Epidemiology of HPV Genotypes among HIV Positive Women in Kenya: A Systematic Review and Meta-Analysis

Self-collection for high-risk HPV-RNA detection among HIV-seropositive and HIV-seronegative women engaged in sex work in Kenya

BACKGROUND

Evidence of self-collection human papillomavirus (HPV)-RNA testing in cervical cancer screening is limited among women with HIV (WHIV). Most studies are in low-risk patient populations in high-income countries. We examine the prevalence of high-risk HPV (hrHPV) using the APTIMA HPV-RNA assay on self-collected versus provider-collected specimens, and the associated risk factors for high-grade cervical intraepithelial neoplasia (CIN2/3) among women engaged in sex work in Kenya. Among WHIV, we examine the performance of both collection methods for the detection of CIN2/3.

METHODS

Participants were aged ≥18 years, non-pregnant and had no previous treatment for cervical precancer. The screening process included self-collection of cervicovaginal samples using a Viba cytobrush (Rovers), provider-collected cervical samples, visual inspection with acetic acid (VIA) and Pap smear. The APTIMA HPV Assay (Hologic) was used to detect E6/E7 oncogene RNA of 14 hrHPV types in both self-collected and on provider-collected samples. Risk factors for CIN2/3 were determined via multivariable logistic regression. We estimated test characteristics for each screening method for CIN2/3 detection.

RESULTS

A total of 400 women (194 WHIV, 206 women without HIV) underwent screening between 2013 and 2018, with 399 valid HPV results. WHIV had a higher prevalence of hrHPV by self-collection compared with women without HIV (44.0% vs 29.6%, p<0.05) and CIN2/3 (19.0% vs 9.7%, p<0.05). After adjusting for age and HIV status, hrHPV-positivity increased the risk of CIN2/3 by 13 to 20 times. Among WHIV, the sensitivity for CIN2/3 detection was similar between self-collection (85% (66-96)) and provider-collection (93% (76-99)), both of which were higher than the sensitivity of high-grade cytology (high-grade squamous intraepithelial lesion cut-off) (47% (95% CI 23 to 72)). The specificity for both collection methods (self: 66% (95% CI 57 to 75) and provider: 67% (95% CI 58 to 75)) was lower than cytology (85% (95% CI 78 to 91)).

CONCLUSION

Self-collection for HPV-RNA testing performed similarly to provider-collection among WHIV. For WHIV, while the higher sensitivity of HPV-RNA testing compared with cytology for the detection of clinically relevant cervical disease is important, the lower specificity supports the inclusion of a triage test in the screening algorithm.

Prevalence and risk factors of high-risk HPV and cervical abnormalities in HIV-positive women in Bali, Indonesia

BACKGROUND

Women living with Human Immunodeficiency Virus (HIV) are at higher risk of cervical cancer, particularly in regions like Indonesia where cervical cancer screening programs are limited. Bali has seen a rise in both HIV and cervical cancer cases, prompting the need for targeted interventions. This study investigates the prevalence of cervical cytological abnormalities and associated risk factors among women with HIV in Bali, focusing on their relationship with high-risk Human Papillomavirus (HR-HPV) types.

METHODS

A cross-sectional study was conducted from July to December 2023, recruiting 245 women from HIV outpatient clinics in Bali. Demographic and clinical data were collected via interviews and physical examinations, including cervical swabs and blood samples. HPV genotyping was performed using ThinPrep cytology followed by a two-stage PCR process. The first stage utilized universal primers (MY09/11) for HPV detection, while the second stage employed type-specific primers to identify high-risk strains, (16,18,31,33,35,39,45,51,52,56,58,59,66 and 68. Blood samples were analyzed to determine CD4 and CD8 T-cell counts.

RESULTS

Of 239 participants, 26 (10.87%) had abnormal cytology (6 cases (2.5%) of atypical squamous cells with high risk (ASC-H), 9 cases (3.8%) of atypical squamous cells of undetermined significance (ASC-US), 4 cases (1.7%) of high-grade squamous intraepithelial lesions (H-SIL), and 7 cases (2.9%) of low-grade squamous intraepithelial lesions (L-SIL)). Furthermore, 58 participants (24%) were tested positive for HPV DNA, with HPV type 18 being the most prevalent (28% in all HPV-positive samples). HPV-positive women had a seven-fold higher risk of abnormal cytology (PR = 7.022, 95% CI = 3.223-15.295). Multivariate analysis revealed HPV 18 as an independent risk factor (ExpB = 9.029, p = 0.007) and a history of pap smear screening reduced HR-HPV risk (ExpB = 0.358, p = 0.013).

CONCLUSION

This study highlights that 10.87% of HIV-positive women in Bali had abnormal cytology, with HPV 18 significantly linked to higher risk. A history of pap smear screening reduced HR-HPV risk. These findings underscore the need for robust cervical cancer screening and HPV vaccination, particularly for younger women, to improve health outcomes in Indonesia.

The role of co-infections and hormonal contraceptives in cervical intraepithelial neoplasia prevalence among women referred to a tertiary hospital in Western Kenya

BACKGROUND

Screening for co-infections with HIV, HSV-2 and Chlamydia trachomatis (CT) among high-risk human papilloma virus (hr-HPV) positive women, coupled with enhanced counseling on contraceptives use remains essential in alleviating high morbidity of cervical cancer (CC). The aim of this study was to determine the prevalence of cervical intraepithelial neoplasia (CIN) among women referred for CC screening at a referral hospital in Kisumu County, Kenya; and to establish the role of co-infection and hormonal contraceptives on CIN.

METHOD

In a cross-sectional study, we collected HPV, HIV, HSV-2 and CT data, cervical cytology results, and demographic information from 517 referrals. Blood samples were obtained for HIV and HSV-2 tests; urine for CT test, cervical swabs for hr-HPV test and colposcopic biopsy for histology confirmation after visual inspection with acetic acid (VIA).

RESULTS

The overall prevalence of CIN was 18.4% (95/517) with CIN1 observed in 56(29.6%), CIN2 in 27(`14.3%), CIN3 and above (CIN3+) in 12(6.3%) and normal biopsy in 94(49.7%) of the patients out of which high grade CIN2 and above (CIN2+) was 7.54% (39/517) equivalent to 32.5 per 100,000 women per year. In a univariate analysis; HPV/HIV co-infection (infected vs. uninfected: OR 2.79; 95% CI 1.56-5.10, p < 0.001); HPV/HSV-2 co-infection (infected vs. uninfected: OR 2.41; 95% CI: 1.12-5.46, p < 0.024); HPV/CT co-infection (infected vs. uninfected: OR 3.83; 95% CI 1.84-8.51, p < 0.001) were found to be significantly associated with CIN. Additionally, hormone-containing intra uterine device (HIUD) contraceptives (users vs. none users: OR 1.43; 95% CI 0.28-10.9, p < 0.017) were also associated with CIN.

CONCLUSION

Co-infections with HIV, HSV-2 or Chlamydia trachomatis and use of HIUD were associated with increased risk of testing positive for CIN in HPV positive women. Although the overall prevalence of CIN was high, high-grade CIN2 + was comparable to the rates reported earlier. Therefore, population screening for co-infections alongside hr-HPV is desirable and is likely to reduce the burden of CIN in the region. Besides, women positive for hr-HPV and opting for contraceptives ought to be counseled about the possible positive and negative side-effects of different contraception options.

Association between tumour necrosis factor-a polymorphism and cervical cancer in Lagos State, Nigeria

Background

The data on tumour necrosis factor-α (TNF-α) promoter gene polymorphism in the African population are relatively limited, especially in Nigerian women.

Objectives

This study aimed to determine the prevalence and allele distribution of three TNF-α promoter gene SNPs loci - rs361525 (-238 G>A), rs1799964(-1031 T>C) and rs1800629 (-308 G>A) in women with cervical cancer (CC) and then evaluated the association between TNF-α SNPs and CC among women in Lagos, Nigeria.

Methods

This is a cross-sectional study of 75 unmatched human immunodeficiency virus (HIV)-infected and uninfected women with and without CC enrolled from October 2021 to January 2023 at the gynaecological oncology, cytology, adult HIV and blood donor clinics of the Lagos University Teaching Hospital. About 5 mL of peripheral blood was collected from each participant for total Deoxyribonucleic acid extraction, primer synthesis and genotyping. The probability of developing CC based on the given SNP genotype was expressed as an odds ratio (OR) with a 95% confidence interval. Allelic frequency deviations from Hardy-Weinberg equilibrium were calculated using chi-square, and the statistical significance level was considered as two-tailed and set at p ≤ 0.05.

Results

Our study found that TNF-α -1031 T>C polymorphism was significantly associated with increased CC risk in HIV-negative women (HIV+/CC-; OR = 1.4, 95%CI 0.23-8.42, p = 0.03 and HIV-/CC-; OR = 1.37, 95%CI 0.01-1.68, p = 0.03) while the -308A>G A allele was also significantly associated with CC in HIV-positive women (OR = 1.33, 95%CI = 0.23-7.75).

Conclusion

We observed that HIV-negative and HIV-positive women who carry the C allele of -1031T>C and the A allele of -308G>A TNF-a promoter gene loci, respectively, are more susceptible to CC. We were also able to show protective linkages for the minor allele of the three SNPs of interest suggesting the potential of TNF-a as a surrogate marker for CC screening in addition to human papillomavirus primary testing. Further studies are required to determine the association between host factors and TNF-a polymorphism to harness the diagnostic and therapeutic advantage these associations will provide in the management of CC.

HIV prevalence among cervical (pre)cancer diagnoses in Suriname: a retrospective population study

Objective

To determine the prevalence of HIV in women with (pre)cancerous cervical lesions in Suriname and their retention in care.

Methods

A retrospective population study including all women diagnosed with (pre)invasive cervical intraepithelial neoplasia (CIN I to III or cervical cancer) in the only pathology department, during 2010-2020. The HIV test coverage and the HIV positivity ratio were determined through matching pathology data with the national HIV test database. The relation between retention in HIV care up to 2022 and different covariates was determined through Kaplan-Meier survival analysis and log-rank tests.

Results

There were 2 901 (1 395 CIN I, 396 CIN II, 444 CIN III, and 666 cervical cancer) diagnoses of (pre)invasive cervical neoplasia. An overall HIV test coverage of 57.5% and a positivity ratio of 5.8% were found, with no difference among the (pre)cancer stages. The undiagnosed prevalence (women not previously known HIV-positive at cervical diagnosis) was 1.6% and 2.9% among precancer and cancer diagnoses, respectively. The median time in care of women with cervical cancer was 8 months for those not on antiretroviral therapy (ART) and 4 years for those starting ART. Among women with precancer stages this was 5 and 10 years, respectively (p < 0.05).

Conclusions

HIV testing, followed by treatment initiation when found HIV-positive, should be prioritized in women diagnosed with cervical neoplasia. This will enhance the individual clinical outcomes and facilitate the control of the HIV epidemic in Suriname.

The role of co-infections on cervical intraepithelial neoplasia prevalence in western Kenya

Background

Screening for co-infections with HIV, HSV-2 and Chlamydia trachomatis (CT) among high-risk human papilloma virus (hr-HPV) positive women remains essential in alleviating high morbidity of cervical cancer (CC). The aim of this study was to determine the prevalence of cervical intraepithelial neoplasia (CIN) among women referred for CC screening at a referral hospital in Kisumu County, Kenya; and to establish the role of co-infection on CIN.

Method

In a cross-sectional study, we collected HPV, HIV, HSV-2 and CT data, cervical cytology results, and demographic information from 517 referrals. Blood samples were obtained for HIV and HSV-2 tests; urine for CT test and cervical swabs for hr-HPV test.

Results

The overall prevalence of CIN was 18.4% (95/517) with CIN1 observed in 56(29.6%), CIN2 in 27(`14.3%), CIN3 + in 12(6.3%) and normal biopsy in 94(49.7%) of the patients out of which high grade CIN2 and above (CIN2+) was 7.54% (39/517) equivalent to 32.5 per 100,000 women per year. HPV/HIV co-infection (infected vs. uninfected: OR 2.79; 95% CI 1.56-5.10, p < 0.001); HPV/HSV-2 co-infection (infected vs. uninfected: OR 2.41, 95% CI: 1.12-5.46, p < 0.024); HPV/CT co-infection (infected vs. uninfected: OR 3.83; 95% CI 1.84-8.51, p < 0.001) were found to be significantly associated with CIN.

Conclusion

Overall prevalence of CIN was high in the region although high-grade CIN2 + remained relatively lower as reported earlier. Age factor, widowhood and co-infections with HIV, HSV-2 or Chlamydia trachomatis were associated with increased risk of testing positive for CIN.

Prevalence and Associated Factors of High-Risk Human Papillomavirus Infections among Human Immunodeficiency Virus-Infected Women in Lagos, Nigeria

Background

Given the synergistic relationship between human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections, knowledge of the genotypic prevalence and associated factors of high-risk HPV (HR-HPV) among HIV-infected women is crucial for developing targeted interventions such as appropriate screening tests and effective genotype-specific vaccination.

Objectives

We determined the prevalence of any HR-HPV and multiple HR-HPV infections and identified associated factors among a cohort of women living with HIV infections (WLHIV) in Lagos, Nigeria.

Methods

This descriptive cross-sectional study analysed the data of 516 WLHIV who underwent cervical cancer screening as part of the COMPASS-DUST study at the HIV treatment centre of Lagos University Teaching Hospital from July 2023 to March 2024. Multivariable binary logistic regression models were performed to explore factors associated with HR-HPV and multiple HR-HPV infections.

Results

Among the 516 WLHIV enrolled (mean age, 46.5±7.3 years), the overall HR-HPV prevalence was 13.4% (95% CI, 10.6-16.6), disaggregated as 3.3% for HPV16/18 (95% CI, 1.9-5.2) and 11.6% for other HR-HPV genotypes (95% CI, 9.0-14.7). Nineteen women (3.7%; 95% CI, 2.2-5.7)had multiple HR-HPV genotype infections. Having a recent serum CD4+ cell count ≤560 cells/μL (adjusted OR 3.32; 95% CI 1.06-10.38) and HPV 16/18 genotype infections (adjusted OR 38.98; 95% CI 11.93-127.37) were independently associated with an increased risk of multiple HR-HPV infections.

Conclusion

The findings of this study provide valuable insights into the epidemiology of HR-HPV infections and highlight the need for tailored interventions and continuous monitoring. By addressing these challenges through targeted screening, effective ART management, and vaccination programs, we can improve health outcomes and reduce the burden of cervical cancer in this vulnerable population.

Human papillomavirus genotype distribution patterns in Zimbabwe; is the bivalent vaccine sufficient?

BACKGROUND

Vaccination against Human papillomavirus (HPV) is the primary preventative strategy that has been shown to reduce the burden of HPV related diseases. Zimbabwe introduced the bivalent vaccine (HPV 16/18) in the vaccination program targeting prepubescent girls in 2018. This review is an analysis of the distribution of HPV genotypes from various studies conducted in Zimbabwe to ascertain the effectiveness of the bivalent vaccine and make recommendations for future HPV vaccine choices.

SUMMARY

Zimbabwean studies have mostly reported on cervical HPV in the urban areas. The most frequent HPV genotypes from cervical sites were 16, 18, 33, 35, 45, 56 and 58. These were identified from samples with normal cytology, pre-cancer and invasive cervical cancer. The few studies that have been done in rural areas reported HPV 35 as the most frequent cervicovaginal genotype. From the anal region of individuals reporting for routine screening, HPV 16, 18, 35 52 and 58 were the most frequent. A study on genital warts identified HPV 6, 11, 16, 40, 51and 54. In a study on children with recurrent respiratory papillomatosis (RRP), HPV 6 and 11 were the most common and HPV 35 was also identified in these children. There is no available published data on HPV distribution in head and neck cancers in Zimbabwe.

KEY MESSAGES

Given that 83% of cervical cancers in Zimbabwe are caused by HPV 16/18, the bivalent vaccine could cover a significant proportion of HPV related cervical cancer. The current limitation of the bivalent vaccine is its failure to prevent benign lesions such as genital warts and RRP or all cervical cancer cases in Zimbabwe. For the prevention of most HPV related conditions, the nonavalent vaccine would be the most appropriate option for the Zimbabwean population. Currently there is no vaccine that includes HPV 35, yet this genotype was frequently identified in HPV related diseases. Vaccine developers may need to consider HPV 35 when manufacturing the next generation HPV vaccines. Furthermore, boys should also be included in HPV vaccination programs to improve herd immunity, as well as prevent RRP and HPV-related head and neck cancers.

HPV co-infections with other pathogens in cancer development: A comprehensive review

High-risk human papillomaviruses (HR-HPVs) cause various malignancies in the anogenital and oropharyngeal regions. About 70% of cervical and oropharyngeal cancers are caused by HPV types 16 and 18. Notably, some viruses including herpes simplex virus, Epstein-Barr virus, and human immunodeficiency virus along with various bacteria often interact with HPV, potentially impacting its replication, persistence, and cancer progression. Thus, HPV infection can be significantly influenced by co-infecting agents that influence infection dynamics and disease progression. Bacterial co-infections (e.g., Chlamydia trachomatis) along with bacterial vaginosis-related species also interact with HPV in genital tract leading to viral persistence and disease outcomes. Co-infections involving HPV and diverse infectious agents have significant implications for disease transmission and clinical progression. This review explores multiple facets of HPV infection encompassing the co-infection dynamics with other pathogens, interaction with the human microbiome, and its role in disease development.

High prevalence of vaccine-preventable anal human papillomavirus infections is associated with HIV infection among gay, bisexual, and men who have sex with men in Nairobi, Kenya

BACKGROUND

Human papillomavirus (HPV) infection is associated with anal cancers and is more prevalent in gay, bisexual, and men who have sex with men (gbMSM), partly due to their vulnerability to HIV infection. Baseline HPV genotype distributions and risk factors can inform the design of next-generation HPV vaccines to prevent anal cancer.

METHODS

A cross-sectional study was conducted among gbMSM receiving care at a HIV/STI clinic in Nairobi, Kenya. Anal swabs were genotyped using a Luminex microsphere array. Multiple logistic regression methods were used to identify risk factors for four HPV outcomes (any HPV, any HR-HPV, and 4- and 9-valent vaccine-preventable HPVs).

RESULTS

Among 115 gbMSM, 51 (44.3%) were HIV-infected. Overall HPV prevalence was 51.3%; 84.3% among gbMSM living with HIV and 24.6% among gbMSM without HIV (p < 0.001). One-third (32.2%) had HR-HPV and the most prevalent vaccine-preventable HR-HPV genotypes were 16, 35, 45, and 58. HPV-18 was uncommon (n = 2). The 9-valent Gardasil vaccine would have prevented 61.0% of HPV types observed in this population. In multivariate analyses, HIV status was the only significant risk factor for any HPV (adjusted odds ratio [aOR]:23.0, 95% confidence interval [95% CI]: 7.3-86.0, p < 0.001) and for HR-HPV (aOR: 8.9, 95% CI: 2.8-36.0, p < 0.001). Similar findings were obtained for vaccine-preventable HPVs. Being married to a woman significantly increased the odds of having HR-HPV infections (aOR: 8.1, 95% CI: 1.6-52.0, p = 0.016).

CONCLUSIONS

GbMSM living with HIV in Kenya are at higher risk of anal HPV infections including genotypes that are preventable with available vaccines. Our findings support the need for a targeted HPV vaccination campaign in this population.

Prevalence of high-risk human papillomavirus infections and associated factors among women living with HIV in Shashemene town public health facilities, Southern Ethiopia

BACKGROUND

Every year, large number of women are suffering from cervical cancer. Particularly women living with HIV are at high-risk of being suffered with it. Early testing of high-risk human papillomavirus infection can significantly reduce the incidence of cervical cancer. However, lack of early and regular testing has been identified as one of the major problems among risky populations.

METHODS

Institutional-based cross-sectional study design was conducted among women living with HIV in Shashemene town public health facilities with a total sample size of 406 from February 1-March 30, 2022. Systematic random sampling technique was employed to select the study subjects. A structured questionnaire and checklist was used to collect data. The collected data were cleaned, coded, and entered into Epi-info version 7.2.5 and exported to statistical package for social science version 24 for analysis. Finally, bi-variable and multivariable logistic regression analyses were performed to identify determinants of high-risk human papillomavirus. Odds ratio with 95% confidence interval was used to test association between exposure and outcome under study and p-value < 0.05 was considered significant.

RESULTS

The prevalence of high-risk HPV infections among study participant was 173(35.2%) with 95% CI (30.5%-40.1%). Prevalence of high-risk HPV type 16, 18 and other high-risk HPV types were 62(15.3%), 23(5.7%) and 58(14.3%), respectively. Having history of sexually transmitted infections [AOR = 3.120; 95% CI (1.977-4.923)], Endline CD4 count < 200 cells/mm3 [AOR = 3.072; 95% CI(1.009-9.350)], Endline HIV viral-load ≥ 50 copies/ml [AOR = 3.446; 95% CI(1.368-8.683)] and more than one-lifetime sexual partner [AOR = 2.112; 95% CI(1.297-3.441)] were significantly associated with high-risk HPV infections.

CONCLUSION

More than one third of women living with HIV had high-risk HPV. Having history of STI, low CD4 count, high viral load and multiple sexual partners were associated with high risk HPV. HIV positive women with these risk factors should be given special consideration in clinical and public health intervention.

HPV genotyping in biopsies of HSIL and invasive cervical cancers in women living with HIV: A cohort- and a nested -case control study

OBJECTIVE

To characterize HPV genotype distribution in HSIL and ICC- biopsies, of WLWH, in Europe, as compared to HIV-negative women.

DESIGN

Cohort- and nested -case control study.

METHOD

We characterized HPV genotype distribution by performing PCR on HSIL and ICC biopsies from WLWH (n = 170); 85 cases were compared to 85 HIV-negative matched controls. The proportion of patients that might be protected by HPV vaccines was estimated.

RESULTS

Among WLWH (median age 36 years-old, median duration of HIV infection 70,5 months, 79% under cART): the most frequently detected HPV were HPV16 (30%), HPV35 (16%), HPV58 (14,7%), HPV31 (13,5%), and HPV52 (11,7%). HPV16 was less frequently found in WLWH, originating from Central Africa (20,5%) compared to other African regions (35,5%) (p = 0,05) or world regions (38,8%) (p = 0,007). Multiple versus single high-risk HPV infections were associated with younger age (≤35 years)(odds ratio (OR) 2,65 (95%IC: 1,3-5,2,p = 0,002), lymphocyte CD4 count < 350 cells / µL (OR 2,7 (95%IC: 2-8,5; p = 0,005), use of cART for < 18 month OR 2,2 (95%IC: 1,1-4,5),p = 0,04) or a cumulative time with undetectable HIV viral load of less than 12 months (OR 4,2 (95%IC: 2-8.5,p = 0,001). HPV 31, 33 and 35 were more frequently detected in samples from WLWH than in HIV-negative controls (p < 0,05). The 9-valent vaccine would increase HPV protection, in HIV-positive and negative women (p < 0,001).

CONCLUSION

WLWH are more frequently infected with high-risk HPV other than 16 and 18 than HIV-negative ones. The use of 9-valent vaccine may prevent HSIL or ICC in up to 85% of the women. Adding HPV 35 to the HPV vaccine panel, might improve vaccine effectiveness in WLWH.

Primary and Triage Cervical Screening Diagnostic Value of Methods for the Detection of Cervical Dysplasia

Background. Cervical cancer is a leading cause of mortality among women globally. Approaches to reduce cervical cancer incidence and mortality are “screen-and-treat,” where positive primary test only is used in the treatment and “screen, triage and treat,” where treatment is based on positive primary and triage tests with/without histological analysis. Objectives. To determine cervical screening outcomes among HIV-infected and noninfected women using VIA, Pap smear, and HPV-PCR cervical screening methods and to determine the sensitivity, specificity, PPV and NPV of VIA, Pap smear, and HPV-PCR as primary test and sequential triage based on abnormal histopathology among HIV-infected and noninfected women. Methodology. This was a comparative cross-sectional study where women aged 18-46 years women underwent cervical screening and colposcopy-biopsy test as a positive-confirmatory test in the Referral Hospitals of Eastern Kenya. Results. A total of 317 (HIV negative: 156/317 (49.2%) and HIV positive: 161/317 (50.8%)) women were enrolled. Of these 81/317 (25.6%), 84/317 (26.5%), 96/317 (30.2%), and 78/122 (63.9%) participants had VIA, HPV DNA-PCR, Pap smear, and cervical histology positive results, respectively; average: 27.4% (HIV positive: 21.5%; HIV negative: 5.9%). Majority of women with LSIL [17/317 (5.4%)], HSIL [22/317 (6.9%)], invasive cancer [5/317 (1.6%)], cervicitis [45/317 (14.2%], and candidiasis 47/317 (14.8%) were HIV-infected ( $p<0.001$ ). 78/317 (24.6%) participants had positive histology test [ASCUS: 34/317 (10.7%) CIN1:17/317 (5.3%), CIN2: 16/317 (5.0%), CIN3:6/317 (1.9%), and ICC: 5/317 (1.6%)] ( $p>0.001$ ). A higher primary diagnostic accuracy was established by HPV DNA-PCR (sensitivity: 95.5%; specificity: 92.6%) than Pap smear and VIA test while in triage testing, high sensitivity was obtained by HPV DNA-PCR parallel testing with VIA test (92.6%) and Pap smear test (92.7%) and VIA cotesting with Pap smear (99.9%). HIV-infected women had increased specificity and reduced sensitivity and diagnostic accuracy by both primary and triage testing approaches. Discussion. Abnormal cervical screening outcome was high among HIV-infected than noninfected women. HIV-infected women had significantly high cases of cervical neoplastic changes. The diagnostic value of primary tests increased upon concurrent testing with other test methods hence reducing the number of women who would have been referred for biopsy. Conclusion. High sensitivity and specificity in detection of CIN+ were established among HIV-infected than HIV noninfected women by HPV DNA-PCR and Pap smear than VIA test. HPV DNA-PCR test and Pap smear are more accurate in primary and sequential triage cervical screening based on abnormal histopathology outcomes among HIV-infected than noninfected women.

Anal and cervical human papillomavirus genotypes in women co-infected with human immunodeficiency virus: A systematic review

Human papillomavirus (HPV) and human immunodeficiency virus (HIV) infections are sexually transmitted. There are several HPV genotypes and clinical manifestations. Determining which genotypes circulate worldwide and/or in specific geographic areas can help with prevention programs and vaccine distribution. This systematic review aimed to investigate the most frequent anal and cervical HPV genotypes in women co-infected with HPV/HIV. The PubMed, Scientific Electronic Library Online, and Latin American and Caribbean Literature in Health Sciences databases were used to search for articles published between January 2015 and August 2021, and the included articles followed the defined selection criteria. Based on the 51 articles included, HPV16 was the most prevalent (41%) genotype, followed by HPV52 (17%) and HPV58 (14%). Based on the comparative analyses of the HIV-negative women with HPV and the HPV/HIV co-infected groups, HPV16 was frequent in both groups; HPV58, HPV31, and HPV52 were more frequent in the co-infected group; and HPV18 was more common in HIV-negative women with HPV. HPV/HIV co-infected women most frequently presented the HPV genotypes 16, 58, and 52, whereas HIV-negative women with HPV had a higher frequency of HPV16, HPV18, and HPV52 genotypes. The results indicate the importance of genotype surveillance as a strategy to improve preventive measures against HPV infection and its complications. International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD42020220121.

Meta-synthesis and science mapping analysis of HIV/HPV co-infection: a global perspective with emphasis on Africa

Background

Viral infections are emerging with diverse clinical relevance both in endemic environments and non-endemic regions of the world. Some of the viruses cause co-infections that are of public health importance. The progress of studies on human immunodeficiency virus / Human papillomavirus (HIV/HPV) co-infection is not well documented especially in Africa where cases are endemic.

Method

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a global three-decade meta-synthesis and science mapping analysis on HIV/HPV co-infections. Assessment of progress, Author/Country productivity/trends, topic conceptual framework, and international collaborative networks were analyzed.

Results

We recovered 196 documents of 115 sources from the web of science database. The meta-synthesis revealed 1203 prolific authors containing nine solo authors, an annual growth rate of 8.09%, a significant average citation per article of 20.7%, and an average citation per year per document of 2.1. A significant high correlation between the mean/TC per article and the mean total citation (TC) per year showed 80.98% of the articles produced between 2005 and 2007 on HPV/HIV co-infection. The co-author per document index were 7.0 and the collaboration index was 6.4. The meta-analysis also revealed inadequate funding from individual or governmental organizations; among the 196 documents dataset, 114 (58.2%) were funded, and only 31 (15.8%) were funded in Africa where HIV/HPV co-infection cases are endemic.

Conclusions

Authors’ collaboration network, countries’ collaboration, authors’ citations and implementation of research-based finding in previous studies are yet to receive the relevant outcome, especially as various countries in the African continent have received poor funding with a repeated reporting of co-infection associated with HIV/HPV. African needs to re-awaken and stir up research-based interest in HPV/HIV co-infection studies to resolve indigenous public health concerns associated with the viral endemicity.

Human papillomavirus genotype distribution in Ethiopia: an updated systematic review

BACKGROUND

Cervical cancer is caused by infection with high-risk human papillomaviruses (HR-HPVs). It is one of the leading causes of cancer-related deaths in Ethiopia and globally. To develop efficient vaccination and HPV-based cervical cancer screening approaches, data on genotype distribution of HPVs is crucial. Hence, the study was aimed to review HPV genotype distribution in Ethiopia.

METHODS

Research articles were systematically searched using comprehensive search strings from PubMed/Medline and SCOPUS. Besides, Google Scholar was searched manually for grey literature. The last search was conducted on 18 August 2021. The first two authors independently appraised the studies for scientific quality and extracted the data using Excel sheet. The pooled HPV genotype distribution was presented with descriptive statistics.

RESULTS

We have included ten studies that were reported from different parts of the country during 2005 and 2019. These studies included 3633 women presented with different kinds of cervical abnormalities, from whom 29 different HPV genotypes with a sum of 1926 sequences were reported. The proportion of high-risk, possible/probable high-risk and low-risk HPVs were at 1493 (77.5%), 182 (9.4%) and 195 (10.1%), respectively. Of the reported genotypes, the top five were HPV 16 (37.3%; 95% CI 35.2.1-39.5%), HPV 52 (6.8%; 95% CI 5.8-8.0%), HPV 35 (4.8%; 95% CI 3.9-5.8%), HPV 18 (4.4%; 95% CI 3.5-5.3%) and HPV 56 (3.9%: 95% CI 3.1-4.9%). Some of other HR-HPV groups include HPV 31 (3.8%), HPV 45 (3.5%), HPV 58 (3.1%), HPV 59(2.3%), and HPV 68 (2.3%). Among the high-risk types, the combined prevalence of HPV 16/18 was at 53.7% (95% CI 51.2-56.3%). HPV 11 (2.7%: 95% CI 2.1-3.5%), HPV 42 (2.1%: 95% CI 1.5-2.8%) and HPV 6 (2.1%: 95% CI 1.4-2.7%) were the most common low-risk HPV types.

CONCLUSIONS

We noted that the proportion of HR-HPV types was higher and HPV 16 in particular, but also HPV 52, HPV 35 and HPV 18, warrant special attention in Ethiopian's vaccination and HPV based cervical screening program. Additional data from other parts of the country where there is no previous HPV genotype report are needed to better map the national HPV genotypes distribution of Ethiopia.

Identification of Genetic Variants of Human Papillomavirus in a Group of Mexican HIV/AIDS Patients and Their Possible Association with Cervical Cancer

Infections caused by the human immunodeficiency virus (HIV) and human papillomavirus (HPV) cause thousands of deaths worldwide each year. So far, there has been no consensus on whether there is a direct relationship between the incidence of neoplasms and the immunosuppression caused by HIV that could help understand if coinfection increases the likelihood of cervical cancer. The objective of the study was to identify the presence of genetic variants of HPV in a group of HIV-positive women and their possible association with cervical cancer. Cervical samples were taken from HIV-positive patients for cytological analysis to identify the HPV genotype by polymerase chain reaction (PCR) and sequencing. The most prevalent L1 capsid protein mutations in the HPV genotype were analyzed in silico. Various types of HPV were identified, both high-risk (HR) and low-risk (LR). The most prevalent genotype was HPV51. Analysis of the L1 gene sequences of HPV51 isolates showed nucleotide variations. Of the samples analyzed in Puebla, Mexico, HPV51 had the highest incidence (17.5%, 7/40). Different mutations, which could be used as population markers, were detected in this area, and they have not been reported in the L1 databases for HPV51 in Mexico. Genotypes 6, 14, 86, 87, 89, and 91, not detected or reported in samples from patients with HPV in Mexico, were also identified. Data from the population analyzed suggest no direct relationship between HIV immunosuppression and cervical cancer, regardless of the high- or low-risk HPV genotype. Furthermore, it is possible to develop regional population markers for the detection of HPV based on the mutations that occur in the sequence of nucleotides analyzed.

Comparative assessment of test characteristics of cervical cancer screening methods for implementation in low-resource settings

Cervical cancer disproportionately affects low-resource settings. Papanicolaou, human papillomavirus (HPV), and visual inspection of cervix with acetic acid (VIA) testing, each with different characteristics, will reduce cervical cancer burden. We conducted a critical literature review using PubMed, Cochrane, WHO, and grey literature from 1994 to 2020. We examined efficacy, harms, and comparative effectiveness of screening methods by age, human immunodeficiency virus, provider characteristics, and assessed implementation challenges in low-resource settings. Comprehensive data on utility and efficacy of screening tests indicates that each screening has strengths and shortcomings but all confer acceptable performance. HPV and VIA appear more promising. Primary HPV test-and-treat, self-testing, and co-testing have been studied but data on triage plans, cost, support system, implementation and sustainability is unclear in low-resource settings. HPV testing could help target subgroups of older or higher risk women. VIA offers local capacity-building and scalability. Quality VIA technique after HPV testing is still required to guide post-screening treatments. VIA competencies decline gradually with current standard trainings. Stationary cervicography improves VIA quality but isn't scalable. Affordable smartphones eliminate this barrier, enhance training through mentorship, and advance continuing education and peer-to-peer training. Smartphone-based VIA facilitates cervical image storage for patient education, health promotion, record-keeping, follow-up care, remote expert support, and quality control to improve VIA reliability and reproducibility and reduce mis-diagnoses and burden to health systems. Rather than ranking screening methods using test characteristics alone in study or higher-resource settings, we advocate for scalable strategies that maximize reliability and access and reduce cost and human resources.

Human Papillomavirus Types Associated with Cervical Dysplasia among HIV- and Non-HIV-Infected Women Attending Reproductive Health Clinics in Eastern Kenya

Background

Human papillomavirus (HPV) causes over 99% of all cervical cancer globally. In 2019, it was responsible for 3286 deaths in Kenya. Data on the epidemiological distribution of HPV genotypes by cervical dysplasia and HIV-infected women which is important in designing prevention strategy monitoring treatment and management of cervical cancer is lacking in Eastern Kenya.

Objective

To determine HPV genotype prevalence and their association with cervical dysplasia among HIV-infected (cases) and noninfected (control) women aged 18-48 years seeking reproductive healthcare.

Methods

A cervical broom was softly rotated 360 degrees five times to exfoliate cells from the region of the transformation zone, squamocolumnar junction, and endocervical canal for HPV genotyping. Social-demographic and risk factors responsible for HPV acquisition were collected using a questionnaire. Laboratory outcome and questionnaire data statistical relationships were computed using Pearson chi-square test.

Results

317 women (cases: 161 (50.8%), control 156 (49.2%), mean age: 34.3,SD ± 10.4, range 18-46 years) were recruited from Embu (85/317 (26.8%)), Isiolo (64/317 (20.2%)), Kirinyaga (56/317 (17.7%)), Meru (81/317 (25.6%)), and Tharaka-Nithi (31/317 (9.8%)). The frequency HPV genotypes detected by cervical dysplasia were CIN1 (cases: HPV81 (12/317 (3.8%)), HPV11 (2/317 (0.6%)); control: HPV53 and 66 coinfection (1/317 (0.3%)), CIN2 (cases: HPV11, HPV16, HPV66 ((1/317 (0.3%) each), HPV81 (6/317 (1.9%)), and single case (1/317 (0.3%)) of HPV11 and 66, HPV81 and 44, HPV81 and 88, HPV9 and 53, and HPV16 and 58 coinfection; control: HPV81 (2/317 (0.6%)) and invasive cervical cancer (cases: HPV16 (1/317 (0.3%)) and HPV81 (3/317 (0.9%)); control: HPV16 and 66 (1/317 (0.3%))).

Conclusions

There was a higher frequency of both high-risk and low-risk HPV genotypes associated with cervical dysplasia among HIV-infected than HIV-uninfected women seeking reproductive health care. This study provides epidemiological data on the existence of nonvaccine HPV types associated with cervical dysplasia in the region.

A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Detection of HIV mRNA in routine liquid-based cytology specimens of HIV-infected women

OBJECTIVE

Human immunodeficiency virus-infected women have a high incidence of HPV infection, and HIV and HPV coinfection is associated with high incidence of cervical intraepithelial lesions and cervical cancer. This study investigated the ability to detect HIV mRNA in routine screening cervical liquid-based cytology (LBC) samples and its correlation with HPV coinfection and cervical intraepithelial lesions.

METHODS

Liquid-based cytology samples from 80 HIV-infected women under combined antiretroviral therapy (cART) were studied for detection of HIV and HPV mRNA using Aptima^® tests and for cytology diagnosis according to the 2014 Bethesda System for Reporting Cervical Cytology. Peripheral blood (PB) HIV mRNAs were assessed by real-time polymerase chain reaction (RT-PCR). Statistical analysis used Fisher's exact or Chi-square test to compare frequencies among groups and the Mann-Whitney U test to compare continuous variables.

RESULTS

Human immunodeficiency virus mRNA was present in 21.3% of routine LBC samples in HIV-infected women, 12.5% of which had no detectable PB viral load. Among 10 patients diagnosed with high-grade squamous intraepithelial lesion (HSIL), 50% had detectable HIV viral load. The occurrence of HSIL vs low-grade intraepithelial lesion/negative intraepithelial lesion or malignancy in LBC samples was significantly higher in women with detectable HIV viral load (P = .029).

CONCLUSIONS

Human immunodeficiency virus mRNA was present in routine LBC samples in HIV-positive women under cART. Detection of HIV viral load in LBC is significantly associated with cervical HSIL. This suggests the relevance of HIV mRNA viral load assessment in routine LBC, to evaluate patients' infectious potential and monitor efficacy of the cART scheme.

Cytological physiognomies and genotype distribution of human papillomaviruses among HPV/HIV co-infected and HPV mono-infected women

BACKGROUND

Co-infection of High Risk Human Papillomavirus (HR-HPV) and HIV is thought to favour initiation of intraepithelial squamous cell lesion and subsequent progression to cervical carcinoma.

OBJECTIVES

Evaluation of cytological physiognomies in relation to possible age influence and the genotype distribution of human papillomaviruses among HPV/HIV co-infected and HPV monoinfected women in Kisii, Kenya.

METHODS

The case-control study enrolled 42 HPV/HIV co-infected and 42 HPV monoinfected women. Cervical swabs were collected in ThinPrep vials for HPV tying and cytological analysis. HPV subtypes were assayed by Xpert® HPV system (GXHPV-CE-10).

RESULTS

Mono-infected women aged 30-39 years had the highest proportion of low grade squamous intraepithelial lesion (LSIL) at 14 (16.67%) while the co-infected aged 50-59 years had the highest proportion of high grade squamous intraepithelial lesion (HSIL) at 9 (10.71%). HPV-16 genotype was the most predominant and it increased with age rise. Older coinfected and mono-infected women (>40 years) had HSIL and LSIL as the most predominant cytological grade respectively.

CONCLUSION

The predominance of HPV-16 and HPV-18/45 genotypes in the study setting is a consideration that would benefit targeted prophylactic vaccination programs. HPV testing and cervical cancer screening for young and older women on a regular basis ought to be reinforced.

Distribution of Human Papillomavirus (HPV) Genotypes in HIV-Negative and HIV-Positive Women with Cervical Intraepithelial Lesions in the Eastern Cape Province, South Africa

South African women have a high rate of cervical cancer cases, but there are limited data on human papillomavirus (HPV) genotypes in cervical intraepithelial neoplasia (CIN) in the Eastern Cape province, South Africa. A total of 193 cervical specimens with confirmed CIN from women aged 18 years or older, recruited from a referral hospital, were tested for HPV infection. The cervical specimens, smeared onto FTA cards, were screened for 36 HPV types using an HPV direct flow kit. HPV prevalence was 93.5% (43/46) in CIN2 and 96.6% (142/147) in CIN3. HIV-positive women had a significantly higher HPV prevalence than HIV-negative women (98.0% vs. 89.1%, p = 0.012). The prevalence of multiple types was significantly higher in HIV-positive than HIV-negative women (p = 0.034). The frequently detected genotypes were HPV35 (23.9%), HPV58 (23.9%), HPV45 (19.6%), and HPV16 (17.3%) in CIN2 cases, while in CIN3, HPV35 (22.5%), HPV16 (21.8%), HPV33 (15.6%), and HPV58 (14.3%) were the most common identified HPV types, independent of HIV status. The prevalence of HPV types targeted by the nonavalent HPV vaccine was 60.9% and 68.7% among women with CIN2 and CIN3, respectively, indicating that vaccination would have an impact both in HIV-negative and HIV-positive South African women, although it will not provide full protection in preventing HPV infection and cervical cancer lesions.

Cervical human papillomavirus prevalence, risk factors and outcomes in a cohort of HIV-infected women in Harare, Zimbabwe

Background

Human papillomavirus (HPV) associated invasive cervical cancer (ICC) is common in Zimbabwe, disproportionately affecting women living with HIV (WLHIV). Understanding high-risk HPV (hrHPV) infection in relation to cervical disease is important for ICC prevention amongst WLHIV.

Objectives

To describe the prevalence of cervical hrHPV, type distribution, associated risk factors and ICC screening outcomes in an urban cohort of Zimbabwean women.

Methods

In this cohort study, WLHIV were tested for hrHPV infection using the Cepheid Xpert® HPV assay and followed up for incident cervical disease. Follow-up assessments were done by visual inspection with acetic acid (VIA). Descriptive statistics and logistic regression were used to describe hrHPV burden and association between hrHPV and potential risk factors. Incidence rates (IR) and rate ratios of cervical disease by hrHPV infection status were also calculated.

Results

Amongst 321 WLHIV recruited, hrHPV prevalence was 24.9% (n = 80). Fifty-two of these women (65%) were positive for hrHPV types other than 16 or 18/45. Younger age (22–29 years), early sexual debut (13–16 years) and antiretroviral therapy (ART) regimen (second-line ART) were independently associated with hrHPV positivity. Positive VIA IR ratio between hrHPV-positive and -negative women was 12.57 (95% confidence interval [CI]: 4.14–38.19). Only women with hrHPV infection had incident cervical disease (IR: 6.41/100 person-years, (95% CI: 3.33–12.32). There were no ICC cases by the end of the 2-year follow-up.

Conclusion

There was a high prevalence of hrHPV infection other than 16 and 18/45 in this cohort. Integrating HPV testing in cervical cancer screening programmes may increase screening intervals in hrHPV-negative women, reducing costs for programmes. We recommend further research into cross protectivity of the bivalent and quadrivalent HPV vaccines against these other hrHPV types.

Molecular epidemiology of human papillomavirus among HIV infected women in developing countries: systematic review and meta-analysis

Background

Although, there is a variable burden of human papillomavirus (HPV) in women infected with HIV in developing countries, there are few studies that attempted to surmise such variable evidences. This review aimed to estimate the pooled prevalence of HPV genotype distribution and risk factors contributing to HPV infection among women infected with HIV in low- and middle-income countries.

Methods

We conducted a systematic review and meta-analysis of studies conducted in developing countries and reported HPV prevalence. We searched electronic databases: PubMed/Medline, SCOPUS, ScienceDirect, Excerpta Medical Database from Elsevier, Web of science, Cumulative Index of Nursing and allied Health Sciences and Google scholar databases to retrieve primary studies published in English language till 11th August 2019. We used random-effects model to estimate the pooled prevalence of HPV genotypes, and funnel plot to assess publication bias. The registration number of this review study protocol is CRD42019123549.

Results

We included nineteen studies with a total of 8,175 participants in this review. The prevalence of HPV was extremely heterogeneous across the studies (χ²₌ 3782.80, p value < 0.001, I² = 99.6%). The estimated pooled prevalence of all HPV genotypes was 63.0% (95% CI: 48.0–78.0) while the pooled prevalence of high risk and low risk HPV genotypes were 51.0% (95% CI: 38.0–63.0) and 28.0% (95% CI: 12.0–43.0), respectively. The pooled prevalence of HPV genotype 16 was 20%, while genotype 18 and 52 were 15% and 13%, respectively. Different risk factors reported for HPV infection and the frequently reported were low CD4 count below 200 cells/mm³ and high HIV viral load.

Conclusion

The pooled prevalence of HPV among HIV infected women in low- and middle-income countries was considerable and the proportion of high risk HPV genotypes were high when compared with low risk genotypes. Therefore, it is essential for the HPV prevention program to prevent the double burden of HPV and HIV in women.

Detection of types of HPV among HIV-infected and HIV-uninfected Kenyan women undergoing cryotherapy or loop electrosurgical excision procedure

OBJECTIVE

To assess the baseline types of HPV infection among HIV-positive and HIV-negative women in western Kenya undergoing cryotherapy or loop electrosurgical excision procedure (LEEP) for cervical intraepithelial neoplasia.

METHODS

A prospective observational study was conducted of baseline HPV characteristics of women undergoing visual inspection with acetic acid (VIA) and cryotherapy or LEEP. After a positive VIA in HIV-positive and HIV-negative women, data on demographics, CD4 count, and use of antiretroviral therapy and a cervical swab were collected. HPV typing was performed using the Roche Linear Array.

RESULTS

Of 175 participants, 86 (49.1%) were HIV-positive and had a higher prevalence of low-risk HPV types (odds ratio [OR] 5.28, P=0.005) compared with HIV-negative women. The most common high-risk (HR)-HPV types in HIV-positive women were HPV 16 (13.9%) and HPV 18 (11.1%). HIV-positive women requiring LEEP were more likely to have HR-HPV types (OR 6.67, P=0.012) and to be infected with multiple HR-HPV types (OR 7.79, P=0.024) compared to those undergoing cryotherapy.

CONCLUSION

HIV-positive women requiring LEEP versus cryotherapy had a higher prevalence of any HR-HPV type and multiple HR-HPV types. There were no such differences in HPV types identified among HIV-negative women.

Novel concepts in cervical cancer screening: a comparison of VIA, HPV DNA test and p16INK4a/Ki-67 dual stain cytology in Western Kenya

BACKGROUND

Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16INK4a/Ki-67 dual stain cytology.

METHODS

We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology.

RESULTS

In 701 of a total of 800 women aged 18-64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5-4.3), 1.9 (95%CI 0.89-4.4) and 3.4 (95%CI 1.07-10.9) respectively. The sensitivity of VIA to detect a p16INK4a/Ki-67 positive transforming infection was 13% (95%CI 2-38).

CONCLUSIONS

Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.

Prevalence and Type Distribution of Human Papillomavirus Recovered from the Uterine Cervix of Nigerian Women: A Systematic Review and Meta-Analysis

Background: Infection with an oncogenic type of human papillomavirus is a prerequisite for the development of precancerous cervical lesions and its subsequent progression to cervical cancer. With an alarming increase in the detection of other suspicious papillomavirus genotypes in both healthy and women with cervical lesions, there is a need for comprehensive data on cervical papillomavirus infection to address cervical cancer and other associated disease burden, especially in Sub-Sarahan Africa, where the bulk of the problem exists. The present study was conducted to develop comprehensive data on the prevalence and circulating genotypes of human papillomavirus in various risk categories in Nigeria. Methods: A systematic review and meta-analysis of peer-reviewed publications on cervical papillomavirus infection were performed. Relevant data were extracted from eligible studies published in PubMed, Web of Science, Embase, Scopus, and Google Scholar, from inception to July 31, 2019. The random-effect model was used to estimate the pooled prevalence. We identified 327 potential studies and pooled data from 18 studies, involving 5697 women aged 15-86 years. Results: The overall pooled prevalence of cervical papillomavirus infection was 42% (95%CI: 30-54%) in the general population and 37% (95%CI: 25-50%) among women living with HIV/AIDS, with the predominance of genotypes 16, 18, 31, 35, 52, 58 and 45. The highest prevalence was observed in teenagers and young adults and the second peak in women 50 years and above. Conclusion: The prevalence of cervical human papillomavirus infection is cumulatively high in Nigeria and HIV is a strong co-factor. We, therefore, strongly recommend the co-screening of human papillomavirus and cervical cancer and integration of the intervention strategy into the existing HIV-care guideline in Nigeria.

Knowledge, attitudes and preventive practices for human Papilloma virus infection among female sex workers in Lagos metropolis

Introduction

risky and hard-to-reach populations like female sex workers (FSW) face a huge burden with sexually transmitted infections (STIs) among which is human Papilloma virus (HPV) infection. This study was conducted to evaluate the knowledge, attitudes and preventive practices for HPV infection among FSW in Lagos, Nigeria.

Methods

a descriptive cross-sectional study was carried out among 403 respondents. The sampling units were FSW in brothels in two urban communities of Lagos. A multistage sampling technique was used for selection of respondents. Pre-tested, validated questionnaire was used for data collection. Responses to knowledge, attitude and practice questions were scored graded as poor (<50%) and good (≥50%). Bivariate analysis were carried out using Chi-square, Fisher exact test and student t-test. Logistic regression model was used for multivariate analysis. P-value < 0.05 was considered statistically significant.

Results

the mean age of the respondents was 32.97 ± 8.43. Majority of the respondents were within the age range of 18-34 years (51.61%), christians (51.12%), single (42.93%) and had secondary education (52.61%). Among the respondents 51.61% had good knowledge, 97.27% had good attitude and 62.28% had good preventive practice. FSW belonging to the age group 35-51 or 52-68 years, were more likely to have a good knowledge compared to those between 18-34 years. FSW with no formal education or living with a relative are less likely to have a good knowledge, compared to those having primary education or living alone. FSW with traditional or other religious beliefs are less likely to have good preventive practices against HPV compared to christian religious belief. Having tertiary education or married makes a FSW less likely, while being widowed makes her more likely to have good preventive practice. FSW living with friends are more likely to be exposed to good preventive practices compared to those living alone.

Conclusion

there is a need for regular health education program on HPV for FSW in order to increase their awareness and encourage best preventive practices against HPV.

Performance and acceptability of self-collected human papillomavirus testing among women living with HIV

•

Women living with HIV are under-screened for cervical cancer.

•

Human papillomavirus (HPV) self-testing at home could become a more efficient strategy in the post-COVID-19 era.

•

Self-collected HPV testing has good sensitivity and moderate specificity among women living with HIV.

•

Self-sampling is highly accepted by women.

•

Improvement in self-sampling techniques is needed due to possibly inadequate sample volume.

Objective

To assess the validity, reliability, and acceptability of self-collected human papillomavirus (HPV) tests in women living with HIV (WLHIV) in the United States.

Methods

WLHIV ≥30 years of age underwent self-collected (clinic and home) and clinician-collected HPV tests. Sensitivity and specificity analyses were performed using the clinician-collected HPV tests as the comparator. The unweighted kappa statistic was used to evaluate the validity and reliability of self-collected HPV testing, and the level of agreement between the clinician-collected mRNA test and a DNA test that was used for routine care. A 13-question survey was used to assess acceptability.

Results

Among the 70 participants, the median age was 50 years, 75% had an undetectable HIV RNA, and 11% had a CD4 count of <200 cells/μl. Nearly 63% had at least one positive HPV test. The sensitivity and specificity of the self-collected HPV test were 84.6% (95% confidence interval (CI) 65.1–95.6%) and 62.9% (95% CI 44.9–78.5%), respectively (κ = 0.5, 95% CI 0.2–0.7). The agreement between the two self-collected tests was good (κ = 0.8, 95% CI 0.5–1.0). There was good agreement between clinician-collected mRNA tests and DNA tests (κ = 0.8, 95% CI 0.7–1.0). Self-collection was highly acceptable.

Conclusions

Among WLHIV, self-collected HPV tests had good sensitivity and moderate specificity compared to clinician-collected HPV tests. The reliability between self-collected testing locations was good. Self-collected HPV testing had high acceptability.

Human papillomavirus epidemiology in populations with normal or abnormal cervical cytology or cervical cancer in the Middle East and North Africa: A systematic review and meta-analysis

BACKGROUND

Human papillomavirus (HPV), one of the most common sexually transmitted viral infections worldwide, is the leading cause of cervical cancer. In Middle East and North Africa (MENA) Region HPV data is at scarce, and most of the countries haven't implemented any vaccination programs. This present meta-analysis and systematic review aimed to describe human papillomavirus (HPV) epidemiology by clinical subgroups in the (MENA) region.

METHODS

Studies assessing HPV prevalence rates were systematically reviewed, and the selected articles were reported following the PRISMA guideline. Random-effects meta-analyses and meta-regression were used to estimate HPV pooled mean prevalence rates and their association with other factors.

RESULTS

For the cervical cancer population in the MENA region, the pooled HPV prevalence rate was 81% (95% CI, 70%-90%). HPV detected in cervical cancer samples was most prevalent in the Maghreb countries (88%; 95% CI, 78%-96%) and least prevalent in Iran (73%; 95% CI, 62%-83%).For the subgroup with abnormal-cervical cytology in the MENA region, the pooled HPV prevalence rate was 54% (95% CI, 41%-67%), with the highest prevalence reported in Northeast Africa (94%; 95% CI, 91%-96%), and the lowest prevalence in the Levant region (31%; 95 CI, 16%-49%). In the general population subgroup in the MENA region, the pooled HPV prevalence rate was 16% (95% CI, 14%-17%), HPV was most prevalent in the Northeast Africa region (21%; 95 CI, 7%-40%) and least prevalent in the Levant region (7%; 95 CI, 2%-14%).

CONCLUSION

The present meta-analysis comprehensively described the current HPV prevalence rates in the MENA region and found that the rates have continued to increase with time, especially in African regions. Designing personalized awareness and vaccination programs that respect the various cultural and religious values remains the main challenge in prevention of cervical cancer in the MENA region.

Cervical Dysplasia, Infection, and Phylogeny of Human Papillomavirus in HIV-Infected and HIV-Uninfected Women at a Reproductive Health Clinic in Nairobi, Kenya

High risk human Papillomavirus (HPV) infections ultimately cause cervical cancer. Human Immunodeficiency Virus (HIV) infected women often present with multiple high-risk HPV infections and are thus at a higher risk of developing cervical cancer. However, information on the circulating high-risk HPV genotypes in Kenya in both HIV-infected and HIV-uninfected women is still scanty. This study is aimed at determining the phylogeny and the HPV genotypes in women with respect to their HIV status and at correlating this with cytology results. This study was carried out among women attending the Reproductive Health Clinic at Kenyatta National Hospital, a referral hospital in Nairobi, Kenya. A cross-sectional study recruited a total of 217 women aged 18 to 50 years. Paired blood and cervical samples were obtained from consenting participants. Blood was used for serological HIV screening while cervical smears were used for cytology followed by HPV DNA extraction, HPV DNA PCR amplification, and phylogenetic analysis. Out of 217 participants, 29 (13.4%) were HIV seropositive, while 68 (31.3%) were positive for HPV DNA. Eight (3.7%) of the participants had abnormal cervical cytology. High-risk HPV 16 was the most prevalent followed by HPV 81, 73, 35, and 52. One participant had cervical cancer, was HIV infected, and had multiple high-risk infections with HPV 26, 35, and 58. HPV 16, 6, and 81 had two variants each. HPV 16 in this study clustered with HPV from Iran and Africa. This study shows the circulation of other HPV 35, 52, 73, 81, 31, 51, 45, 58, and 26 in the Kenyan population that play important roles in cancer etiology but are not included in the HPV vaccine. Data from this study could inform vaccination strategies. Additionally, this data will be useful in future epidemiological studies of HPV in Nairobi as the introduction or development of new variants can be detected.

Type-Specific Human Papillomavirus Prevalence, Incident Cases, Persistence, and Associated Pregnancy Outcomes Among HIV-Infected Women in Kenya

BACKGROUND

Persistent infection with high-risk types of human papillomavirus (HPV) is the preeminent factor driving the development of cervical cancer. There are large gaps in knowledge about both the role of pregnancy in the natural history of HPV infection and the impact of HPV on pregnancy outcomes.

METHODS

This single-site prospective cohort substudy, nested within an international multisite randomized controlled trial, assessed prevalence, incident cases, and persistence of type-specific HPV infection, and the association between persistence of high-risk HPV infection with pregnancy outcomes among HIV-infected pregnant women in Kenya, including HIV transmission to infants. Type-specific HPV was assessed using a line probe assay in pregnancy and again at 3 months after delivery. HIV status of children was determined using polymerase chain reaction at 6 weeks.

RESULTS

In total, 84.1% (206/245) of women had a high-risk HPV infection at enrollment. Three quarters (157/206) of these infections persisted postpartum. Persistence of HPV16 and/or HPV18 types was observed in more than half (53.4%; 39/73) of women with this infection at enrollment. Almost two-thirds had an incident high-risk HPV infection postpartum, which was not present in pregnancy (62.5%), most commonly HPV52 (19.0%). After adjustments, no association was detected between persistent high-risk HPV and preterm birth. All mothers of the 7 cases of infant HIV infection had persistent high-risk HPV infection (P = 0.044).

CONCLUSIONS

High levels of high-risk HPV infection and type-specific persistence were documented, heightening the urgency of mass role out of HPV vaccination. The association between HPV persistence and HIV transmission is a novel finding, warranting further study.

Human papillomavirus genotype profiles and cytological grades interlinkages in coinfection with HIV

Introduction

The study aimed to examine and characterize human papilloma virus (HPV) cytological grade trends and genotypes among HPV/HIV co-infected/cases and HPV monoinfected/control women attending Kisii Teaching and Referral Hospital, Kenya.

Methods

HIV positive co-infected with HPV (HPV/HIV) and HIV negative women monoinfected with HPV profiled as co-infected/cases and monoinfected/control arms respectively were enrolled. HPV subtypes were assayed by Xpert^® HPV system (GXHPV-CE-10) alongside pathological cytology analysis of cervical tissue samples.

Results

Low grade intraepithelial lesion (LSIL) was the most predominant cytological grade across cases and controls with a prevalence of 32 (38.1%) while high grade squamous intraepithelial lesion (HSIL) was highest among HPV/HIV co-infected with a prevalence of 23 (27.38%). Among the monoinfected (controls) the predominant lesion was low grade intraepithelial lesions (LSIL) with a prevalence of 23 (27.38%). HPV type 16 had the highest prevalence 26 (30.8%) among the VIA positive women in the overall study participants followed by combinations of HPV types (16, 18/45) at 19 (22.6%).

Conclusion

High risk HPV types 16 and 18/45 were the most predominant in the established cytological grades and among the co-infected women. Routine screening using both cytological and HPV testing should be embraced and/or reinforced as early screening and preventive strategies in the covered geographical region population. Provision of the currently available vaccines to these women at an early age would provide effective protection since the HPV type profiles in this population are covered by such vaccines.

Prevalence, incidence, and distribution of human papillomavirus types in female sex workers in Kenya

Female sex workers (FSWs) have a notably high risk of acquiring human papillomavirus (HPV) infections. Relatively few studies address the type-specific prevalence and incidence of HPV among FSWs in sub-Saharan Africa. FSWs (n = 348) attending the Korogocho clinic in Nairobi, Kenya participated from August 2009 to March 2011. HPV DNA was detected using the SPF10-LiPA25 PCR assay. Baseline prevalence of HPV infection and cervical dysplasia were calculated, stratified by HIV-serostatus. Incidence rate (IR) of infection was calculated as number of new infections from baseline over person-months among 160 HPV-negative participants with complete 12-month follow-up. Baseline HPV prevalence was 23.6% for any HPV and 20.4% for high-risk HPV (hrHPV) types. Most prevalent types were HPV52 (10.1%), HPV35 (2.3%), and HPV51 (2.3%). A quarter (24%) of participants were HIV-positive. HPV prevalence was higher in HIV-positive (32.1%) than HIV-negative (20.8%) participants. hrHPV prevalence was higher in HIV-positive (27.4%) than HIV-negative (18.2%) women. During follow-up, HPV IR was 31.4 (95% CI: 23.8–41.5) for any HPV and 24.2 (95% CI: 17.9–32.8) for hrHPV types. HPV52 had the highest IR (6.0; 95% CI: 6.5–10.3). Overall HPV and hrHPV prevalence were lower than expected, but both prevalence and incidence were higher in HIV-positive than in HIV-negative women.

Frequent inappropriate use of unweighted summary statistics in systematic reviews of pathogen genotypes or genogroups

OBJECTIVES

Our study aimed to systematically assess and report the methodological quality used in epidemiological systematic reviews (SRs) and meta-analysis (MA) of pathogen genotypes/genogroups.

STUDY DESIGN AND SETTING

Nine electronic databases and manual search of reference lists were used to identify relevant studies. The method types were divided into three groups: 1) with weighted pooling analysis (which we call MA), (2) unweighted analysis of the study-level measures (which we call summary statistics), and (3) without any data pooling (which we call SR only). Characteristics were evaluated using Assessment of Multiple Systematic Reviews (AMSTAR), Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA), and Risk Of Bias In Systematic reviews (ROBIS) tools. The protocol was registered in PROSPERO with CRD42017078146.

RESULTS

Among 36 included articles, 5 (14%) studies conducted SR only, 16 (44%) performed MA, and 15 (42%) used summary statistics. The univariable and multivariable linear regression of AMSTAR and PRISMA scores showed that MA had higher quality compared with those with summary statistics. The SR only and summary statistics groups had approximately equal scores among three scales of AMSTAR, PRISMA, and ROBIS. The methodological quality of epidemiological studies has improved from 1999 to 2017.

CONCLUSION

Despite the frequent use of unweighted summary statistics, MA remains the most suitable method for reaching rational conclusions in epidemiological studies of pathogen genotypes/genogroups.

Determining the HPV vaccine schedule for a HIV-infected population in sub Saharan Africa, a commentary

BACKGROUND

Epidemiological studies have established human papillomavirus (HPV) infection as the central cause of invasive cervical cancer (ICC) and its precursor lesions. HIV is associated with a higher prevalence and persistence of a broader range of high-risk HPV genotypes, which in turn results in a higher risk of cervical disease. Recent WHO HPV vaccination schedule recommendations, along with the roll out of HAART at an earlier CD4 count within the female HIV-infected population, may have programmatic implications for sub Saharan Africa. This communication identifies research areas, which will need to be addressed for determining a HPV vaccine schedule for this population in sub Saharan Africa. A review of WHO latest recommendations and the evidence concerning one-dose HPV vaccine schedules was undertaken.

CONCLUSION

For females ≥15 years at the time of first dose and immunocompromised and/or HIV-infected, a 3-dose schedule (0, 1-2, 6 months) is recommended for all three vaccines. There is some evidence that there is similar protection against HPV 16 and 18 infection from a single vaccination than from two or three doses, however there is no cross protection conferred to other genotypes. There is a need for periodic prevalence studies to determine the vaccination coverage of bivalent, quadrivalent and nonavalent vaccine targeted oncogenic HPV genotypes in women with CIN 3 or ICC at national level. In light of the increasing number of sub Saharan HIV-infected girls initiating HAART at a CD4 count above 350 mm3, there are a number of clinical, virological and public health research gaps to address before a tailored vaccine schedule can be established for this population.

Prevention of human papillomavirus (HPV)-related tumors in people living with human immunodeficiency virus (HIV)

INTRODUCTION

In comparison to their HIV-negative counterparts, people living with HIV (PLWH) have a higher prevalence of human papillomavirus (HPV) infection in various anatomical sites coupled with increased HPV persistence, higher risk of HPV-related tumors, and faster disease progression. Areas covered: Gender-neutral prevention strategies for HPV-related cancers in PLWH discussed: ABC approach, HPV vaccination, antiretroviral treatment (ART), anal cancer screening, and smoking cessation. Gender specific strategies: cervical cancer screening reduces the incidence and mortality of cervical cancer and circumcision might reduce the risk of HPV infections in men. Expert commentary: HPV-related cancer incidence has not declined (e.g. cervical cancer) and has even increased (e.g. anal cancer) in the ART era, demanding an effective HPV prevention strategy. HPV vaccination should be introduced into national prevention programs worldwide immediately because current prophylactic vaccines are safe, tolerable, and immunogenic in PLWH. HPV vaccine efficacy trials in PLWH are essential to determine the most appropriate immunization schedule. The population most at risk of anal cancer is HIV-positive men who have sex with men, who are not protected by herd immunity if only the female population is vaccinated. Unvaccinated PLWH need enhanced surveillance for early detection of HPV-related cancers and their precursors.

Public health approach to prevent cervical cancer in HIV-infected women in Kenya: Issues to consider in the design of prevention programs

Women living with HIV in Africa are at increased risk to be co-infected with Human Papilloma Virus (HPV), persistent high risk (HR) HPV infection and bacterial vaginosis (BV), which compounds HPV persistence, thereby increasing the risk for cervical dysplasia. New guidance from WHO in 2014 advocating for a “screen and treat” approach in resource poor settings is becoming a more widely recommended screening tool for cervical cancer prevention programs in such contexts. This review article summarizes the risk factors to be considered when designing a primary and secondary cervical prevention program in a post-vaccination era for HIV-infected women in Kenya.

This review article is based on our prior research on the epidemiology of pHR/HR-HPV genotypes in HIV-infected women and CIN 2 + in Kenya and other sub-Saharan contexts. In order to contextualize the findings, a literature search was carried out in March 2017 by means of four electronic databases: PUBMED, EMBASE, SCOPUS, and PROQUEST.

Risk factors for potential (pHR)/HR HPV acquisition, including CD4 count, HAART initiation, Female Sex Worker status (FSW) and BV need to be considered. Furthermore, there may be risk factors for abnormal cytology, including FSW status, multiple potential (p)HR/HR HPV genotypes, which may require that HIV-infected women be subjected to screening at more frequent intervals than the three year recommended by the WHO. The quadruple synergistic interaction between HIV, HPV and BV and its related cervicitis may need to be reflected within a larger prevention framework at the community level. The opportunities brought forth by the roll out of HAART could lead to task shifting of HIV-HPV-BV care to nurses, which may increase access in poorly-served areas.

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Bacterial Vaginosis treatment should be an integral component of cervical cancer prevention.

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A larger cervical cancer prevention framework at the community level is needed.

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Task shifting to nurses of Bacterial Vaginosis management in HIV-HPV co-infected women should be explored.

Clinical implications of the interaction between HPV and HIV infections

HIV-related immunodeficiency has complex effects on female genital HPV, which include increased risks of infection, multiple types, persistence, reactivation and the risk to develop pre-invasive and invasive disease. Reconstitution of immunity with anti-viral drugs improves cellular immunity, but the risk of HPV-related malignancy remains higher than background incidences and presents at younger ages. Early initiation of antiretroviral therapy (ART) allows improved retention of immune memory through existing antibodies and T-cell clones and improves long-term outcomes. Suggestions of a higher risk to contract HIV if there is existing genital HPV infection are supported and explained by pathophysiological cervical changes, including inflammation. HIV-HPV interactions should influence public health decisions towards prioritising large-scale prepubertal HPV-vaccine roll-out, secondary cervical cancer prevention and early detection programmes for HIV-infected women and early initiation of ART. This chapter will also focus on special considerations for the management of women with co-infection with these two viruses and genital HPV-related diseases.

Human papillomavirus type distribution and HPV16 intratype diversity in southern Brazil in women with and without cervical lesions

BACKGROUND

Increasing evidence suggests that human papillomavirus (HPV) intratype variants (specific lineages and sublineages) are associated with pathogenesis and progression from HPV infection to persistence and the development of cervical cancer.

OBJECTIVES

This study aimed to verify the prevalence of HPV infection and distribution of HPV types and HPV16 variants in southern Brazil in women with normal cytology or intraepithelial lesions.

METHODS

HPV typing was determined by L1 gene sequencing. To identify HPV16 variants, the LCR and E6 regions were sequenced, and characteristic single nucleotide variants were identified.

FINDINGS

A total of 445 samples were studied, with 355 from cervical scrapes and 90 from cervical biopsies. HPV was detected in 24% and 91% of these samples, respectively. The most prevalent HPV types observed were 16 (cervical, 24%; biopsies, 57%) and 58 (cervical, 12%; biopsies, 12%). Seventy-five percent of the HPV16-positive samples were classified into lineages, with 88% defined as lineage A, 10% as lineage D, and 2% as lineage B.

MAIN CONCLUSIONS

This study identified a high frequency of European and North American HPV16 lineages, consistent with the genetic background of the human population in southern Brazil.

Analysis of HPV distribution in patients with cervical precancerous lesions in Western China

Cervical human papillomavirus (HPV) infection is a dangerous disease, whose subtypes exhibit different distribution patterns in particular countries, regions, and races. In this study, the HPV distribution in patients with cervical precancerous lesions in Western China was investigated to assess a probability for prevention of cervical cancer and the clinical application of an HPV vaccine in China. The retrospective study of patients with different HPV subtypes and cervical precancerous lesions, who have undergone loop eelectrosurgical excision procedure, cold knife conization, or a total hysterectomy in our hospital from January 2016 to August 2016, was performed. All patients were tested for 27 HPV subtypes via the liquid suspension chip technology (Luminex 200). A total of 3393 cases of cervical intraepithelial neoplasia (CIN) were investigated, including 1098 cases of CIN I, 762 cases of CIN II, and 1533 cases of CIN III. The overall HPV infection rate was 82.58%. The high-risk HPV infection rate was 76.61%, and the low-risk rate was 9.88%. The most common 5 subtypes were HPV16, HPV52, HPV58, HPV33, and HPV18. The patients were grouped into 6 age groups: ≤20, 21 to 30, 31 to 40, 41 to 50, 50 to 64, and ≥65. The HPV subtypes' distribution varied across different age groups. In patients with cervical precancerous lesions in Western China, the top 5 HPV subtypes with the highest infection rates were HPV16, HPV52, HPV58, HPV33, and HPV18. The rate of cervical precancerous lesions unrelated to HPV was 17.42%. Thus, HPV screening with no cytology may leave unobserved about 20% of cervical precancerous lesions, which is worth of significant clinical attention.