, paraffin-embedded cervical cancer specimens from 53 Alaska natives, 32 Greenland natives and 34 Danish Caucasians were analyzed for human papillomavirus (HPV) genotypes 16, 18, 31, 33, 35 and 45 and unidentified genotypes (HPV X) using PCR. The specimens were from the time period 1980-1989. No significant differences were observed in the overall HPV detection rates among cases from Alaska (98.1%), Greenland (84.4%) and Denmark (85.3%). HPV genotype 16 was the most prevalent type: 78.8% in Alaska natives, 96.3% in Greenland natives and 82.8% in Danish Caucasians. A prevalence of 21.2% HPV 31 and 30.8% HPV 33 was found in Alaska natives, of which most were coinfections with HPV 16. Only 3.7% HPV 31 and 3.7% HPV 33 were found in Greenland natives and no HPV 31 and 6.9% HPV 33 were found in Danish Caucasians. HPV 18 was only detected in Alaska natives and HPV 35 and 45 were not detected in any of the three populations. Infections with multiple genotypes were prevalent in Alaskan (36.5%) but not in Greenland natives (3. 7%) and Danish Caucasians (6.9%). The Eskimo subgroup of the Alaska native population has a significantly higher prevalence of HPV genotypes 31 and 33 associated with mixed infections in invasive cancer than the two other native subgroups (P = 0.04) and Greenland and Danish populations, reflecting genotype distributions in dysplasia and normal cervical cytology. The reason for HPV genotype diversity, although unknown, may be relevant to the current development of HPV vaccines.

Risk factors for the acquisition of genital warts: are condoms protective?

OBJECTIVES

To characterise risk factors for the acquisition of genital warts and specifically to determine whether condoms confer protection from infection.

METHODS

A retrospective case-control study comparing demographic, behavioural, and sexual factors in men and women with and without newly diagnosed genital warts, who attended Sydney Sexual Health Centre (SSHC), an inner city public sexual health centre, in 1996. Data were extracted from the SSHC database. Crude odds ratios (OR) were calculated to compare cases and controls and significant factors were then controlled for using multivariate logistic regression to obtain adjusted odds ratios (ORs).

RESULTS

977 patients with warts and 977 controls matched by sex and date of attendance were included. In both sexes, univariate analysis revealed that younger age, more lifetime sexual partners, failure to use condoms, greater cigarette smoking and alcohol consumption were associated with warts, and there was a negative association with previous infection with Chlamydia trachomatis, Neisseria gonorrhoeae, hepatitis B, and genital herpes. In males, on multivariate analysis, factors which remained significant were younger age, more lifetime sexual partners; failure to use condoms, greater cigarette smoking, and previous chlamydia. In women, factors which remained significant were younger age, more lifetime sexual partners, condom use, marital status, and previous infections with Chlamydia trachomatis and herpes.

CONCLUSIONS

Independent risk factors for genital warts include younger age, greater number of lifetime sexual partners, and smoking. Consistent condom use significantly reduces the risk of acquiring genital warts.

Human papillomavirus infection in adolescents

The recent gain in knowledge of the genomic function of HPV has led to a greater understanding of the natural history of HPV infection in women, starting from infection to the development of invasive cancer. LSIL is reflective of a benign process associated with HPV replication, and in the majority of women, HPV is eradicated or put into some type of immunologic control so that it remains undetected. In contrast, in the minority of women who have persistent infection, HSIL and invasive cancer are more likely to occur. These findings can be translated clinically to suggest that LSIL can be followed up for a defined period of time and that HPV testing in older women may be useful to identify persistent HPV infections and subsequent risk for invasive cancers.

'With the best of reasons': cervical cancer prevention policy and the suppression of sexual risk factor information

Cervical cancer is a very common but largely preventable cancer. Despite considerable medical knowledge of risk and even causal factors, possible social-behavioural strategies for the primary prevention of cervical cancer have rarely been explored as a viable addition to cervical screening. We examine key policy documents and interview 18 key informants on cervical cancer prevention in New Zealand. Using a discourse analytic approach we identify and discuss two discourses (which we have labelled 'protectionism' and 'right to know') which inform positions on whether or not women should be provided with information regarding sexual risk factors for cervical cancer. Cervical cancer prevention policy in New Zealand, which largely reflects a protectionist discourse, suppresses sexual risk factor information and focuses exclusively on cervical screening. The right to know discourse informs an alternative position, which contends that women have a right to be informed about risk factors. We discuss these positions in relation to questions about women's rights, the principle of informed choice, and attempts to judge what is in women's 'best interests.'

The significance of squamous metaplasia in the development of low grade squamous intraepithelial lesions in young women

BACKGROUND

The purpose of this study was to examine, prospectively, the presence and extent of cervical epithelial immaturity as well as the rate of squamous metaplastic activity as a risk for the development of low grade squamous intraepithelial lesions (LSIL).

METHODS

The study was a nested case-control design that used subjects from an ongoing cohort study of human papillomavirus infection. Fifty-four sexually active young women who developed LSIL were matched for age and number of visits with 54 women who had never developed LSIL. The percent of cervical immaturity was interpreted from colpophotography using a computer-generated pixel count of delineated immature and total cervical areas. Activity of squamous metaplasia was interpreted as the percent change in the area of immaturity over a defined time period. Conditional logistic regression analysis examined risks for the development of LSIL.

RESULTS

Baseline area of biologic immaturity was not a predictor of LSIL. However, women with the a high degree of metaplastic activity near the SIL event were more likely to develop LSIL (odds ratio = 3.01 [95% confidence interval, 1.3, 6.8] for every 10% unit change in area of immaturity).

CONCLUSIONS

A rapid rate of metaplastic change within the transformation zone, rather than the initial area of biologic immaturity, is a significant risk factor for the development of LSIL.

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

OBJECTIVE

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

Cervicovaginal human papillomavirus infection in human immunodeficiency virus-1 (HIV)-positive and high-risk HIV-negative women

BACKGROUND

Human papillomavirus (HPV) infection is associated with precancerous cervical squamous intraepithelial lesions commonly seen among women infected with human immunodeficiency virus-1 (HIV). We characterized HPV infection in a large cohort of HIV-positive and HIV-negative women participating in the Women's Interagency HIV Study to determine the prevalence of and risk factors for cervicovaginal HPV infection in HIV-positive women.

METHODS

HIV-positive (n = 1778) and HIV-negative (n = 500) women were tested at enrollment for the presence of HPV DNA in a cervicovaginal lavage specimen. Blood samples were tested for HIV antibody status, level of CD4-positive T cells, and HIV RNA load (copies/mL). An interview detailing risk factors was conducted. Univariate and multivariate analyses were performed.

RESULTS

Compared with HIV-negative women, HIV-positive women with a CD4+ cell count of less than 200/mm3 were at the highest risk of HPV infection, regardless of HIV RNA load (odds ratio [OR] = 10.13; 95% confidence interval [CI] = 7.32-14.04), followed by women with a CD4+ count greater than 200/mm3 and an HIV RNA load greater than 20,000 copies/mL (OR = 5.78; 95% CI = 4.17-8.08) and women with a CD4+ count greater than 200/mm3 and an HIV RNA load less than 20,000 copies/mL (OR = 3.12; 95% CI = 2.36-4.12), after adjustment for other factors. Other risk factors among HIV-positive women included racial/ethnic background (African-American versus Caucasian, OR = 1.64; 95% CI = 1.19-2.28), current smoking (yes versus no; OR = 1.55; 95% CI = 1.20-1.99), and younger age (age < 30 years versus > or = 40 years; OR = 1.75; 95% CI = 1.23-2.49).

CONCLUSIONS

Although the strongest risk factors of HPV infection among HIV-positive women were indicators of more advanced HIV-related disease, other factors commonly found in studies of HIV-negative women, including racial/ethnic background, current smoking, and age, were important in HIV-positive women as well.

Adolescent abstinence and condom use: are we sure we are really teaching what is safe?

This article reviews existing research on condom and abstinence method- and user-failure rates, and the use of this research in determining sexuality education curricula. Latex condoms effectively prevent pregnancies and most sexually transmitted diseases or infections (STIs), with method-failure rates between 0.5% and 7%, but with user-failure rates between 12% and 70%. Total abstinence presumably has a method-failure rate of zero, but research on periodic abstinence indicates user-failure rates between 26% and 86%. No researchers have attempted to establish total abstinence user-failure rates. Abstinence-only curricula evaluations have demonstrated changes in adolescents' attitudes but little change in sexual behaviors. Comprehensive sexuality education curricula have demonstrated attitudinal changes and delays in adolescents' sexual activity. Since inconsistent use of either condoms or abstinence threatens adolescents' health, this article urges more scientific research on total abstinence user-failure rates, better and clearer dissemination of research findings, and encourages funders to require educators to show thorough knowledge of research findings.

Risk factors for incident and recurrent condylomata acuminata among women. A population-based study

BACKGROUND

Condylomata acuminata is one of the most common sexually transmitted diseases (STDs) diagnosed in the United States, yet relatively little research has been conducted on the determinants of this disease in well-defined populations.

GOAL

To determine the exposures that predispose a woman to the development of condylomata acuminata or genital warts.

STUDY DESIGN

A population-based case-control study was conducted among enrollees of Group Health Cooperative of Puget Sound. Patients (94 women with incident and 55 women with recurrent condyloma) were diagnosed between April 1, 1987 and September 30, 1991. Control subjects were 133 women without a history of genital warts. An in-person interview was conducted to collect information on subject characteristics, exposures, and on all episodes of genital warts.

RESULTS

Women with five or more partners within the 5 years before reference date were over seven times more likely to have incident condyloma (relative risk [RR], 7.5; 95% confidence interval [CI], 3.1-18.1) and over 12 times more likely to have recurrent condyloma (RR, 12.8; 95% CI, 4.2-38.9) compared with women with only one sexual partner during this time period. An increased risk of incident condyloma was also associated with a history of any STD (RR, 2.6; 95% CI, 1.1-5.8), a history of oral herpes (RR, 2.2; 95% CI, 1.1-4.4), and a history of allergies (RR, 2.0 95% CI, 1.0-3.8). Our data did not support a strong association between risk of condyloma and smoking or recent use of oral contraceptives.

CONCLUSION

Our results suggest that risk of condyloma is primarily related to sexual behavior. We did not observe a strong association between risk of condyloma and many of the exposures considered to be potential cofactors for anogenital cancers associated with other types of human papillomaviruses.

Sexually transmitted diseases in sexually abused children: medical and legal implications

Sexually transmitted diseases (STDs) may be transmitted during sexual assault. In children, the isolation of a sexually transmitted organism may be the first indication that abuse has occurred. Although the presence of a sexually transmissible agent from a child beyond the neonatal period is suggestive of sexual abuse, exceptions do exist. In this review I discuss the issues of the transmissibility and diagnosis of STDs in the context of child sexual abuse. Rectal or genital infection with Chlamydia trachomatis among young children may be the result of perinatally acquired infection and may persist for as long as 3 years. A major problem with chlamydia testing in the context of suspected sexual abuse in children has been the inappropriate use of non-culture tests. Although the new generation of nucleic acid amplification tests have shown high sensitivity and specificity with genital specimens from adults, data on use of these tests on any site in children are practically non-existent. Bacterial vaginosis (BV) has been identified among children who have been abused and among those who have not been abused. However, many of the methods used to diagnose BV in adults have not been evaluated in children. Recent studies of perinatal infection with human papillomavirus (HPV) have been inconclusive. HPV DNA has been detected at various sites in children who have not been abused. The relation to the development of clinically apparent genital warts is unclear. Although HIV can be acquired through sexual abuse in children, the exact risk to the child and which children should be screened is still controversial.