1
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Stier EA, Clarke MA, Deshmukh AA, Wentzensen N, Liu Y, Poynten IM, Cavallari EN, Fink V, Barroso LF, Clifford GM, Cuming T, Goldstone SE, Hillman RJ, Rosa-Cunha I, La Rosa L, Palefsky JM, Plotzker R, Roberts JM, Jay N. International Anal Neoplasia Society's consensus guidelines for anal cancer screening. Int J Cancer 2024; 154:1694-1702. [PMID: 38297406 DOI: 10.1002/ijc.34850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/17/2023] [Accepted: 12/21/2023] [Indexed: 02/02/2024]
Abstract
The International Anal Neoplasia Society (IANS) developed consensus guidelines to inform anal cancer screening use among various high-risk groups. Anal cancer incidence estimates by age among risk groups provided the basis to identify risk thresholds to recommend screening. Guided by risk thresholds, screening initiation at age 35 years was recommended for men who have sex with men (MSM) and transgender women (TW) with HIV. For other people with HIV and MSM and TW not with HIV, screening initiation at age 45 years was recommended. For solid organ transplant recipients, screening initiation beginning from 10 years post-transplant was recommended. For persons with a history of vulvar precancer or cancer, screening initiation was recommended starting within 1 year of diagnosis of vulvar precancer or cancer. Persons aged ≥45 years with a history of cervical/vaginal HSIL or cancer, perianal warts, persistent (>1 year) cervical HPV16, or autoimmune conditions could be considered for screening with shared decision-making, provided there is adequate capacity to perform diagnostic procedures (high-resolution anoscopy [HRA]). Anal cytology, high-risk (hr) human papillomavirus (HPV) testing (including genotyping for HPV16), and hrHPV-cytology co-testing are different strategies currently used for anal cancer screening that show acceptable performance. Thresholds for referral for HRA or follow-up screening tests are delineated. These recommendations from IANS provide the basis to inform management of abnormal screening results, considering currently available screening tools. These guidelines provide a pivotal foundation to help generate consensus among providers and inform the introduction and implementation of risk-targeted screening for anal cancer prevention.
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Affiliation(s)
- Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Ashish A Deshmukh
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Yuxin Liu
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - I Mary Poynten
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Eugenio Nelson Cavallari
- Department of Public Health and Infectious Diseases, Policlinico Umberto I hospital-"Sapienza" University of Rome, Rome, Italy
| | - Valeria Fink
- Department of Research, Fundación Huésped, Buenos Aires, Argentina
| | - Luis F Barroso
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Tamzin Cuming
- Department of Colorectal Surgery, Homerton University Hospital NHS Foundation Trust, London, UK
| | | | - Richard J Hillman
- The Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
- St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Isabela Rosa-Cunha
- Department of Medicine/Division of Infectious Diseases, University of Miami, Miami, Florida, USA
| | - Luciana La Rosa
- Centro Privado de Cirugía y Coloproctología, Buenos Aires, Argentina
- Department of Surgery, Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | - Joel M Palefsky
- Anal Neoplasia Clinic, Research, and Education Center, University of California, San Francisco, San Francisco, California, USA
| | - Rosalyn Plotzker
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | | | - Naomi Jay
- Anal Neoplasia Clinic, Research, and Education Center, University of California, San Francisco, San Francisco, California, USA
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2
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Janczewski LM, Browner A, Cotler J, Nelson H, Ballman KV, LeBlanc M, Gollub MJ, Eng C, Brierley JD, Palefsky JM, Goldberg RM, Goodman KA, Washington MK, Asare EA, Palis B. Data-driven optimization of version 9 American Joint Committee on Cancer staging system for anal cancer. Cancer 2024; 130:1702-1710. [PMID: 38140735 DOI: 10.1002/cncr.35155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/25/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION The American Joint Committee on Cancer (AJCC) staging system undergoes periodic revisions to maintain contemporary survival outcomes related to stage. Recently, the AJCC has developed a novel, systematic approach incorporating survival data to refine stage groupings. The objective of this study was to demonstrate data-driven optimization of the version 9 AJCC staging system for anal cancer assessed through a defined validation approach. METHODS The National Cancer Database was queried for patients diagnosed with anal cancer in 2012 through 2017. Kaplan-Meier methods analyzed 5-year survival by individual clinical T category, N category, M category, and overall stage. Cox proportional hazards models validated overall survival of the revised TNM stage groupings. RESULTS Overall, 24,328 cases of anal cancer were included. Evaluation of the 8th edition AJCC stage groups demonstrated a lack of hierarchical prognostic order. Survival at 5 years for stage I was 84.4%, 77.4% for stage IIA, and 63.7% for stage IIB; however, stage IIIA disease demonstrated a 73.0% survival, followed by 58.4% for stage IIIB, 59.9% for stage IIIC, and 22.5% for stage IV (p <.001). Thus, stage IIB was redefined as T1-2N1M0, whereas Stage IIIA was redefined as T3N0-1M0. Reevaluation of 5-year survival based on data-informed stage groupings now demonstrates hierarchical prognostic order and validated via Cox proportional hazards models. CONCLUSION The 8th edition AJCC survival data demonstrated a lack of hierarchical prognostic order and informed revised stage groupings in the version 9 AJCC staging system for anal cancer. Thus, a validated data-driven optimization approach can be implemented for staging revisions across all disease sites moving forward.
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Affiliation(s)
- Lauren M Janczewski
- Department of Surgery, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Amanda Browner
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Joseph Cotler
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Karla V Ballman
- Department of Population Health Sciences, Division of Biostatistics, Weill Cornell Medicine, New York, New York, USA
| | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cathy Eng
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - James D Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Richard M Goldberg
- West Virginia University Cancer Institute, Morgantown, West Virginia, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - M Kay Washington
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elliot A Asare
- Department of Surgery, University of Utah Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Bryan Palis
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
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3
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Brickman CE, Agnello M, Imam N, Camejo P, Pino R, Carroll LN, Chein A, Palefsky JM. Distinct anal microbiome is correlated with anal cancer precursors in men who have sex with men living with HIV. AIDS 2024:00002030-990000000-00484. [PMID: 38691018 DOI: 10.1097/qad.0000000000003920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Anal cancer risk is elevated in men who have sex with men living with HIV (MSMLWH). Anal high-risk human papillomavirus (hr-HPV) infection is necessary but insufficient to develop high-grade squamous intraepithelial lesion (HSIL), the anal cancer precursor, suggesting additional factors. We sought to determine whether the microbiome of the anal canal is distinct by comparing it with the microbiome of stool. We also sought to determine whether changes in the anal microbiome are associated with HSIL among MSMLWH. DESIGN Cross-sectional comparison of the microbiome of the anal canal with the microbiome of stool in MSMLWH and cross-sectional comparison of the anal microbiome of MSMLWH with anal HSIL with the anal microbiome of MSMLWH without anal HSIL. METHODS Sterile swabs were used to sample the anus of MSMLWH for microbiome and HPV testing, followed by high-resolution anoscopy. Stool samples were mailed from home. 16S sequencing was used for bacterial identification. Measures of alpha diversity, beta diversity and differential abundance analysis were used to compare samples. RESULTS 166 anal samples and 103 matching stool samples were sequenced. Beta diversity showed clustering of stool and anal samples. Of hr-HPV-positive MSMLWH, 31 had HSIL and 13 had no SIL. Comparison of the microbiome between these revealed 28 different species. The highest-fold enrichment among MSMLWH/hr-HPV/HSIL included pro-inflammatory and carcinogenic Prevotella, Parasuterella, Hungatella, Sneathia and Fusobacterium species. The anti-inflammatory Anaerostipes caccae showed the greatest reduction among MSMLWH/hr-HPV/HSIL. CONCLUSIONS The anal microbiome is distinct from stool. A pro-inflammatory and carcinogenic environment may be associated with anal HSIL.
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Affiliation(s)
| | - Melissa Agnello
- uBiome, Medical Affairs, San Francisco, USA
- Komodo Health, Inc., San Francisco, USA
| | - Nabeel Imam
- uBiome, Medical Affairs, Santiago, Chile
- Psomagen, Inc., Rockville, USA
| | - Pamela Camejo
- uBiome, Medical Affairs, Santiago, Chile
- Phage Lab, Santiago, Chile
| | - Rodolfo Pino
- uBiome, Medical Affairs, Santiago, Chile
- Sociedad Química y Minera de Chile, Santiago, Chile
| | - Lauren N Carroll
- uBiome, Medical Affairs, San Francisco, USA
- ApotheCom, San Francisco, California
| | - Aung Chein
- University of California, San Francisco, USA
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4
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Murenzi G, Kim HY, Mivumbi JP, Gasana J, Munyaneza A, Tuyisenge P, Kanyabwisha F, Zawadi T, Muhoza B, Kubwimana G, Adedimeji A, Yotebieng M, Mutesa L, Shi Q, Anastos K, Palefsky JM. Incidence, Clearance and Persistence of Penile High-Risk Human Papillomavirus among Rwandan Men who have Sex with Men. J Infect Dis 2024:jiae190. [PMID: 38626186 DOI: 10.1093/infdis/jiae190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 04/04/2024] [Accepted: 04/09/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND Little is known about penile high-risk HPV among MSM in low-and-middle income countries. We aimed to determine the incidence, clearance and persistence of penile hrHPV among Rwandan MSM. METHODS We enrolled 350 MSM (345 with valid HPV results), aged ≥18 years, at each visit (6-12 months apart), we collected penile PreservCyt specimens and blood for HPV and HIV testing, socio-demographic and behavioral variables. HPV testing was performed using the Ampfire assay. Penile hrHPV incidence and clearance/1,000 person-months of follow-up (PMF), prevalent- and incident-persistence were computed and compared by HIV status. RESULTS The mean age was 27.7 ± 6.7 years and 19.4% were living with HIV. Penile hrHPV incidence was 34.8 (95% CI: 29.1, 41.8)/1,000 PMF. HPV16 (11.7, CI 9.26, 14.9) and HPV59 (6.1, CI 4.52, 8.39) had the highest incidence rates. Prevalent- and incident-persistence were 47.5% and 46.6%, respectively. HPV66 (33.3%), HPV52 (30.8%) and HPV16 (29.2%) had the highest prevalent-persistence and HPV33 (53.8%), HPV31 (46.7%) and HPV16 (42.6%) the highest incident-persistence. No differences were found by HIV status except for HPV45 (higher in MSM with HIV). CONCLUSION We found high incidence and prevalent/incident-persistence of penile hrHPV among Rwandan MSM. This highlights the importance of preventive strategies for HPV-associated anogenital cancers.
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Affiliation(s)
- Gad Murenzi
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | | | - Jean Paul Mivumbi
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Josephine Gasana
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Athanase Munyaneza
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Patrick Tuyisenge
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Faustin Kanyabwisha
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | | | - Benjamin Muhoza
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Gallican Kubwimana
- Einstein-Rwanda Research and Capacity Building Program, Research for Development (RD Rwanda) and Rwanda Military Hospital, Kigali, Rwanda
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marcel Yotebieng
- Department of Internal Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Leon Mutesa
- Centre for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Kathryn Anastos
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Internal Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, USA
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Zhitkevich A, Bayurova E, Avdoshina D, Zakirova N, Frolova G, Chowdhury S, Ivanov A, Gordeychuk I, Palefsky JM, Isaguliants M. Correction: Zhitkevich et al. HIV-1 Reverse Transcriptase Expression in HPV16-Infected Epidermoid Carcinoma Cells Alters E6 Expression and Cellular Metabolism, and Induces a Hybrid Epithelial/Mesenchymal Cell Phenotype. Viruses 2024, 16, 193. Viruses 2024; 16:589. [PMID: 38675996 PMCID: PMC11053444 DOI: 10.3390/v16040589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Author Juris Jansons requested his exclusion from the authors of the original publication [...].
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Affiliation(s)
- Alla Zhitkevich
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Ekaterina Bayurova
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
| | - Darya Avdoshina
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Natalia Zakirova
- Centre for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, 119991 Moscow, Russia;
| | - Galina Frolova
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Sona Chowdhury
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
| | - Alexander Ivanov
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
- Centre for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, 119991 Moscow, Russia;
| | - Ilya Gordeychuk
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
| | - Joel M. Palefsky
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
| | - Maria Isaguliants
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 171 77 Stockholm, Sweden
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6
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Stier EA, Jain M, Joshi H, Darragh TM, Deshmukh AA, Lee J, Einstein MH, Jay N, Berry-Lawhorn JM, Palefsky JM, Wilkin T, Ellsworth G, French AL, Barroso LF, Levine R, Guiot HM, Rezaei MK, Chiao E. Two-Year Incidence and Cumulative Risk and Predictors of Anal High-Grade Squamous Intraepithelial Lesions (Anal Precancer) Among Women With Human Immunodeficiency Virus. Clin Infect Dis 2024; 78:681-689. [PMID: 37805952 PMCID: PMC10954341 DOI: 10.1093/cid/ciad614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 08/17/2023] [Accepted: 10/04/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND Detection and treatment of anal histologic high-grade squamous intraepithelial lesions (hHSIL) prevents anal cancer. However, anal hHSIL incidence among women with human immunodeficiency virus (HIV, WHIV) remains unknown. Performance of anal high-risk human papillomavirus ([hr]HPV), anal cytology (anal-cyt), and both for hHSIL detection longitudinally over 2 years also remains undetermined. METHODS We determined 2-year incidence and cumulative risk estimates (2-y-CR) of anal hHSIL among WHIV using prevalence and incidence (per 100 person-years [py]) observations stratified by baseline hrHPV and/or anal-cyt results. RESULTS In total, 229 WHIV with complete baseline data were included in the analysis; 114 women without prevalent anal hHSIL were followed with 2 annual evaluations. Median age was 51, 63% were Black, and 23% were Hispanic. Anal hrHPV or abnormal anal-cyt was associated with an increased risk of incident anal hHSIL at 2 years (18.9/100py [95% confidence interval {CI} 11.4-31.3] and 13.4/100py [95% CI 8.0-22.7], respectively) compared with no detection of anal HPV or negative cytology (2.8/100py [95% CI 1.1-7.4] and 4.2 [95% CI, 1.8-10.2]) The presence of anal hrHPV with abnormal cytology was associated with 2-y-CR of anal hHSIL of 65.6% (95% CI 55.4%-75%); negative hrHPV with negative cytology was associated with 2-y-CR of anal hHSIL of 9.2% (95% CI 7.0-16.0). CONCLUSIONS Detection of anal hrHPV or abnormal anal cytology are comparable predictors for 2-y-CR of anal hHSIL. The absence of anal hrHPV combined with negative cytology was predictive of a lower (but measurable) risk of developing anal hHSIL. These findings provide important data to inform anal cancer screening guidelines for WHIV.
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Affiliation(s)
- Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Mayuri Jain
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, NewYork, New York, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NewYork, New York, USA
| | - Himanshu Joshi
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, NewYork, New York, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, NewYork, New York, USA
| | - Teresa M Darragh
- Department of Pathology, UCSF Mt. Zion Medical Center, SanFrancisco, California, USA
| | - Ashish A Deshmukh
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Mark H Einstein
- Department of OB/GYN & Women's Health, Rutgers- NJMS, Newark, New Jersey, USA
| | - Naomi Jay
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
| | - J Michael Berry-Lawhorn
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
- Division of Hematology Oncology, University of California San Francisco, San Francisco, California, USA
| | - Joel M Palefsky
- Anal Neoplasia Clinic, Research, and Education Center, University of California San Francisco, San Francisco, California, USA
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Timothy Wilkin
- Division of Infectious Diseases, Department of Medicine, Cornell University, NewYork, New York, USA
| | - Grant Ellsworth
- Division of Infectious Diseases, Department of Medicine, Cornell University, NewYork, New York, USA
| | - Audrey L French
- Division of Infectious Diseases, CORE Center/Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Luis F Barroso
- Department of Internal Medicine (Infectious Diseases), Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
| | | | - Humberto M Guiot
- Department of Medicine, University of Puerto Rico School of Medicine, San Juan, PR, USA
- Department of Microbiology & Medical Zoology, University of Puerto Rico School of Medicine, San Juan, Puerto Rico USA
| | - M Katayoon Rezaei
- Department of Pathology, George Washington University, Washington, DC, USA
| | - Elizabeth Chiao
- Department of Epidemiology, Division of Cancer Prevention, University of Texas - MD Anderson Cancer Center, Houston, Texas, USA
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7
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Giuliano AR, Palefsky JM, Goldstone SE, Dubin B, Saah A, Luxembourg A, Velicer C, Tota JE. High Risk of New HPV Infection Acquisition Among Unvaccinated Young Men. J Infect Dis 2024; 229:707-718. [PMID: 38012959 PMCID: PMC10938197 DOI: 10.1093/infdis/jiad485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/28/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND International data on anogenital HPV infection incidence among men are limited. METHODS Incidence of incident-persistent (IP) anogenital HPV infections was evaluated among 295 men who have sex with men (MSM) and 1576 heterosexual men (HM) aged 16-27 years in the placebo arm of a global, multicenter 4-valent (4v) HPV vaccine trial. We estimated IP incidence (penile/scrotal, perineal/perianal, anal) for 4vHPV and 9-valent (9v) HPV vaccine types and cumulative IP incidence over 36 months. RESULTS IP infection incidence per 100 person-years (95% CI) among HM for 4vHPV and 9vHPV types was 4.1 (3.5-4.9) and 6.8 (5.9-7.6) at penile/scrotal, and 1.2 (.8-1.6) and 1.9 (1.5-2.4) at perineal/perianal sites, respectively; and among MSM, IP infection incidence was 2.3 (1.3-3.8) and 3.2 (2.0-4.9) at penile/scrotal, 6.8 (4.9-9.2) and 9.0 (6.9-11.6) at perineal/perianal, and 12.0 (9.4-15.1) and 16.8 (13.7-20.2) at anal sites, respectively. Cumulative IP incidence over 36 months (excluding anal canal; any 9vHPV type) was higher among MSM versus HM (24.1% vs 18.4%). CONCLUSIONS A substantial proportion of unvaccinated men of catch-up vaccination age developed IP 9vHPV-related infections. Gender-neutral vaccination could decrease male HPV infection, contribute to herd protection, and reduce disease burden. Clinical Trials Registration. NCT00090285.
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Affiliation(s)
- Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, Florida, USA
| | - Joel M Palefsky
- University of California SanFrancisco, San Francisco, California, USA
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8
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Engels EA, Shiels MS, Barnabas RV, Bohlius J, Brennan P, Castilho J, Chanock SJ, Clarke MA, Coghill AE, Combes JD, Dryden-Peterson S, D'Souza G, Gopal S, Jaquet A, Lurain K, Makinson A, Martin J, Muchengeti M, Newton R, Okuku F, Orem J, Palefsky JM, Ramaswami R, Robbins HA, Sigel K, Silver S, Suneja G, Yarchoan R, Clifford GM. State of the science and future directions for research on HIV and cancer: Summary of a joint workshop sponsored by IARC and NCI. Int J Cancer 2024; 154:596-606. [PMID: 37715370 DOI: 10.1002/ijc.34727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/14/2023] [Accepted: 06/23/2023] [Indexed: 09/17/2023]
Abstract
An estimated 38 million people live with human immunodeficiency virus (HIV) worldwide and are at excess risk for multiple cancer types. Elevated cancer risks in people living with HIV (PLWH) are driven primarily by increased exposure to carcinogens, most notably oncogenic viruses acquired through shared transmission routes, plus acceleration of viral carcinogenesis by HIV-related immunosuppression. In the era of widespread antiretroviral therapy (ART), life expectancy of PLWH has increased, with cancer now a leading cause of co-morbidity and death. Furthermore, the types of cancers occurring among PLWH are shifting over time and vary in their relative burden in different parts of the world. In this context, the International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) convened a meeting in September 2022 of multinational and multidisciplinary experts to focus on cancer in PLWH. This report summarizes the proceedings, including a review of the state of the science of cancer descriptive epidemiology, etiology, molecular tumor characterization, primary and secondary prevention, treatment disparities and survival in PLWH around the world. A consensus of key research priorities and recommendations in these domains is also presented.
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Affiliation(s)
- Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Ruanne V Barnabas
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Julia Bohlius
- University of Basel, Basel, Switzerland
- Department for Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Paul Brennan
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Jessica Castilho
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephen J Chanock
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Anna E Coghill
- Department of Cancer Epidemiology and Center for Immunization and Infection Research in Cancer, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | - Jean-Damien Combes
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections Branch, Lyon, France
| | - Scott Dryden-Peterson
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard School of Public Health, Boston, Massachusetts, USA
| | - Gypsyamber D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Antoine Jaquet
- National Institute for Health and Medical Research (INSERM), UMR, 1219, Research Institute for Sustainable Development (IRD), EMR 271, Bordeaux Population, Health Centre, University of Bordeaux, Bordeaux, France
| | - Kathryn Lurain
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Alain Makinson
- Infectious Disease Department, CHU La Colombière, Montpellier & Inserm U1175, University of Montpellier, Montpellier, France
| | - Jeffrey Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - Mazvita Muchengeti
- National Cancer Registry, National Health Laboratory Service, Johannesburg, South Africa
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
- South African DSI-NRF Centre of Excellence in Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Robert Newton
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- University of York, York, UK
| | - Fred Okuku
- Uganda Cancer Institute, Kampala, Uganda
| | | | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Ramya Ramaswami
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Hilary A Robbins
- Genomic Epidemiology Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Keith Sigel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Gita Suneja
- Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, USA
| | - Robert Yarchoan
- HIV and AIDS Malignancy Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Gary M Clifford
- International Agency for Research on Cancer (IARC/WHO), Early Detection, Prevention and Infections Branch, Lyon, France
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9
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Zhitkevich A, Bayurova E, Avdoshina D, Zakirova N, Frolova G, Chowdhury S, Ivanov A, Gordeychuk I, Palefsky JM, Isaguliants M. HIV-1 Reverse Transcriptase Expression in HPV16-Infected Epidermoid Carcinoma Cells Alters E6 Expression and Cellular Metabolism, and Induces a Hybrid Epithelial/Mesenchymal Cell Phenotype. Viruses 2024; 16:193. [PMID: 38399969 PMCID: PMC10892743 DOI: 10.3390/v16020193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/25/2024] Open
Abstract
The high incidence of epithelial malignancies in HIV-1 infected individuals is associated with co-infection with oncogenic viruses, such as high-risk human papillomaviruses (HR HPVs), mostly HPV16. The molecular mechanisms underlying the HIV-1-associated increase in epithelial malignancies are not fully understood. A collaboration between HIV-1 and HR HPVs in the malignant transformation of epithelial cells has long been anticipated. Here, we delineated the effects of HIV-1 reverse transcriptase on the in vitro and in vivo properties of HPV16-infected cervical cancer cells. A human cervical carcinoma cell line infected with HPV16 (Ca Ski) was made to express HIV-1 reverse transcriptase (RT) by lentiviral transduction. The levels of the mRNA of the E6 isoforms and of the factors characteristic to the epithelial/mesenchymal transition were assessed by real-time RT-PCR. The parameters of glycolysis and mitochondrial respiration were determined using Seahorse technology. RT expressing Ca Ski subclones were assessed for the capacity to form tumors in nude mice. RT expression increased the expression of the E6*I isoform, modulated the expression of E-CADHERIN and VIMENTIN, indicating the presence of a hybrid epithelial/mesenchymal phenotype, enhanced glycolysis, and inhibited mitochondrial respiration. In addition, the expression of RT induced phenotypic alterations impacting cell motility, clonogenic activity, and the capacity of Ca Ski cells to form tumors in nude mice. These findings suggest that HIV-RT, a multifunctional protein, affects HPV16-induced oncogenesis, which is achieved through modulation of the expression of the E6 oncoprotein. These results highlight a complex interplay between HIV antigens and HPV oncoproteins potentiating the malignant transformation of epithelial cells.
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Affiliation(s)
- Alla Zhitkevich
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Ekaterina Bayurova
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
| | - Darya Avdoshina
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Natalia Zakirova
- Centre for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, 119991 Moscow, Russia;
| | - Galina Frolova
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
| | - Sona Chowdhury
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
| | - Alexander Ivanov
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
- Centre for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology, 119991 Moscow, Russia;
| | - Ilya Gordeychuk
- Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 119991 Moscow, Russia; (E.B.); (D.A.); (G.F.); (I.G.)
- Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia;
| | - Joel M. Palefsky
- Division of Infectious Diseases, Department of Medicine, University of California, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
| | - Maria Isaguliants
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 171 77 Stockholm, Sweden
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10
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Inturrisi F, de Sanjosé S, Desai KT, Dagnall C, Egemen D, Befano B, Rodriguez AC, Jeronimo JA, Zuna RE, Hoffman A, Farhat Nozzari S, Walker JL, Perkins RB, Wentzensen N, Palefsky JM, Schiffman M. A rapid HPV typing assay to support global cervical cancer screening and risk-based management: A cross-sectional study. Int J Cancer 2024; 154:241-250. [PMID: 37772799 DOI: 10.1002/ijc.34698] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/12/2023] [Accepted: 07/31/2023] [Indexed: 09/30/2023]
Abstract
The World Health Organization recommends human papillomavirus (HPV) testing for cervical screening. Extended genotyping can identify the highest-risk HPV-positive women. An inexpensive, rapid, mobile isothermal amplification assay (ScreenFire HPV RS test) was recently redesigned to yield four channels ordered by cancer risk (ie, hierarchical approach): HPV16, HPV18/45, HPV31/33/35/52/58 and HPV39/51/56/59/68. Stored specimens from 2076 women (mean age 30.9) enrolled in a colposcopy clinic, with high HPV prevalence, were tested with ScreenFire. We calculated hierarchical channel positivity and non-hierarchical channel and type positivity, according to histologic diagnosis (256 cancer, 350 cervical intraepithelial neoplasia [CIN]3, 409 CIN2, 1020 < CIN2) and known virologic reference results (Linear Array and TypeSeq). Additionally, we analyzed ScreenFire time-to-positive up to 60 min by channel and histology. Overall clinical sensitivity for CIN3+ was 94.7% (95% confidence interval 92.6-96.4), similar to Linear Array (92.3, 89.7-94.3) and TypeSeq (96.0, 93.9-97.6). Sensitivity was high for all types and channels. The hierarchical approach was well in line with HPV typing and histologic diagnosis, prioritizing higher risk women having HPV16 and precancer. For HPV16, time-to-positive was shorter in women with precancer. ScreenFire showed excellent agreement with research reference typing tests and detection of CIN2+. Risk-based type results could help guide clinical management of HPV-positive women. Time-to-positive combined with genotyping might be useful. ScreenFire is rapid, mobile, relatively inexpensive and designed for implementation of HPV-based screening and management, including in lower-resource settings. Further validation in screening by self-sampling and practical effectiveness merit evaluation.
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Affiliation(s)
- Federica Inturrisi
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Silvia de Sanjosé
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
- ISGlobal, Barcelona, Spain
| | - Kanan T Desai
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Casey Dagnall
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, Maryland, USA
| | - Didem Egemen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Brian Befano
- Information Management Services Inc., Calverton, Maryland, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - Ana Cecilia Rodriguez
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Jose A Jeronimo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Rosemary E Zuna
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Amanda Hoffman
- Cancer Genomics Research Laboratory, Frederick National Laboratory for Cancer Research, Leidos Biomedical Research Inc., Frederick, Maryland, USA
| | - Sepideh Farhat Nozzari
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Joan L Walker
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston Medical Center/Boston University School of Medicine, Boston, Maryland, USA
| | - Nicolas Wentzensen
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Mark Schiffman
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
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11
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Haas CB, Engels EA, Palefsky JM, Clarke MA, Kreimer AR, Luo Q, Pfeiffer RM, Qiao B, Pawlish KS, Monterosso A, Shiels MS. Severe anal intraepithelial neoplasia trends and subsequent invasive anal cancer in the United States. J Natl Cancer Inst 2024; 116:97-104. [PMID: 37632787 PMCID: PMC10777673 DOI: 10.1093/jnci/djad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/13/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023] Open
Abstract
BACKGROUND Anal intraepithelial neoplasia grade III is a precursor to squamous cell carcinoma of the anus for which rates are nearly 20-fold higher in people with HIV than in the general population in the United States. We describe trends in anal intraepithelial neoplasia grade III diagnosis and risk of squamous cell carcinoma of the anus following anal intraepithelial neoplasia grade III by HIV status and sex. METHODS We used data from a population-based linkage between cancer and HIV registries in 11 US states; Puerto Rico; and Washington, DC, during 1996-2019. We identified all individuals with a diagnosis of anal intraepithelial neoplasia grade III and determined their HIV status. We estimated the average annual percentage change of anal intraepithelial neoplasia grade III using Poisson regression stratified by HIV status and sex. We estimated the 5-year cumulative incidence of squamous cell carcinoma of the anus following an anal intraepithelial neoplasia grade III diagnosis stratified by sex, HIV status, and prior AIDS diagnosis. RESULTS Among people with HIV, average annual percentage changes for anal intraepithelial neoplasia grade III were 15% (95% confidence interval [CI] = 12% to 17%) per year among females and 12% (95% CI = 11% to 14%) among males. Average annual percentage changes for those without HIV were 8% (95% CI = 7% to 8%) for females and 8% (95% CI = 6% to 9%) for males. Among people with HIV, a prior AIDS diagnosis was associated with a 2.7-fold (95% CI = 2.23 to 3.40) and 1.9-fold (95% CI = 1.72 to 2.02) increased risk of anal intraepithelial neoplasia grade III diagnosis for females and males, respectively. Five-year cumulative incidence of squamous cell carcinoma of the anus following anal intraepithelial neoplasia grade III for people with HIV with a prior AIDS diagnosis were 3.4% and 3.7% for females and males, respectively. CONCLUSIONS Rates of anal intraepithelial neoplasia grade III diagnoses have increased since 1996, particularly for people with HIV, likely influenced by increased screening. A prior AIDS diagnosis was strongly associated with risk of anal intraepithelial neoplasia grade III diagnosis.
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Affiliation(s)
- Cameron B Haas
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Megan A Clarke
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Qianlai Luo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Baozhen Qiao
- New York State Department of Health, Albany, NY, USA
| | | | | | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
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12
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Haas CB, Engels EA, Horner MJ, Pfeiffer RM, Luo Q, Kreimer AR, Palefsky JM, Shiels MS. Cumulative incidence of anal cancer since HIV or AIDS diagnosis in the United States. J Natl Cancer Inst 2023; 115:1227-1230. [PMID: 37399095 PMCID: PMC10560593 DOI: 10.1093/jnci/djad128] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/05/2023] Open
Abstract
Treatment of screen-detected anal high-grade squamous intraepithelial lesions has been shown to effectively reduce the incidence of invasive anal cancer in people with HIV. We provide population-based estimates of cumulative incidence of anal cancer by risk group and age at HIV or AIDS diagnosis. The 0- to 10-year cumulative incidence of anal cancer for men who have sex with men and are younger than 30 years of age at HIV diagnosis was 0.17% (95% confidence interval [CI] = 0.13% to 0.20%) compared with 0.04% (95% CI = 0.02% to 0.06%) in other men and 0.03% (95% CI = 0.01% to 0.04%) in women. For men who have sex with men and have a diagnosis of AIDS and are younger than 30 years of age, the 0- to 10-year cumulative incidence was 0.35% (95% CI = 0.28% to 0.41%). Among people with HIV, men who have sex with men are at the greatest risk of anal cancer, and those with a diagnosis of AIDS had higher risk than those without AIDS. These estimates may inform recommendations for priority populations that could benefit most from anal cancer screening and treatment.
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Affiliation(s)
- Cameron B Haas
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Eric A Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Marie-Josèphe Horner
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Ruth M Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Qianlai Luo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Aimée R Kreimer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
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13
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Schuind AE, Rees H, Schiller J, Mugo N, Dull P, Barnabas R, Clifford GM, Liu G, Madhi SA, Morse RB, Moscicki AB, Palefsky JM, Plotkin S, Sierra MS, Slifka MK, Vorsters A, Kreimer AR, Didierlaurent AM. State-of-the-Science of human papillomavirus vaccination in women with human immunodeficiency Virus: Summary of a scientific workshop. Prev Med Rep 2023; 35:102331. [PMID: 37576844 PMCID: PMC10413150 DOI: 10.1016/j.pmedr.2023.102331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/27/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
The burden of cervical cancer is disproportionately distributed globally, with the vast majority of cases occurring in low- and middle-income countries. Women with human immunodeficiency virus (HIV) (WWH) are at increased risk of human papillomavirus (HPV) infection and cervical cancer as compared to HIV-negative individuals. HPV vaccination remains a priority in regions with a high burden of cervical cancer and high HIV prevalence. With HPV vaccines becoming more accessible, optimal use beyond the initial World Health Organization-recommended target population of 9 to 14-year-old girls is an important question. In March 2022, a group of experts in epidemiology, immunology, and vaccinology convened to discuss the state-of-the-science of HPV vaccination in WWH. This report summarizes the proceedings: review of HIV epidemiology and its intersection with cervical cancer burden, immunology, HPV vaccination including reduced-dose schedules and experience with other vaccines in people with HIV (PWH), HPV vaccination strategies and knowledge gaps, and outstanding research questions. Studies of HPV vaccine effectiveness among WWH, including duration of protection, are limited. Until data from ongoing research is available, the current recommendation for WWH remains for a multi-dose HPV vaccination regimen. A focus of the discussion included the potential impact of HIV acquisition following HPV vaccination. With no data currently existing for HPV vaccines and limited information from non-HPV vaccines, this question requires further research. Implementation research on optimal HPV vaccine delivery approaches for WWH and other priority populations is also urgently needed.
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Affiliation(s)
| | - Helen Rees
- Wits Reproductive Health and HIV Institute (Wits RHI), University of the Witwatersrand, Johannesburg, South Africa
| | - John Schiller
- National Cancer Institute, National Institutes of Health, Bethesda, United States
| | - Nelly Mugo
- Kenya Medical Research Institute, Nairobi, Kenya and Department of Global Health, University of Washington, Seattle, United States
| | - Peter Dull
- Vaccine Development, Bill & Melinda Gates Foundation, Seattle, United States
| | - Ruanne Barnabas
- Division of Infectious Diseases, Mass General Hospital, Harvard Medical School, Boston, United States
| | - Gary M. Clifford
- Early Detection, Prevention, and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Gui Liu
- Department of Global Health, University of Washington, Seattle, United States
| | - Shabir A. Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Johannesburg, South Africa
| | | | - Anna-Barbara Moscicki
- Department of Pediatrics, University of California Los Angeles, Los Angeles, United States
| | - Joel M. Palefsky
- University of California, San Francisco School of Medicine, San Francisco, United States
| | - Stanley Plotkin
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, United States
| | - Mónica S. Sierra
- National Cancer Institute, National Institutes of Health, Bethesda, United States
| | - Mark K. Slifka
- Oregon Health & Science University, Beaverton, United States
| | - Alex Vorsters
- Vaccine & Infectious Disease Institute, Centre for the Evaluation of Vaccination, University of Antwerp, Antwerp, Belgium
| | - Aimée R. Kreimer
- National Cancer Institute, National Institutes of Health, Bethesda, United States
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14
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Janczewski LM, Faski J, Nelson H, Gollub MJ, Eng C, Brierley JD, Palefsky JM, Goldberg RM, Washington MK, Asare EA, Goodman KA. Survival outcomes used to generate version 9 American Joint Committee on Cancer staging system for anal cancer. CA Cancer J Clin 2023; 73:516-523. [PMID: 37114458 DOI: 10.3322/caac.21780] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
The American Joint Committee on Cancer (AJCC) staging system for all cancer sites, including anal cancer, is the standard for cancer staging in the United States. The AJCC staging criteria are dynamic, and periodic updates are conducted to optimize AJCC staging definitions through a panel of experts charged with evaluating new evidence to implement changes. With greater availability of large data sets, the AJCC has since restructured and updated its processes, incorporating prospectively collected data to validate stage group revisions in the version 9 AJCC staging system, including anal cancer. Survival analysis using AJCC eighth edition staging guidelines revealed a lack of hierarchical order in which stage IIIA anal cancer was associated with a better prognosis than stage IIB disease, suggesting that, for anal cancer, tumor (T) category has a greater effect on survival than lymph node (N) category. Accordingly, version 9 stage groups have been appropriately adjusted to reflect contemporary long-term outcomes. This article highlights the changes to the now published AJCC staging system for anal cancer, which: (1) redefined stage IIB as T1-T2N1M0 disease, (2) redefined stage IIIA as T3N0-N1M0 disease, and (3) eliminated stage 0 disease from its guidelines altogether.
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Affiliation(s)
- Lauren M Janczewski
- Department of Surgery, Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Joseph Faski
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Heidi Nelson
- American College of Surgeons Cancer Programs, Chicago, Illinois, USA
| | - Marc J Gollub
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cathy Eng
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee, USA
| | - James D Brierley
- Radiation Medicine Program, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Richard M Goldberg
- West Virginia University Cancer Institute, Morgantown, West Virginia, USA
| | - M Kay Washington
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Elliot A Asare
- Department of Surgery, University of Utah Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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15
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Kanyabwisha F, Kim HY, Shi Q, Murenzi G, Tuyisenge P, Kubwimana G, Munyaneza A, Murangwa A, Turizigiye O, Da Costa M, Nsengiyumva B, Chen X, Mutesa L, Anastos KM, Palefsky JM. Comparison of AmpFire and MY09/11 assays for HPV genotyping in anogenital specimen of Rwandan men who have sex with men. Heliyon 2023; 9:e16016. [PMID: 37305475 PMCID: PMC10256914 DOI: 10.1016/j.heliyon.2023.e16016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 04/24/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction The AmpFire HPV genotyping Assay (Atila Biosystems, Mountain View, CA, USA) is a new test for which there are few data regarding its analytic performance and reliability. Using anal and penile swab specimens from a cohort study of men who have sex with men (MSM) in Rwanda, we compared high-risk HPV (hrHPV) detection by AmpFire done at two laboratories, one at University of California San Francisco (UCSF) and the other Rwanda Military Hospital, and well-validated MY09/11-based assay done at UCSF. Methods Anal and penile specimens collected from 338 MSM from March 2016 to September 2016 were tested for high-risk HPV genotypes (hrHPV) by MY09/11, AmpFire UCSF and AmpFire RMH. Cohen's kappa coefficient was used to test for reproducibility. Results The hrHPV positivity by MY09/11 and AmpFire UCSF was 13% and 20.7% (k = 0.73) for anal specimens and was 26.3% and 32.6% (k = 0.67) for penile specimens. Specifically, good reproducibility was for types 16 and 18 (k = 0.69 and k = 0.71) for anal specimens and (k = 0.50 and k = 0.72) for penile specimens. The hrHPV positivity by AmpFire at UCSF and RMH was 20.7% for both laboratories (k = 0.87) for anal specimens and was 34.9% and 31.9% (k = 0.89) for penile specimens. Specifically, excellent reproducibility was for types 16 and 18 for anal specimens (k = 0.80 and k = 1.00) and penile specimens (k = 0.85 and k = 0.91). Conclusion Results show that MY09/11 and AmpFire assays have good reproducibility while the AmpFire UCSF and RMH assays have excellent reproducibility. These results show that AmpFire is a promising HPV genotyping test.
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Affiliation(s)
- Faustin Kanyabwisha
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, KK 737 St, Kigali, Rwanda
| | - Hae-Young Kim
- Department of Public Health, New York Medical College, Valhalla, NY, USA
| | - Qiuhu Shi
- Department of Public Health, New York Medical College, Valhalla, NY, USA
| | - Gad Murenzi
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
| | - Patrick Tuyisenge
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
| | - Gallican Kubwimana
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
| | - Athanase Munyaneza
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
| | | | | | - Maria Da Costa
- Department of Infectious Diseases, University of California, San Francisco, USA
| | | | - Xin Chen
- Atila Biosystems Inc, 740 Sierra Vista Ave, Mountain View, CA, 94043, USA
| | - Leon Mutesa
- Rwanda Military Hospital (RMH), KK 80 St, Kigali, Rwanda
- Research for Development (RD Rwanda), KG11 Ave Promise House Building 3rd Floor, Kigali City, Gasabo, Rwanda
- Center for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, KK 737 St, Kigali, Rwanda
| | - Kathryn M. Anastos
- Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10467, USA
| | - Joel M. Palefsky
- Department of Infectious Diseases, University of California, San Francisco, USA
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Atkinson TM, Lensing S, Lee JY, Chang D, Kim SY, Li Y, Lynch KA, Webb A, Holland SM, Lubetkin EI, Goldstone S, Einstein MH, Stier EA, Wiley DJ, Mitsuyasu R, Rosa-Cunha I, Aboulafia DM, Dhanireddy S, Schouten JT, Levine R, Gardner E, Logan J, Dunleavy H, Barroso LF, Bucher G, Korman J, Stearn B, Wilkin TJ, Ellsworth G, Pugliese JC, Arons A, Burkhalter JE, Cella D, Berry-Lawhorn JM, Palefsky JM. Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03. Qual Life Res 2023:10.1007/s11136-023-03391-4. [PMID: 37020153 PMCID: PMC10330891 DOI: 10.1007/s11136-023-03391-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.
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Affiliation(s)
- Thomas M Atkinson
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA.
| | - Shelly Lensing
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeannette Y Lee
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Di Chang
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Soo Young Kim
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Yuelin Li
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Kathleen A Lynch
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
- School of Global Public Health, New York University, New York, NY, USA
| | - Andrew Webb
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - Susan M Holland
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | | | | | | | | | - Dorothy J Wiley
- University of California, Los Angeles School of Nursing, Los Angeles, CA, USA
| | - Ronald Mitsuyasu
- UCLA Center for Clinical AIDS Research and Education, Los Angeles, CA, USA
| | | | | | | | - Jeffrey T Schouten
- Virginia Mason Medical Center, Seattle, WA, USA
- Harborview Medical Center, Seattle, WA, USA
| | | | - Edward Gardner
- Public Health Institute at Denver Health, Denver, CO, USA
| | - Jeffrey Logan
- Public Health Institute at Denver Health, Denver, CO, USA
| | | | - Luis F Barroso
- Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Gary Bucher
- Anal Dysplasia Clinic MidWest, Chicago, IL, USA
| | - Jessica Korman
- Metropolitan Gastroenterology Group, Washington, DC, USA
| | | | | | | | - Julia C Pugliese
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Abigail Arons
- ANCHOR Data Management Center of The Emmes Company, LLC, Rockville, MD, USA
| | - Jack E Burkhalter
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 633 Third Ave, New York, NY, 10017, USA
| | - David Cella
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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17
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Wei F, Xia N, Ocampo R, Goodman MT, Hessol NA, Grinsztejn B, Ortiz AP, Zhao F, Kojic EM, Kaul R, Heard I, Morhason-Bello IO, Moscicki AB, de Pokomandy A, Palefsky JM, Rodrigues LLS, Dube Mandishora RS, Ramautarsing RA, Franceschi S, Godbole SV, Tso FK, Menezes LJ, Lin C, Clifford GM. Age-Specific Prevalence of Anal and Cervical Human Papillomavirus Infection and High-Grade Lesions in 11 177 Women by Human Immunodeficiency Virus Status: A Collaborative Pooled Analysis of 26 Studies. J Infect Dis 2023; 227:488-497. [PMID: 35325151 PMCID: PMC10152502 DOI: 10.1093/infdis/jiac108] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/22/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Age-specific data on anal, and corresponding cervical, human papillomavirus (HPV) infection are needed to inform female anal cancer prevention. METHODS We centrally reanalyzed individual-level data from 26 studies reporting HPV prevalence in paired anal and cervical samples by human immunodeficiency virus (HIV) status and age. For women with HIV (WWH) with anal high-grade squamous intraepithelial lesions or worse (HSIL+), we also investigated concurrent cervical cytopathology. RESULTS In HIV-negative women, HPV16 prevalence decreased significantly with age, both at anus (4.3% at 15-24 years to 1.0% at ≥55 years; ptrend = 0.0026) and cervix (7.4% to 1.7%; ptrend < 0.0001). In WWH, HPV16 prevalence decreased with age at cervix (18.3% to 7.2%; ptrend = 0.0035) but not anus (11.5% to 13.9%; ptrend = 0.5412). Given anal HPV16 positivity, concurrent cervical HPV16 positivity also decreased with age, both in HIV-negative women (ptrend = 0.0005) and WWH (ptrend = 0.0166). Among 48 WWH with HPV16-positive anal HSIL+, 27 (56%) were cervical high-risk HPV-positive, including 8 with cervical HPV16, and 5 were cervical HSIL+. CONCLUSIONS Age-specific shifts in HPV16 prevalence from cervix to anus suggest that HPV infections in the anus persist longer, or occur later in life, than in the cervix, particularly in WWH. This is an important consideration when assessing the utility of cervical screening results to stratify anal cancer risk.
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Affiliation(s)
- Feixue Wei
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer/World Health Organization, Lyon, France
| | - Ningshao Xia
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health, Xiamen University, Xiamen, Fujian, China
| | - Rebeca Ocampo
- Agencia Costarricense de Investigaciones Biomédicas-Fundación INCIENSA, San José, Costa Rica
| | - Marc T Goodman
- Cancer Prevention and Control Program, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Nancy A Hessol
- Department of Clinical Pharmacy, University of California, San Francisco, California, USA
- Department of Medicine, University of California, San Francisco, California, USA
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Ana P Ortiz
- Puerto Rico Cancer Control and Population Sciences Division, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
- Department of Biostatistics and Epidemiology, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico
| | - Fanghui Zhao
- Department of Cancer Epidemiology, National Cancer Center & Cancer Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Erna M Kojic
- Division of Infectious Diseases, Department of Medicine, Mount Sinai West and Morningside, New York, New York, USA
| | - Rupert Kaul
- Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Isabelle Heard
- Department of Endocrinology and Reproductive Medicine, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Assistance Publique - Hôpitaux de Paris, Groupe Hospitalier Pitié- Salpêtrière, Paris, France
| | - Imran O Morhason-Bello
- Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
- Institute of Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
| | | | - Alexandra de Pokomandy
- McGill University Department of Family Medicine and McGill University Health Centre, Montreal, Quebec, Canada
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Luana L S Rodrigues
- Programa de Pós-Graduação em Ciências da Saúde, Instituto de Saúde Coletiva, Universidade Federal do Oeste do Pará, Santarém, Pará, Brazil
- Laboratório de AIDS e Imunologia Molecular, Instituto Oswaldo Cruz, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Racheal S Dube Mandishora
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer/World Health Organization, Lyon, France
- Medical Microbiology Unit, University of Zimbabwe Faculty of Health Sciences, Harare, Zimbabwe
| | | | - Silvia Franceschi
- Centro di Riferimento Oncologico, Istituto di Ricovero e Cura a Carattere Scientifico, Aviano, Italy
| | - Sheela V Godbole
- Division of Epidemiology and Biostatistics, Indian Council of Medical Research, National AIDS Research Institute, Pune, India
| | - Fernanda K Tso
- Department of Gynecology, Federal University of São Paulo, São Paulo, Brazil
| | - Lynette J Menezes
- Division of Infectious Disease and International Medicine, University of South Florida, Tampa, Florida, USA
| | - Chunqing Lin
- National Cancer Center, National Clinical Research Center for Cancer, and Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gary M Clifford
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer/World Health Organization, Lyon, France
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18
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Wei F, Goodman MT, Xia N, Zhang J, Giuliano AR, D’Souza G, Hessol NA, Schim van der Loeff MF, Dai J, Neukam K, de Pokomandy A, Poynten IM, Geskus RB, Burgos J, Etienney I, Moscicki AB, Donà MG, Gillison ML, Nyitray AG, Nowak RG, Yunihastuti E, Zou H, Hidalgo-Tenorio C, Phanuphak N, Molina JM, Schofield AM, Kerr S, Fan S, Lu Y, Ong JJ, Chikandiwa AT, Teeraananchai S, Squillace N, Wiley DJ, Palefsky JM, Georges D, Alberts CJ, Clifford GM. Incidence and Clearance of Anal Human Papillomavirus Infection in 16 164 Individuals, According to Human Immunodeficiency Virus Status, Sex, and Male Sexuality: An International Pooled Analysis of 34 Longitudinal Studies. Clin Infect Dis 2023; 76:e692-e701. [PMID: 35869839 PMCID: PMC10226739 DOI: 10.1093/cid/ciac581] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/24/2022] [Accepted: 07/13/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Understanding the natural history of anal high-risk human papillomavirus (hrHPV) infection is key for designing anal cancer prevention programs but has not been systematically characterized. METHODS We reanalyzed data from 34 studies including 16 164 individuals in 6 risk groups defined by human immunodeficiency virus (HIV) status, sex, and male sexuality: men who have sex with men (MSM) and people with HIV (MSMWH), HIV-negative MSM, women with HIV (WWH), HIV-negative women, men who have sex with women (MSW) with HIV (MSWWH), and HIV-negative MSW. We used Markov models to estimate incidence and clearance of 13 hrHPV types and their determinants. RESULTS Human papillomavirus (HPV) 16 had the highest incidence-clearance ratio of the hrHPV types. MSMWH had the highest hrHPV incidence (eg, 15.5% newly HPV-16 infected within 2 years), followed by HIV-negative MSM (7.5%), WWH (6.6%), HIV-negative women (2.9%), MSWWH (1.7%), and HIV-negative MSW (0.7%). Determinants of HPV-16 incidence included HIV status and number of sexual partners for MSM, women, and MSW, and anal sex behavior for MSM only. HPV-16 clearance was lower for people with HIV (PWH) and lower for prevalent than incident infection. Among MSM, increasing age was associated with lower clearance of prevalent, but not incident, HPV-16 infection. CONCLUSIONS This robust and unifying analysis of anal hrHPV natural history is essential to designing and predicting the impact of HPV vaccination and HPV-based screening programs on anal cancer prevention, particularly in MSM and PWH. Importantly, it demonstrates the higher carcinogenic potential of longstanding anal prevalent hrHPV infection than more recent incident infection.
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Affiliation(s)
- Feixue Wei
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Marc T Goodman
- Cancer Prevention and Control Program, Cedars Cancer, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ningshao Xia
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health, Xiamen University, Xiamen, Fujian, China
| | - Jun Zhang
- State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, National Institute of Diagnostics and Vaccine Development in Infectious Diseases, School of Public Health, Xiamen University, Xiamen, Fujian, China
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer (CIIRC), Moffitt Cancer Center, Tampa, Florida, USA
| | - Gypsyamber D’Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nancy A Hessol
- Department of Clinical Pharmacy, University of CaliforniaSan Francisco, California, USA
| | | | - Jianghong Dai
- School of Public Health, Xinjiang Medical University, Urumqi, Xinjiang, China
| | - Karin Neukam
- Unidad Clínica de Enfermedades Infecciosas y Medicina Preventiva, UCEIMP, Instituto de Biomedicina de Sevilla, CSIC, Universidad de Sevilla, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Alexandra de Pokomandy
- Chronic Viral Illness Service, McGill University Health Centre and Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - I Mary Poynten
- The Kirby Institute, University of New South Wales, Kensington, Sydney, New South Wales, Australia
| | - Ronald B Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Joaquin Burgos
- Infectious Diseases Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Vall d’Hebron Institut de Recerca (VHIR), Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | - Maria Gabriella Donà
- Sexually Transmitted Infections (STI)/HIV Unit, San Gallicano Dermatological Institute IRCCS, Rome, Italy
| | - Maura L Gillison
- Thoracic Head and Neck Medical Oncology Department, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alan G Nyitray
- Center for AIDS Intervention Research and Clinical Cancer Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rebecca G Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Evy Yunihastuti
- Faculty of Medicine Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Huachun Zou
- School of Public Health (Shenzhen), Sun Yat-sen University, Shenzhen, China
- Kirby Institute, University of New South Wales, Sydney, Australia
| | - Carmen Hidalgo-Tenorio
- Early Clinical Trial Unit. Biosanitary Institute (IBS.Granada). Infectious Diseases Unit. University Hospital Virgen de las Nieves, Granada, Spain
| | | | - Jean-Michel Molina
- Department of Infectious diseases, University of Paris Cité, St-Louis Hospital, Paris, France
| | - Alice M Schofield
- Institute of Cancer Sciences, The University of Manchester, Manchester, UK
| | - Stephen Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, and Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Song Fan
- School of Public Health, Southwest Medical University, Luzhou, China
| | - Yong Lu
- School of Public Health, the Key Laboratory of Environmental Pollution Monitoring and Disease Control, Ministry of Education, Guizhou Medical University, Guiyang, China
| | - Jason J Ong
- Central Clinical School, Monash University, Melbourne, Australia
| | - Admire T Chikandiwa
- Wits RHI, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sirinya Teeraananchai
- Department of Statistics, Faculty of Science, Kasetsart University, Bangkok, Thailand
| | - Nicola Squillace
- Infectious Diseases Unit ASST-Monza, San Gerardo Hospital-University of Milano-Bicocca, Monza, Italy
| | - Dorothy J Wiley
- School of Nursing, University of California, Los Angeles, California, USA
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, California, USA
| | - Damien Georges
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Catharina J Alberts
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Gary M Clifford
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
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19
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Hernandez AL, Weatherly CS, Burrowes S, Jimenez JL, Gonzalez R, Palefsky JM. “The problem is that our culture is just so messed up about aging.” Recruiting older men who have sex with men (MSM) into research studies: an example from a study of aging, HIV, and anal HPV. BMC Med Res Methodol 2022; 22:296. [DOI: 10.1186/s12874-022-01752-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 07/11/2022] [Accepted: 10/10/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Background
Anal human papillomavirus (HPV) disproportionately affects men who have sex with men (MSM), particularly those who are older and those living with HIV. After experiencing difficulty recruiting older MSM into a study on aging and anal HPV, we conducted a sub-study to gain feedback on our recruitment methods and explore barriers and facilitators to participating in anal HPV research.
Methods
We conducted focus groups with 30 men who have sex with men (MSM), both HIV-negative and MSM living with HIV, ages 50–75.
Results
We identified multiple themes that were barriers to participation including: (1) lack of knowledge about human papillomavirus and anal cancer; (2) research focused on anal cancer or discomfort with topics or procedures concerning the anus; (3) stigma including stigma associated with being men who have sex with men, being out, being a receptive partner, and being considered “older” in the gay community; and (4) confidentiality concerns including a fear of breach of confidentiality. Facilitators to participation were also identified; these motivational factors include altruism, wanting recommendations from a doctor, and desire to receive the best available care.
Conclusion
Researchers seeking to enroll older men who have sex with men should be aware of these barriers and facilitators to participation in order to maximize recruitment.
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Hernandez AL, Weatherly CS, Gonzalez R, Farhat S, Da Costa M, Calderon J, Kauffman J, Akha AS, Hilton JF, Palefsky JM. Rationale and design of the Anal HPV, HIV and Aging (AHHA) study: Protocol for a prospective study of anal HPV infection and HSIL among men who have sex (MSM) or trans women living with and without HIV, ages 50 and older. Front Epidemiol 2022; 2:992718. [PMID: 38455337 PMCID: PMC10910993 DOI: 10.3389/fepid.2022.992718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/06/2022] [Indexed: 03/09/2024]
Abstract
Introduction More than half of people living with HIV in the US are 50+ years old. Despite the benefits of antiretroviral therapy, older individuals with HIV are at higher risk for illnesses than their HIV-negative counterparts. Anal cancer, anal high-grade squamous intraepithelial lesions (HSIL), and anal HPV-16 infection occur most frequently among men who have sex with men living with HIV (MSMLWH). Men aged 60+ are 3-fold more likely to be diagnosed with anal cancer compared with younger men. Despite the increasing risk of anal cancer with age and HIV, little is known about the relationships among aging, HPV infection, HSIL and HIV. Methods and analysis The Anal HPV, HIV, and Aging (AHHA) Study is a two-stage project to evaluate the relationships among anal HPV infection, HSIL, HIV infection, and biomarkers of biological aging in MSM or trans women over the age of 50 years. Stage 1 will estimate the cross-sectional prevalence of both anal HPV infection and HSIL, based on outcomes of anal HPV DNA testing, and high-resolution anoscopy with biopsy. We will also study associations with study outcomes and serological biomarkers of inflammation (interleukin-6, C-reactive protein, D-dimer) and with the Veterans Aging Cohort Study Index and the Fried Frailty Phenotype using multivariable models. Participants living with HIV (n = 150) and HIV-negative participants (n = 150) will be enrolled. The 3-year Stage 2 longitudinal sample restricted to HSIL-negative and anal HPV-16 DNA-negative participants will estimate the 3-year incidence of both anal HSIL and anal HPV, stratified by HIV status through Cox proportional hazards regression. The effect of biomarkers of inflammation and markers of aging on study outcomes will be evaluated through multivariable repeated measures models stratified by HIV status. Ethics and dissemination This protocol was approved by the University of California, San Francisco Institutional Review Board (IRB: 16-18966). Results will be disseminated through presentations at national/international scientific conferences and publication in peer-reviewed journals.
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Affiliation(s)
- Alexandra L. Hernandez
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- Public Health Program, College of Education and Health Sciences, Touro University, Vallejo, CA, United States
| | - Christopher Scott Weatherly
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
- College of Osteopathic Medicine, Touro University Nevada, Henderson, NV, United States
| | - Ryan Gonzalez
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Sepideh Farhat
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Maria Da Costa
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Joanne Calderon
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jason Kauffman
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Arezou Sadighi Akha
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Joan F. Hilton
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States
| | - Joel M. Palefsky
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
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21
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Atkinson TM, Lynch KA, Vera J, Olivares NM, Webb A, Diamond LC, González J, Lubetkin EI, Bucher G, Rosa-Cunha I, Berry-Lawhorn JM, Levine R, Aboulafia D, Schouten J, Holland SM, Cella D, Palefsky JM. Linguistic validation of the Spanish version of the Anal Cancer High-Grade squamous intraepithelial lesions outcomes Research Health-Related Symptom Index (A-HRSI): AMC-A04. J Patient Rep Outcomes 2022; 6:108. [PMID: 36219358 PMCID: PMC9552152 DOI: 10.1186/s41687-022-00515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/21/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The Anal Cancer High-grade squamous intraepithelial lesions (HSIL) Outcomes Research (ANCHOR) Health-Related Symptom Index (A-HRSI) is a 25-item measure that assesses physical symptoms and impacts, and psychological symptoms. To promote generalizability and equity in the capture of these concepts in Spanish-speaking participants, we linguistically validated a Spanish version of A-HRSI. METHODS Following independent forward translation and reconciliation of A-HRSI from English to Spanish, two rounds of cognitive interviews were completed with ANCHOR participants who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish. Interviews were coded to highlight any items and concepts that were reported as being difficult for any reason by ≥ 3 participants, with such items revised during a research team panel discussion and tested in a second round of interviews if applicable. RESULTS Seventeen participants representing 8 nationalities were enrolled (Round 1 n=10, Round 2 n=7); 7 participants reported not completing high school (41.2%). No difficulties were reported with respect to the theoretical concepts measured by A-HRSI. We made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s). CONCLUSION The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL. Language is a tremendous barrier to enrolling patients to clinical trials. The anal cancer high-grade squamous intraepithelial lesions (HSIL) outcomes research [ANCHOR] trial is a randomized clinical trial that recently established that the treatment of anal HSIL, versus active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV (PLWH). The ANCHOR Health-Related Symptom Index (A-HRSI) is a 25-item patient-reported outcomes measure that was developed to assess physical symptoms, physical impacts, and psychological symptoms related to anal HSIL. As approximately 10% of ANCHOR participants preferred the delivery of their healthcare in Spanish, the purpose of the present study was to linguistically validate a Spanish version of A-HRSI. Based on feedback from interviews with 17 participants from the ANCHOR trial who had been diagnosed with anal HSIL in the prior nine months and preferred delivery of their healthcare in Spanish, we made modifications to the Spanish translation of eight items and two response option terms in cases where participants had difficulty understanding a term, experienced problems in discriminating between terms, or preferred the use of an alternative term to represent the concept(s). The Spanish version of A-HRSI is a linguistically valid tool that can be used to assess physical symptoms, impacts, and psychological symptoms related to anal HSIL as part of clinical trials or routine care.
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Affiliation(s)
- Thomas M. Atkinson
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - Kathleen A. Lynch
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA ,grid.137628.90000 0004 1936 8753New York University, New York, NY USA
| | - Jacqueline Vera
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - Nuria Mendoza Olivares
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA ,grid.137628.90000 0004 1936 8753New York University, New York, NY USA
| | - Andrew Webb
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - Lisa C. Diamond
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - Javier González
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - Erica I. Lubetkin
- grid.254250.40000 0001 2264 7145CUNY School of Medicine, New York, NY USA
| | - Gary Bucher
- Anal Dysplasia Clinic MidWest, Chicago, IL USA
| | | | | | - Rebecca Levine
- grid.240283.f0000 0001 2152 0791Montefiore Medical Center, New York, NY USA
| | - David Aboulafia
- grid.416879.50000 0001 2219 0587Virginia Mason Medical Center, Seattle, WA USA
| | - Jeffrey Schouten
- grid.416879.50000 0001 2219 0587Virginia Mason Medical Center, Seattle, WA USA
| | - Susan M. Holland
- grid.51462.340000 0001 2171 9952Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center, 641 Lexington Ave., 7th Floor, 10022 New York, NY USA
| | - David Cella
- grid.16753.360000 0001 2299 3507Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Joel M. Palefsky
- grid.266102.10000 0001 2297 6811University of California-San Francisco, San Francisco, CA USA
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Palefsky JM, Lee JY, Jay N, Goldstone SE, Darragh TM, Dunlevy HA, Rosa-Cunha I, Arons A, Pugliese JC, Vena D, Sparano JA, Wilkin TJ, Bucher G, Stier EA, Tirado Gomez M, Flowers L, Barroso LF, Mitsuyasu RT, Lensing SY, Logan J, Aboulafia DM, Schouten JT, de la Ossa J, Levine R, Korman JD, Hagensee M, Atkinson TM, Einstein MH, Cracchiolo BM, Wiley D, Ellsworth GB, Brickman C, Berry-Lawhorn JM. Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer. N Engl J Med 2022; 386:2273-2282. [PMID: 35704479 PMCID: PMC9717677 DOI: 10.1056/nejmoa2201048] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking. METHODS We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer. RESULTS Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test). CONCLUSIONS Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).
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Affiliation(s)
- Joel M Palefsky
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeannette Y Lee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Naomi Jay
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Stephen E Goldstone
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Teresa M Darragh
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Hillary A Dunlevy
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Isabella Rosa-Cunha
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Abigail Arons
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Julia C Pugliese
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Don Vena
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Joseph A Sparano
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Timothy J Wilkin
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Gary Bucher
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Elizabeth A Stier
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Maribel Tirado Gomez
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Lisa Flowers
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Luis F Barroso
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Ronald T Mitsuyasu
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Shelly Y Lensing
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey Logan
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - David M Aboulafia
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jeffrey T Schouten
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Juan de la Ossa
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Rebecca Levine
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Jessica D Korman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Michael Hagensee
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Thomas M Atkinson
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Mark H Einstein
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Bernadette M Cracchiolo
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Dorothy Wiley
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Grant B Ellsworth
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - Cristina Brickman
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
| | - J Michael Berry-Lawhorn
- From the University of California, San Francisco School of Medicine, San Francisco (J.M.P., N.J., T.M.D., A.A., C.B., J.M.B.-L.); University of Arkansas for Medical Sciences, Little Rock (J.Y.L., S.Y.L.); Icahn School of Medicine at Mount Sinai (S.E.G., J.A.S.), Weill Cornell Medicine (T.J.W., G.B.E.), Montefiore Medical Center, Albert Einstein School of Medicine (R.L.), and Memorial Sloan Kettering Cancer Center (T.M.A.) - all in New York; University of Colorado School of Medicine, Aurora (H.A.D.); University of Miami School of Medicine, Miami (I.R.-C.); the Emmes Company, Rockland, MD (J.C.P., D.V.); Anal Dysplasia Clinic Midwest, Chicago (G.B.); Boston University School of Medicine, Boston (E.A.S.); University of Puerto Rico Comprehensive Cancer Center, San Juan (M.T.G.); Emory University School of Medicine, Atlanta (L.F.); Wake Forest University Health Sciences, Winston-Salem, NC (L.F.B.); University of California, Los Angeles Schools of Medicine (R.T.M.) and Nursing (D.W.), Los Angeles; Denver Public Health, Denver (J.L.); University of Washington School of Medicine (D.M.A., J.T.S.) and the Polyclinic, Virginia Mason Medical Center (J.O.) - both in Seattle; Capital Digestive Care, Washington, DC (J.D.K.); Louisiana State University School of Medicine, New Orleans (M.H.); and Rutgers New Jersey Medical School, Newark (M.H.E., B.M.C.)
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23
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Faber MT, Frederiksen K, Palefsky JM, Kjaer SK. A nationwide longitudinal study on risk factors for progression of anal intraepithelial neoplasia grade 3 to anal cancer. Int J Cancer 2022; 151:1240-1247. [PMID: 35657350 PMCID: PMC9545245 DOI: 10.1002/ijc.34143] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/13/2022]
Abstract
Little is known about risk factors for progression of high‐grade anal intraepithelial neoplasia (AIN) to anal squamous cell carcinoma (ASCC). In this large, population‐based study, we assess the role of factors related to immune status for the risk of ASCC among individuals from the general population with a diagnosis of AIN3. Individuals diagnosed with AIN3 during 1985‐2016 were identified in the Danish Pathology Registry and followed for subsequent development of ASCC. The study population was linked to the National Patient Registry, the Danish Prescription Registry and the Danish HIV Cohort Study for information on autoimmune disease, genital warts and HIV status. To study the progression rate, Cox regression models with hazard ratios (HR) and 95% confidence intervals (CI) were applied with time since AIN3 as the underlying time scale and with adjustment for age at AIN3 diagnosis, year of AIN3 diagnosis and sex. The study population comprised 1222 individuals with AIN3 contributing 12 824 person‐years of follow‐up. Ninety‐seven individuals (7.9%) developed ASCC. Individuals registered with an autoimmune disease or genital warts before and/or after the AIN3 diagnosis had an increased rate of progression to ASCC compared to individuals without these conditions. People living with HIV had a higher progression rate than HIV‐negative individuals (HR = 4.25; 95% CI: 1.87‐9.65) with the highest progression rate among those with CD4 count ≤200 cells/μL. These associations may be caused by an interplay between HPV infection and immunosuppression.
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Affiliation(s)
- Mette T Faber
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
| | - Kirsten Frederiksen
- Danish Cancer Society Research Center, Statistics and Data Analysis, Strandboulevarden 49, DK-2100, Copenhagen, Denmark
| | - Joel M Palefsky
- Department of Medicine, University of California, 513 Parnassus Ave, San Francisco, CA, USA
| | - Susanne K Kjaer
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Strandboulevarden 49, DK-2100, Copenhagen, Denmark.,Department of Gynecology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK2100, Copenhagen, Denmark
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24
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Tota JE, Giuliano AR, Goldstone SE, Dubin B, Saah A, Luxembourg A, Velicer C, Palefsky JM. Anogenital Human Papillomavirus (HPV) Infection, Seroprevalence, and Risk Factors for HPV Seropositivity Among Sexually Active Men Enrolled in a Global HPV Vaccine Trial. Clin Infect Dis 2022; 74:1247-1256. [PMID: 34265048 DOI: 10.1093/cid/ciab603] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In men, the incidence of human papillomavirus (HPV)-related cancer is rising, but data regarding male HPV infection and seroprevalence are available from only a few countries. METHODS This analysis of a global HPV vaccine trial evaluated baseline data from 1399 human immunodeficiency virus-negative heterosexual men (HM) and men who have sex with men (MSM). Key objectives included assessment of HPV prevalence and risk factors for seropositivity to 9-valent HPV (9vHPV) vaccine types (6, 11, 16, 18, 31, 33, 45, 52, and 58), and concordance between seropositivity and prevalent HPV type. RESULTS Overall, 455 of 3463 HM (13.1%) and 228 of 602 MSM (37.9%) were HPV DNA positive for any 9vHPV vaccine type at baseline. Infection prevalence and seroprevalence (≥1 9vHPV vaccine type) were 13.2% and 8.1%, respectively, among 333 HM from Europe, and 37.9% and 29.9%, respectively, among 335 MSM from Europe or North America. Among men with baseline infection, MSM had higher seroprevalence for concordant HPV types (39.5% vs 10.8% in HM). The seropositivity risk (irrespective of baseline infection status) was higher among MSM versus HM (age-adjusted odds ratio, 3.0 [95% confidence interval, 2.4-6.4]). Among MSM, statistically significant seropositivity risk factors included younger age at sexual debut, higher number of receptive anal sex partners, and less frequent condom use. No factors assessed were associated with seropositivity in HM. CONCLUSIONS Higher proportions of MSM than HM were HPV DNA positive and seropositive, and concordance between HPV DNA positivity and seropositivity, a potential marker of true infection versus carriage, was higher in MSM. Most MSM and HM were seronegative for all 9vHPV vaccine types, suggesting the potential benefit of catch-up vaccination after sexual debut.Clinical Trials Registration. NCT00090285.
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Affiliation(s)
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center and Research Institute, Tampa, Florida, USA
| | | | | | | | | | | | - Joel M Palefsky
- Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
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25
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Nowak RG, Bentzen SM, Schumaker LM, Ambulos NP, Ndembi N, Dauda W, Mitchell A, Mathias TJ, Crowell TA, Baral SD, Blattner WA, Charurat ME, Palefsky JM, Cullen KJ. Evaluating the Jaccard Similarity Index as a Persistence Measure of Multiple Anal Human Papillomavirus Among Nigerian Men Who Have Sex With Men. Sex Transm Dis 2022; 49:297-303. [PMID: 34840323 PMCID: PMC8940626 DOI: 10.1097/olq.0000000000001587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multiple anal human papillomavirus (HPVs) may increase the risk of anal cancer among men who have sex with men (MSM) living with human immunodeficiency virus (HIV). The Jaccard Similarity Index (JSI) was explored as a measure of multiple HPV persistence. METHODS The TRUST/RV368 cohort enrolled MSM living with and without HIV in Abuja and Lagos, Nigeria. Participants with anal swabs at baseline, 3- and 12-month visits were tested for high- and low-risk HPVs using a next-generation sequencing assay. Persistence of the same HPV genotypes over time was calculated using the JSI and categorized into high, medium, and low similarity tertiles. Factors associated with higher versus lower similarity were estimated with multivariable ordinal logistic regression and reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS Of the 225 participants, median age was 25 years (interquartile range, 22-29 years), 62% were living with HIV, median HPVs was 3 (interquartile range, 2-5), and HPV6 (28%), HPV16 (26%), HPV11 (23%), and HPV45 (20%) were most prevalent. Fifty-three percent of participants had highly similar HPVs at 3 months, and the similarity was associated with HIV (aOR, 3.11; 95% CI, 1.6-5.9) and recent receptive sex (aOR, 1.9; 95% CI, 1.0-3.5). By 12 months, 20% had highly similar HPVs, and it was associated with 12 years or longer since anal coital debut (aOR, 6.8; 95% CI, 3.1-5.2), self-reported genital warts (aOR, 3.1; 95% CI, 1.5-6.6), and 200 or less CD4 cells/mm3 (aOR, 13.3; 95% CI, 2.7-65.2) for those living with HIV. CONCLUSIONS Studies evaluating the JSI as a predictor of high-grade intraepithelial lesions would further confirm its applicability as a quantitative measure of multiple HPV persistence.
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Affiliation(s)
| | - Søren M Bentzen
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Lisa M Schumaker
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Nicholas P Ambulos
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | | | - Wuese Dauda
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | | | - Trevor J Mathias
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | | | | | | | | | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, CA
| | - Kevin J Cullen
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
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26
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Lee JY, Lensing SY, Berry-Lawhorn JM, Jay N, Darragh TM, Goldstone SE, Wilkin TJ, Stier EA, Einstein M, Pugliese JC, Palefsky JM. Design of the ANal Cancer/HSIL Outcomes Research study (ANCHOR study): A randomized study to prevent anal cancer among persons living with HIV. Contemp Clin Trials 2022; 113:106679. [PMID: 35017115 PMCID: PMC8844243 DOI: 10.1016/j.cct.2022.106679] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/06/2022] [Accepted: 01/07/2022] [Indexed: 02/03/2023]
Abstract
It is well established that persons living with HIV (PLWH) have highly elevated rates of anal HSIL and anal cancer compared with those who are not living with HIV. The 5-year risk of anal cancer following anal HSIL has been reported to be as high as 14.1% among PLWH compared with 3.2% among those who are not living with HIV. To address these concerns, the AIDS Malignancy Consortium completed a large-scale, randomized trial to compare strategies for the prevention of anal cancer among PLWH with anal HSIL. The objective of the study was to determine whether treating anal HSIL was effective in reducing the incidence of anal cancer in PLWH compared with active monitoring. This paper describes the design of the ANal Cancer/HSIL Outcomes Research Study (ANCHOR) with respect to estimating the anal cancer event rate in this high risk population.
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Affiliation(s)
- Jeannette Y Lee
- University of Arkansas for Medical Sciences, 4301 West Markham, Slot #781, Little Rock, AR 72205, USA.
| | - Shelly Y Lensing
- University of Arkansas for Medical Sciences, 4301 West Markham, Slot #781, Little Rock, AR 72205, USA.
| | - J Michael Berry-Lawhorn
- University of California, San Francisco, Hematology Oncology, 1600 Divisadero Street, Room A641, Box 1699, San Francisco, CA 94143, USA.
| | - Naomi Jay
- University of California, San Francisco, Mt. Zion Medical Center, 1701 Divisadero Street, Suite 480, Box 1217, San Francisco, CA 94143, USA.
| | - Teresa M Darragh
- University of California, San Francisco, Mt. Zion Medical Center Depts. of Pathology, OB/Gyn Box 1785, 1600 Divisadero Street, Room B618, San Francisco, CA 94143, USA.
| | - Stephen E Goldstone
- Laser Surgery Care Center, 420 West 23rd Street, Suite PB, New York, NY 10011, USA
| | - Timothy J Wilkin
- Weill Medical College of Cornell University, Cornell Clinical Trials Unit, 53 West 23rd Street, 6th Floor, New York, NY 10010, USA.
| | - Elizabeth A Stier
- Boston Medical Center, Department of Obstetrics and Gynecology, 85 E. Concord Street, 6th Floor, Boston, MA 02118, USA.
| | - Mark Einstein
- Rutgers New Jersey Medical School, Medical Science Building (MSB), 185 South Orange Avenue, Room E-506, Newark, NJ 07101, USA.
| | - Julia C Pugliese
- Emmes Company, LLC, 401 N. Washington Street, Rockville, MD 20850, USA.
| | - Joel M Palefsky
- University of California, San Francisco, 513 Parnassus Ave, Room S420, Box 0654, San Francisco, CA 94143, USA.
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27
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Goldstone SE, Giuliano AR, Palefsky JM, Lazcano-Ponce E, Penny ME, Cabello RE, Moreira ED, Baraldi E, Jessen H, Ferenczy A, Kurman R, Ronnett BM, Stoler MH, Bautista O, Das R, Group T, Luxembourg A, Zhou HJ, Saah A. Efficacy, immunogenicity, and safety of a quadrivalent HPV vaccine in men: results of an open-label, long-term extension of a randomised, placebo-controlled, phase 3 trial. Lancet Infect Dis 2021; 22:413-425. [PMID: 34780705 DOI: 10.1016/s1473-3099(21)00327-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/02/2021] [Accepted: 05/25/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The quadrivalent human papillomavirus (HPV) vaccine was shown to prevent infections and lesions related to HPV6, 11, 16, and 18 in a randomised, placebo-controlled study in men aged 16-26 years. We assessed the incidences of external genital warts related to HPV6 or 11, and external genital lesions and anal dysplasia related to HPV6, 11, 16, or 18, over 10 years of follow-up. METHODS The 3-year base study was an international, multicentre, double-blind, randomised, placebo-controlled trial done at 71 sites in 18 countries. Eligible participants were heterosexual men (aged 16-23 years) or men who have sex with men (MSM; aged 16-26 years). Men who had clinically detectable anogenital warts or genital lesions at screening that were suggestive of infection with non-HPV sexually transmitted diseases, or who had a history of such findings, were excluded. Eligible participants were randomly assigned (1:1) to receive three doses of either quadrivalent HPV vaccine or placebo on day 1, month 2, and month 6, administered as a 0·5-mL injection into the deltoid muscle. The 7-year, open-label, long-term follow-up extension study was done at 46 centres in 16 countries. Participants who received one or more doses of the quadrivalent HPV vaccine in the base study were eligible for enrolment into the long-term follow-up study (early vaccination group). Placebo recipients were offered the three-dose quadrivalent HPV vaccine at the end of the base study; those who received one or more quadrivalent HPV vaccine doses were eligible for enrolment into the long-term follow-up study (catch-up vaccination group). The primary efficacy endpoints were the incidence of external genital warts related to HPV6 or 11 and the incidence of external genital lesions related to HPV6, 11, 16, or 18 in all participants and the incidence of anal intraepithelial neoplasia (including anal warts and flat lesions) or anal cancer related to HPV6, 11, 16, or 18 in MSM only. The primary efficacy analysis was done in the per-protocol population for the early vaccination group, which included participants who received all three vaccine doses, were seronegative at day 1 and PCR-negative from day 1 through month 7 of the base study for the HPV type being analysed, had no protocol violations that could affect evaluation of vaccine efficacy, and had attended at least one visit during the long-term follow-up study. For the catch-up vaccination group, efficacy was assessed in the modified intention-to-treat population, which included participants who had received at least one vaccine dose, were seronegative and PCR-negative for HPV types analysed from day 1 of the base study to the final follow-up visit before receiving the quadrivalent HPV vaccine, and had at least one long-term follow-up visit. Safety was assessed in all randomised participants who received at least one vaccine dose. This study is registered with ClinicalTrials.gov, NCT00090285. FINDINGS Between Aug 10, 2010, and April 3, 2017, 1803 participants were enrolled in the long-term follow-up study, of whom 936 (827 heterosexual men and 109 MSM) were included in the early vaccination group and 867 (739 heterosexual men and 128 MSM) were included in the catch-up vaccination group. Participants in the early vaccination group were followed up for a median of 9·5 years (range 0·1-11·5) after receiving the third dose of the quadrivalent HPV vaccine, and participants in the catch-up vaccination group were followed up for a median of 4·7 years (0·0-6·6) after receiving the third dose. In early vaccine group participants during long-term follow-up compared with the placebo group in the base study, the incidence per 10 000 person-years of external genital warts related to HPV6 or 11 was 0·0 (95% CI 0·0-8·7) versus 137·3 (83·9-212·1), of external genital lesions related to HPV6, 11, 16, or 18 was 0·0 (0·0-7·7) versus 140·4 (89·0-210·7), and of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 in MSM only was 20·5 (0·5-114·4) versus 906·2 (553·5-1399·5). Compared with during the base study (ie, before quadrivalent HPV vaccine administration), during the long-term follow-up period, participants in the catch-up vaccination group had no new reported cases of external genital warts related to HPV6 or 11 (149·6 cases per 10 000 person-years [95% CI 101·6-212·3] vs 0 cases per 10 000 person-years [0·0-13·5]) or external genital lesions related to HPV6, 11, 16, or 18 (155·1 cases per 10 000 person-years [108·0-215·7] vs 0 cases per 10 000 person-years [0·0-10·2]), and a lower incidence of anal intraepithelial neoplasia or anal cancer related to HPV6, 11, 16, or 18 (886·0 cases per 10 000 person-years [583·9-1289·1] vs 101·3 cases per 10 000 person-years [32·9-236·3]). No vaccine-related serious adverse events were reported. INTERPRETATION The quadrivalent HPV vaccine provides durable protection against anogenital disease related to HPV6, 11, 16, and 18. The results support quadrivalent HPV vaccination in men, including catch-up vaccination. FUNDING Merck Sharp & Dohme.
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Affiliation(s)
| | - Anna R Giuliano
- Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, USA
| | - Joel M Palefsky
- Department of Medicine, University of California at San Francisco, CA, USA
| | | | - Mary E Penny
- Instituto de Investigación Nutricional, Lima, Peru
| | | | - Edson D Moreira
- Associação Obras Sociais Irmã Dulce and Oswaldo Cruz Foundation, Brazilian Ministry of Health, Salvador, Bahia, Brazil
| | - Ezio Baraldi
- Trialtech Research Institute, Pretoria, South Africa
| | | | - Alex Ferenczy
- McGill University Health Center, Montreal, QC, Canada
| | - Robert Kurman
- Department of Gynecology and Obstetrics and Department of Pathology Johns Hopkins University, Baltimore, MD, USA
| | - Brigitte M Ronnett
- Department of Gynecology and Obstetrics and Department of Pathology Johns Hopkins University, Baltimore, MD, USA
| | - Mark H Stoler
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | | | | | | | | | - Hao Jin Zhou
- MSD China, Beijing, China; Sun Yat-sen University, Guangzhou, China
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28
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Munyaneza A, Adedimeji A, Kim HY, Shi Q, Hoover DR, Ross J, Murchison L, Murenzi G, Kabahizi J, Gasana J, Nsengiyumva B, Kubwimana G, Kanyabwisha F, Muhoza B, Ingabire C, Mutesa L, Castle PE, Palefsky JM, Anastos K, Patel VV. Awareness and Willingness to Use HIV Pre-exposure Prophylaxis Among Men Who Have Sex With Men in Rwanda: A Cross-Sectional Descriptive Survey. J Assoc Nurses AIDS Care 2021; 32:693-700. [PMID: 33449579 PMCID: PMC8610030 DOI: 10.1097/jnc.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Athanase Munyaneza
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Adebola Adedimeji
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Hae-Young Kim
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Qiuhu Shi
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Donald R Hoover
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Jonathan Ross
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Lynn Murchison
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Gad Murenzi
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Jules Kabahizi
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Josephine Gasana
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Boniface Nsengiyumva
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Gallican Kubwimana
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Faustin Kanyabwisha
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Benjamin Muhoza
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Charles Ingabire
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Leon Mutesa
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Philip E Castle
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Joel M. Palefsky
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Kathryn Anastos
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
| | - Viraj V. Patel
- Athanase Munyaneza, RN, MPH, is a Research Operations and Nurse Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Adebola Adedimeji, PhD, MPH, is an Associate Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Hae-Young Kim, DrPH, is an Associate Professor and Director of Biostatistics Division, Department of Public Health, New York Medical College, Valhalla, New York, USA. Qiuhu Shi, PhD, is a Biostatistician, Department of Public Health, New York Medical College, Valhalla, New York, USA. Donald R. Hoover, PhD, is a Biostatistician, Department of Statistics and Institute for Health, Health-Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA. Jonathan Ross, MD, MSc, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Lynn Murchison, MPH, is a Grant Manager, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. GadMurenzi, MD, MPH, is a Program Director, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Jules Kabahizi, MD, is a Chief Consultant Physician, Division of General Internal Medicine, Rwanda Military Hospital (RMH), Kigali, Rwanda. Josephine Gasana, BSc, is a Social Worker, Rwanda Military Hospital (RMH), Kigali, Rwanda. Boniface Nsengiyumva, MSc, is a Biostatistician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Gallican Kubwimana, MBA, is a Grant Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Faustin Kanyabwisha, MPH, is a Senior Laboratory Technician, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Benjamin Muhoza, MSc, is a Database Manager, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Charles Ingabire, MPH, is a Qualitative Research Coordinator, Division of Clinical Education and Research, Rwanda Military Hospital (RMH), Kigali, Rwanda. Leon Mutesa, MD, PhD, is a Professor, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda. Philip E. Castle, PhD, MPH, is a Professor, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA. Joel M. Palefsky, MD, is a Professor of Medicine, Department of Infectious Diseases, University of California, San Francisco, San Francisco, California, USA. Kathryn Anastos, MD, is a Professor of Medicine and Population Health, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA. Viraj V. Patel, MD, MPH, is an Assistant Professor, Division of General Internal Medicine, Albert Einstein College of Medicine/MontefioreMedical Center, Bronx, New York, USA
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Hernandez AL, Karthik R, Sivasubramanian M, Raghavendran A, Lensing S, Lee JY, Abraham P, Mathai D, Palefsky JM. Prevalence of oral human papillomavirus infection among Indian HIV-positive men who have sex with men: a cross-sectional study. BMC Infect Dis 2021; 21:675. [PMID: 34247583 PMCID: PMC8274002 DOI: 10.1186/s12879-021-06301-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 06/09/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Oral human papillomavirus (HPV) infection has been causally linked to a subset of oropharyngeal cancers in Western populations, and both oropharyngeal cancer and oral HPV infection are increased among HIV-positive individuals. India has high incidences of oral and oropharyngeal cancers, and Indian HIV-positive men who have sex with men (MSM) may be at increased risk of developing oropharyngeal cancers. However, there is little information available on the prevalence of oral HPV in this population. METHODS We tested 302 HIV-positive Indian MSM for oral HPV infection using L1 HPV DNA PCR with probes specific for 29 types and a mixture of 10 additional types. CD4+ level and plasma HIV viral load (VL) were measured. Participants completed an interviewer-administered questionnaire including a sexual history. RESULTS The prevalence of oral HPV was 23.7% (95% CI: 19-29%) and 2.4% of participants had oncogenic HPV types. No participants had oral HPV type 16 (HPV-16) and the prevalence of other anogenital HPV types was low. Participants with higher CD4+ levels had reduced odds of having any oral HPV infection (OR: 3.1 [1.4-6.9]) in multivariable analyses. CONCLUSIONS This is the first report of oral HPV among Indian HIV-positive MSM. Our results show a high prevalence of oral HPV infection consistent with studies from Western populations. However, oncogenic anogenital HPV types were relatively uncommon in our study population. It is unknown what the impact of this distribution of oral HPV will be on oropharyngeal cancers. HIV-positive MSM in India should be monitored closely for oral and oropharyngeal pre-cancer and cancer.
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Affiliation(s)
- Alexandra L Hernandez
- Division of Infectious Diseases, Department of Medicine, University of California, Box 0654, 513 Parnassus Ave, Room S420, San Francisco, CA, 94143, USA.
- Public Health Program, College of Education and Health Sciences, Touro University, Vallejo, CA, USA.
| | - Rajiv Karthik
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | | | | | - Shelly Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeannette Y Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Priya Abraham
- Department of Clinical Virology, Christian Medical College, Vellore, India
| | - Dilip Mathai
- Apollo Institute of Medical Sciences and Research, Hyderabad, India
| | - Joel M Palefsky
- Division of Infectious Diseases, Department of Medicine, University of California, Box 0654, 513 Parnassus Ave, Room S420, San Francisco, CA, 94143, USA
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30
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Larsen HK, Hædersdal M, Thomsen LT, Hertzum-Larsen R, Lok TT, Bonde J, Sørensen SS, Hansen JM, Palefsky JM, Kjær SK. Risk of Anal High-grade Squamous Intraepithelial Lesions Among Renal Transplant Recipients Compared With Immunocompetent Controls. Clin Infect Dis 2021; 73:21-29. [PMID: 32544223 DOI: 10.1093/cid/ciaa781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 06/11/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Renal transplant recipients (RTRs) have increased risk of human papillomavirus (HPV)-related cancers, including anal cancer. We investigated the prevalence of anal high-grade intraepithelial lesions (HSILs) in RTRs compared with immunocompetent controls and risk factors for anal HSIL in RTRs. METHODS We included 247 RTRs and 248 controls in this cross-sectional study. We obtained anal samples for HPV testing with INNO-LiPA and performed high-resolution anoscopy on all participants. The participants completed a questionnaire on lifestyle and sexual habits. We used logistic regression to estimate odds ratios (ORs) of histologically confirmed anal HSIL in RTRs vs controls and risk factors for anal HSIL in RTRs, stratified by sex and anal high-risk (hr) HPV status, adjusting for age, smoking, lifetime sexual partners, and receptive anal sex. RESULTS RTRs had higher anal HSIL prevalence than controls, both among men (6.5% vs 0.8%; adjusted OR [aOR], 11.21 [95% confidence interval {CI}, 1.46-291.17]) and women (15.4% vs 4.0%; aOR, 6.41 [95% CI, 2.14-24.10]). Among those with anal hrHPV, RTRs had higher anal HSIL prevalence than controls (33.8% vs 9.5%; aOR, 6.06 [95% CI, 2.16-20.27]). Having had receptive anal sex (aOR, 6.23 [95% CI, 2.23-19.08]) or genital warts (aOR, 4.21 [95% CI, 1.53-11.48]) were risk factors for anal HSIL in RTRs. All HSIL cases occurred in individuals with anal hrHPV. CONCLUSIONS RTRs had increased risk of anal HSIL compared with immunocompetent controls, with particularly high prevalence in female RTRs. Receptive anal sex, previous genital warts, and anal hrHPV infection were risk factors for anal HSIL in RTRs. Screening for anal HSIL in RTRs should be considered. CLINICAL TRIALS REGISTRATION NCT03018927.
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Affiliation(s)
- Helle K Larsen
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Dermatology and Venereology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Merete Hædersdal
- Department of Dermatology and Venereology, Copenhagen University Hospital, Bispebjerg Hospital, Copenhagen, Denmark
| | - Louise T Thomsen
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Rasmus Hertzum-Larsen
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Trine Thorborg Lok
- Department of Pathology, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Jesper Bonde
- Department of Pathology, Copenhagen University Hospital, Hvidovre Hospital, Hvidovre, Denmark
| | - Søren S Sørensen
- Department of Nephrology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Melchior Hansen
- Department of Nephrology, Copenhagen University Hospital, Herlev Hospital, Copenhagen, Denmark
| | - Joel M Palefsky
- Research and Education Center, University of California, San Francisco Anal Neoplasia Clinic, San Francisco, California, USA
| | - Susanne K Kjær
- Unit of Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark.,Department of Gynecology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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31
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Ellsworth GB, Stier EA, Chiao EY, Lensing SY, Darragh T, Jay N, Berry-Lawhorn JM, Einstein M, Barroso LF, Cranston RD, Levine R, Guiot HM, French AL, Goldstone SE, Preiser W, Claassen M, Palefsky JM, Wilkin TJ. Xpert HPV as a Screening Tool for Anal Histologic High-Grade Squamous Intraepithelial Lesions in Women Living With HIV. J Acquir Immune Defic Syndr 2021; 87:978-984. [PMID: 34110312 PMCID: PMC8341010 DOI: 10.1097/qai.0000000000002672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/15/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Women living with HIV (WLWH) experience high rates of anal cancer. Screening using anal cytology, high-resolution anoscopy (HRA) with biopsies, can histologically diagnose anal cancer precursors called high-grade squamous intraepithelial lesions (HSIL). The low specificity of screening using anal cytology results in HRA referral for many WLWH without HSIL. Screening using high-risk human papillomavirus (HR-HPV) may improve specificity. METHODS Two hundred seven WLWH (63% non-Hispanic black) were screened for anal histologic HSIL (hHSIL) using cytology, HRA-guided biopsies, and Xpert HPV. Xpert performance for predicting anal hHSIL was compared with that of cytology. Usng Xpert 5 HPV genotypic results and accompanying cycle thresholds, receiver operator characteristic curve and recursive partitioning analyses were used to create predictive models for hHSIL. RESULTS The performance of Xpert to predict hHSIL was not different from that of cytology with a sensitivity (Sn) of 89% and specificity (Sp) of 49%. Interpretation of Xpert was modified using genotypic results and receiver operator characteristic curve analysis, which produced a screen with an Sn and Sp of 75% and 84% for hHSIL, respectively. Another reinterpretation of Xpert was created using recursive partitioning and cycle thresholds, which predicted hHSIL with an Sn and Sp of 75% and 86%, respectively. The detection of HPV-16 was highly predictive of hHSIL in all analyses. These modified screening tests would reduce HRA referral in this population by almost half compared with anal cytology. CONCLUSIONS Xpert HPV is an alternative to anal cytology to screen for anal HSIL and can be optimized to reduce the number of unnecessary HRAs performed in WLWH.
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Affiliation(s)
| | | | | | | | - Teresa Darragh
- University of California San Francisco, San Francisco, CA
| | - Naomi Jay
- University of California San Francisco, San Francisco, CA
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Isaguliants M, Nosik M, Karlsen A, Petrakova N, Enaeva M, Lebedeva N, Podchufarova D, Laga V, Gromov K, Nazarov A, Chowdhury S, Sinitsyn M, Sobkin A, Chistyakova N, Aleshina S, Grabarnik A, Palefsky JM. Prevalence and Risk Factors of Infection with High Risk Human Papilloma Viruses among HIV-Positive Women with Clinical Manifestations of Tuberculosis in a Middle-Income Country. Biomedicines 2021; 9:biomedicines9060683. [PMID: 34208764 PMCID: PMC8234035 DOI: 10.3390/biomedicines9060683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/22/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022] Open
Abstract
Women living with HIV-1 are at high risk of infection with human papillomavirus of high carcinogenic risk (HR HPVs). M. tuberculosis (TB) promotes HPV infection and increases the risk to develop HPV-associated cancer. Our knowledge of persisting HR HPVs genotypes, and of the factors promoting HR HPV infection in people living with HIV-1 with clinical TB manifestations is sparse. Here, we analyzed 58 women living with HIV-1 with clinical TB manifestations (WLWH with TB) followed up in specialized centers in Russia, a middle income country endemic for HIV-1 and TB, for the presence in cervical smears of DNA of twelve HR HPV genotypes. DNA encoding HPV16 E5, E6/E7 was sequenced. Sociodemographic data of patients was collected by questionnaire. All women were at C2-C3 stages of HIV-infection (by CDC). The majority were over 30 years old, had secondary education, were unemployed, had sexual partners, experienced 2–3 pregnancies and at least one abortion, and were smokers. The most prevalent was HPV16 detected in the cervical smears of 38% of study participants. Altogether 34.5% of study participants were positive for HR HPV types other than HPV16; however, but none of these types was seen in more than 7% of tested samples. Altogether, 20.7% of study participants were positive for several HR HPV types. Infections with HPVs other than HPV16 were common among WLWH with generalized TB receiving combined ART/TB-therapy, and associated with their ability to work, indirectly reflecting both their health and lifestyle. The overall prevalence of HR HPVs was associated with sexual activity of women reflected by the number of pregnancies, and of HPV 16, with young age; none was associated to CD4+-counts, route of HIV-infection, duration of life with HIV, forms of TB-infection, or duration of ART, characterizing the immune status. Thus, WLWH with TB—especially young—were predisposed to infection with HPV16, advancing it as a basis for a therapeutic HPV vaccine. Phylogenetic analysis of HPV16 E5, E6/E7 DNA revealed no common ancestry; sequences were similar to those of the European and American HPV16 strains, indicating that HPV vaccine for WLWH could be the same as HPV16 vaccines developed for the general population. Sociodemographic and health correlates of HR HPV prevalence in WLWH deserve further analysis to develop criteria/recommendations for prophylactic catch-up and therapeutic HPV vaccination of this highly susceptible and vulnerable population group.
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Affiliation(s)
- Maria Isaguliants
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 17177 Stockholm, Sweden
- Institute of Microbiology and Virology, Riga Stradins University, LV-1007 Riga, Latvia
- N.F. Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (A.K.); (N.P.); (V.L.); (K.G.)
- Correspondence: or
| | - Marina Nosik
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia;
| | - Anastasia Karlsen
- N.F. Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (A.K.); (N.P.); (V.L.); (K.G.)
- I.I. Mechnikov Institute of Vaccine and Sera, 105064 Moscow, Russia;
- Medical Academy for Continuous Professional Education, 125993 Moscow, Russia
| | - Natalia Petrakova
- N.F. Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (A.K.); (N.P.); (V.L.); (K.G.)
| | - Marina Enaeva
- Moscow Clinical Scientific Center Named after A.S. Loginov, 111123 Moscow, Russia;
| | - Natalia Lebedeva
- Moscow Regional Center for Prevention and Control of AIDS and Infectious Diseases, 129110 Moscow, Russia; (N.L.); (D.P.)
| | - Daria Podchufarova
- Moscow Regional Center for Prevention and Control of AIDS and Infectious Diseases, 129110 Moscow, Russia; (N.L.); (D.P.)
| | - Vita Laga
- N.F. Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (A.K.); (N.P.); (V.L.); (K.G.)
| | - Konstantin Gromov
- N.F. Gamaleya National Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (A.K.); (N.P.); (V.L.); (K.G.)
| | | | - Sona Chowdhury
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
| | - Mikhail Sinitsyn
- Moscow Scientific and Clinical Center for TB Control, 107076 Moscow, Russia; (M.S.); (S.A.); (A.G.)
| | - Alexander Sobkin
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (A.S.); (N.C.)
| | - Natalya Chistyakova
- G.A. Zaharyan Moscow Tuberculosis Clinic, Department for Treatment of TB Patients with HIV Infection, 125466 Moscow, Russia; (A.S.); (N.C.)
| | - Svetlana Aleshina
- Moscow Scientific and Clinical Center for TB Control, 107076 Moscow, Russia; (M.S.); (S.A.); (A.G.)
| | - Alexei Grabarnik
- Moscow Scientific and Clinical Center for TB Control, 107076 Moscow, Russia; (M.S.); (S.A.); (A.G.)
| | - Joel M. Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; (S.C.); (J.M.P.)
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Palefsky JM, Poongulali S, Lensing S, Lee J, Da Costa M, Chein A, Beulah F, Murugavel KG, Kumarasamy N. AIDS Malignancy Consortium 054: Safety and Immunogenicity of the Quadrivalent Vaccine in Indian Women Living With HIV. J Acquir Immune Defic Syndr 2021; 87:875-881. [PMID: 33587509 PMCID: PMC9310671 DOI: 10.1097/qai.0000000000002657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Human papillomavirus (HPV)-associated cervical cancer is a leading cause of death among Indian women. Indian women living with HIV (WLWH) may be at especially high risk. The quadrivalent HPV (qHPV) vaccine is effective in prevention of initial infection with HPV-6/11/16/18 in HIV-negative women. Little is known about previous exposure to HPV-6/11/16/18, safety, and immunogenicity of qHPV in Indian WLWH. METHODOLOGY One hundred fifty WLWH with different CD4 levels and HIV viral load (VL) were vaccinated at 0/2/6 months at CART-CRS-IDMC, Chennai, India. Serology was performed at weeks 0, 28, and 52 for HPV-6/11/16/18 using a competitive Luminex immunoassay and for HPV-16/18 using a pseudovirion-based neutralization assay. RESULTS Mean age was 30.8 years (range, 19-44 years). 71/87/73/81% of women were naive (sero-negative and DNA-negative) to HPV-6/11/16/18 at baseline, respectively. Among per-protocol women naive to HPV-6/11/16/18 at baseline, 100/99/99/90%, respectively, seroconverted at week 28 and 95/96/98/71% were sero-positive at week 52, respectively. Pseudovirion-based neutralization assay identified more seroconversion to HPV-18 than competitive Luminex immunoassay. There were no significant differences in the proportion seroconverting by baseline or nadir CD4 or HIV VL; however, there was a trend for increased proportion seroconverting to HPV-18 among women with higher baseline CD4 level (P = 0.052). There were no qHPV-related serious adverse events and no change in CD4 level or HIV VL among women on ART. CONCLUSIONS qHPV vaccine was safe and immunogenic in Indian WLWH. A high proportion were naive to HPV-6/11/16/18 and may benefit from vaccination although many were married and several years post-initiation of sexual activity.
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Affiliation(s)
- Joel M Palefsky
- Department of Medicine, University of California, San Francisco, CA
| | - Selvamuthu Poongulali
- Chennai Antiviral Research and Treatment Centre Clinical Research Site, CART-CRS-Infectious Diseases Medical Centre, VHS Chennai, India
| | - Shelly Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR; and YRGCARE Infectious Diseases Laboratory
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR; and YRGCARE Infectious Diseases Laboratory
| | - Maria Da Costa
- Department of Medicine, University of California, San Francisco, CA
| | - Aung Chein
- Department of Medicine, University of California, San Francisco, CA
| | - Faith Beulah
- Chennai Antiviral Research and Treatment Centre Clinical Research Site, CART-CRS-Infectious Diseases Medical Centre, VHS Chennai, India
| | - K G Murugavel
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR; and YRGCARE Infectious Diseases Laboratory
| | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Centre Clinical Research Site, CART-CRS-Infectious Diseases Medical Centre, VHS Chennai, India
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Strickler HD, Keller MJ, Hessol NA, Eltoum IE, Einstein MH, Castle PE, Massad LS, Flowers L, Rahangdale L, Atrio JM, Ramirez C, Minkoff H, Adimora AA, Ofotokun I, Colie C, Huchko MJ, Fischl M, Wright R, D'Souza G, Leider J, Diaz O, Sanchez-Keeland L, Shrestha S, Xie X, Xue X, Anastos K, Palefsky JM, Burk RD. Primary HPV and Molecular Cervical Cancer Screening in US Women Living With Human Immunodeficiency Virus. Clin Infect Dis 2021; 72:1529-1537. [PMID: 32881999 DOI: 10.1093/cid/ciaa1317] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Primary human papillomavirus (HPV) screening (PHS) utilizes oncogenic human papillomavirus (oncHPV) testing as the initial cervical cancer screening method and typically, if positive, additional reflex-triage (eg, HPV16/18-genotyping, Pap testing). While US guidelines support PHS usage in the general population, PHS has been little studied in women living with HIV (WLWH). METHODS We enrolled n = 865 WLWH (323 from the Women's Interagency HIV Study [WIHS] and 542 from WIHS-affiliated colposcopy clinics). All participants underwent Pap and oncHPV testing, including HPV16/18-genotyping. WIHS WLWH who tested oncHPV[+] or had cytologic atypical squamous cells of undetermined significance or worse (ASC-US+) underwent colposcopy, as did a random 21% of WLWH who were oncHPV[-]/Pap[-] (controls). Most participants additionally underwent p16/Ki-67 immunocytochemistry. RESULTS Mean age was 46 years, median CD4 was 592 cells/µL, 95% used antiretroviral therapy. Seventy WLWH had histologically-determined cervical intraepithelial neoplasia grade 2 or greater (CIN-2+), of which 33 were defined as precancer (ie, [i] CIN-3+ or [ii] CIN-2 if concurrent with cytologic high grade squamous intraepithelial lesions [HSILs]). PHS had 87% sensitivity (Se) for precancer, 9% positive predictive value (PPV), and a 35% colposcopy referral rate (Colpo). "PHS with reflex HPV16/18-genotyping and Pap testing" had 84% Se, 16% PPV, 30% Colpo. PHS with only HPV16/18-genotyping had 24% Colpo. "Concurrent oncHPV and Pap Testing" (Co-Testing) had 91% Se, 12% PPV, 40% Colpo. p16/Ki-67 immunochemistry had the highest PPV, 20%, but 13% specimen inadequacy. CONCLUSIONS PHS with reflex HPV16/18-genotyping had fewer unnecessary colposcopies and (if confirmed) could be a potential alternative to Co-Testing in WLWH.
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Affiliation(s)
- Howard D Strickler
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Marla J Keller
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Nancy A Hessol
- University of California, San Francisco, California, USA
| | | | | | - Philip E Castle
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Lisa Flowers
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Lisa Rahangdale
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jessica M Atrio
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Catalina Ramirez
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Adaora A Adimora
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Igho Ofotokun
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine Colie
- Georgetown University, Washington, District of Columbia, USA
| | - Megan J Huchko
- University of California, San Francisco, California, USA
| | - Margaret Fischl
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Rodney Wright
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Gypsyamber D'Souza
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Olga Diaz
- Jacobi Medical Center, Bronx, New York, USA
| | | | | | - Xianhong Xie
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Xiaonan Xue
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | - Kathryn Anastos
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
| | | | - Robert D Burk
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA
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Palefsky JM, Lensing SY, Belzer M, Lee J, Gaur AH, Mayer K, Futterman D, Stier EA, Paul ME, Chiao EY, Reirden D, Goldstone SE, Tirado M, Cachay ER, Barroso LF, Da Costa M, Darragh TM, Rudy BJ, Wilson CM, Kahn JA. High prevalence of anal high-grade squamous intraepithelial lesions, and prevention through human papillomavirus vaccination, in young men who have sex with men living with HIV. Clin Infect Dis 2021; 73:1388-1396. [PMID: 33991185 PMCID: PMC8528397 DOI: 10.1093/cid/ciab434] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Indexed: 01/06/2023] Open
Abstract
Background Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV)–related anal cancer. Little is known about the prevalence of low-grade squamous intraepithelial lesions (LSILs) and the anal cancer precursor, high-grade squamous intraepithelial lesions (HSILs), among young MSM with HIV (MSMLWH). HPV vaccination is recommended in this group, but its safety, immunogenicity, and protection against vaccine-type HPV infection and associated LSILs/HSILs have not been studied. Methods Two hundred and sixty MSMLWH aged 18–26 years were screened at 17 US sites for a clinical trial of the quadrivalent (HPV6,11,16,18) HPV (qHPV) vaccine. Those without HSILs were vaccinated at 0, 2, and 6 months. Cytology, high-resolution anoscopy with biopsies of lesions, serology, and HPV testing of the mouth/penis/scrotum/anus/perianus were performed at screening/month 0 and months 7, 12, and 24. Results Among 260 MSMLWH screened, the most common reason for exclusion was detection of HSILs in 88/260 (34%). 144 MSMLWH were enrolled. 47% of enrollees were previously exposed to HPV16. No incident qHPV type–associated anal LSILs/HSILs were detected among men naive to that type, compared with 11.1, 2.2, 4.5, and 2.8 cases/100 person-years for HPV6,11,16,18–associated LSILs/HSILs, respectively, among those previously exposed to that type. qHPV was immunogenic and safe with no vaccine-associated serious adverse events. Conclusions 18–26-year-old MSMLWH naive to qHPV vaccine types were protected against incident qHPV type–associated LSILs/HSILs. Given their high prevalence of HSILs, there is an urgent need to vaccinate young MSMLWH before exposure to vaccine HPV types, before initiating sexual activity, and to perform catch-up vaccination.
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Affiliation(s)
- Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Marvin Belzer
- Department of Pediatrics, University of Southern California, Los Angeles, CA, USA
| | - Jeannette Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aditya H Gaur
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kenneth Mayer
- Fenway Health and Harvard Medical School, Boston, MA, USA
| | | | | | - Mary E Paul
- Baylor College of Medicine, Houston, TX, USA
| | | | - Daniel Reirden
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Maribel Tirado
- Cancer Control and Population Sciences Program, University of Puerto Rico, San Juan, PR, USA
| | | | - Luis F Barroso
- Department of Medicine, Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - Maria Da Costa
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Teresa M Darragh
- Department of Pathology, University of California San Francisco, San Francisco, CA, USA
| | - Bret J Rudy
- Department of Pediatrics, New York University Grossman School of Medicine New York, NY, USA
| | - Craig M Wilson
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jessica A Kahn
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Deshmukh AA, Suk R, Shiels MS, Sonawane K, Nyitray AG, Liu Y, Gaisa MM, Palefsky JM, Sigel K. Recent Trends in Squamous Cell Carcinoma of the Anus Incidence and Mortality in the United States, 2001-2015. J Natl Cancer Inst 2021; 112:829-838. [PMID: 31742639 DOI: 10.1093/jnci/djz219] [Citation(s) in RCA: 157] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/03/2019] [Accepted: 10/31/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Squamous cell carcinoma of the anus (SCCA) incidence is rising in the United States. Study of incidence trends by stage at diagnosis, age-specific and birth cohort patterns, and trends in mortality could provide evidence for a true increase and etiological clues for the increase in incidence. METHODS Using the US Cancer Statistics dataset, we examined trends in SCCA incidence (2001-2015) and mortality (2001-2016) rates. Join-point regression was used to compute annual and average annual percentage change (AAPC). Incidence patterns by 5-year age group and birth cohort were evaluated using incidence rate ratios (IRRs) and age-period-cohort modeling. RESULTS SCCA incidence increased 2.7% per year (95% confidence interval [CI] = 2.1% to 3.3%), with pronounced increases in age groups 50 years and older. Distant-stage SCCA incidence tripled (AAPC = 8.6%, 95% CI = 5.4% to 12.0%, among men and AAPC = 7.5%, 95% CI = 4.8% to 10.2%, among women) and regional-stage SCCA incidence nearly doubled (AAPC = 4.7% for men and women) in both sexes; the AAPC for localized stage was 1.3% (95% CI = 0.6% to 2.0%) in men and 2.3% (95% CI = 1.8% to 2.8%) in women. Compared with adults born circa 1946, recently born black men (born circa 1986) had a nearly fivefold higher risk (IRR = 4.7, 95% CI = 2.1 to 10.2) of SCCA, and the risk doubled among white men (IRR = 2.0, 95% CI = 1.7 to 2.2) and white women (IRR = 2.1, 95% CI = 1.9 to 2.3) born after circa 1960. Anal cancer mortality rates increased 3.1% per year (95% CI = 2.6% to 3.5%) with statistically significant increases in age groups 50 years and older. SCCA incidence-based mortality increased 1.9% annually (95% CI = 0.5% to 3.4%), with a notable (4.9%, 95% CI = 2.4% to 7.3%, per year) rise in adults ages 60-69 years. CONCLUSION The increase in SCCA incidence, particularly advanced-stage disease, and a similar increase in mortality suggest a true increase in the occurrence of SCCA. Future research and improved prevention are urgently needed to mitigate the increasing disease burden.
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Affiliation(s)
| | - Ryan Suk
- Center for Health Services Research and Center for Healthcare Data
| | - Meredith S Shiels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD
| | - Kalyani Sonawane
- Center for Health Services Research and Center for Healthcare Data
| | - Alan G Nyitray
- Department of Management, Policy, and Community Health, UTHealth School of Public Health, Houston, TX
- Clinical Cancer Center/Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI
| | | | - Michael M Gaisa
- Department of Pathology (YL) and Division of Infectious Diseases, Department of Medicine
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Keith Sigel
- Department of General Internal Medicine, Department of Medicine (KSi), Mt. Sinai Icahn School of Medicine, New York, NY
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Isaguliants M, Bayurova E, Avdoshina D, Kondrashova A, Chiodi F, Palefsky JM. Oncogenic Effects of HIV-1 Proteins, Mechanisms Behind. Cancers (Basel) 2021; 13:305. [PMID: 33467638 PMCID: PMC7830613 DOI: 10.3390/cancers13020305] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 02/08/2023] Open
Abstract
People living with human immunodeficiency virus (HIV-1) are at increased risk of developing cancer, such as Kaposi sarcoma (KS), non-Hodgkin lymphoma (NHL), cervical cancer, and other cancers associated with chronic viral infections. Traditionally, this is linked to HIV-1-induced immune suppression with depletion of CD4+ T-helper cells, exhaustion of lymphopoiesis and lymphocyte dysfunction. However, the long-term successful implementation of antiretroviral therapy (ART) with an early start did not preclude the oncological complications, implying that HIV-1 and its antigens are directly involved in carcinogenesis and may exert their effects on the background of restored immune system even when present at extremely low levels. Experimental data indicate that HIV-1 virions and single viral antigens can enter a wide variety of cells, including epithelial. This review is focused on the effects of five viral proteins: envelope protein gp120, accessory protein negative factor Nef, matrix protein p17, transactivator of transcription Tat and reverse transcriptase RT. Gp120, Nef, p17, Tat, and RT cause oxidative stress, can be released from HIV-1-infected cells and are oncogenic. All five are in a position to affect "innocent" bystander cells, specifically, to cause the propagation of (pre)existing malignant and malignant transformation of normal epithelial cells, giving grounds to the direct carcinogenic effects of HIV-1.
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Affiliation(s)
- Maria Isaguliants
- Gamaleya Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (E.B.); (D.A.)
- M.P. Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 108819 Moscow, Russia;
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 17177 Stockholm, Sweden;
- Department of Research, Riga Stradins University, LV-1007 Riga, Latvia
| | - Ekaterina Bayurova
- Gamaleya Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (E.B.); (D.A.)
- M.P. Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 108819 Moscow, Russia;
| | - Darya Avdoshina
- Gamaleya Research Center for Epidemiology and Microbiology, 123098 Moscow, Russia; (E.B.); (D.A.)
- M.P. Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 108819 Moscow, Russia;
| | - Alla Kondrashova
- M.P. Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products of Russian Academy of Sciences, 108819 Moscow, Russia;
| | - Francesca Chiodi
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet, 17177 Stockholm, Sweden;
| | - Joel M. Palefsky
- Department of Medicine, University of California, San Francisco, CA 94117, USA;
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Stier EA, Lensing SY, Darragh TM, Deshmukh AA, Einstein MH, Palefsky JM, Jay N, Berry-Lawhorn JM, Wilkin T, Wiley DJ, Barroso LF, Cranston RD, Levine R, Guiot HM, French AL, Citron D, Rezaei MK, Goldstone SE, Chiao E. Prevalence of and Risk Factors for Anal High-grade Squamous Intraepithelial Lesions in Women Living with Human Immunodeficiency Virus. Clin Infect Dis 2021; 70:1701-1707. [PMID: 31292602 DOI: 10.1093/cid/ciz408] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/30/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Women living with human immunodeficiency virus (WLHIV) have disproportionately high rates of squamous cell carcinoma of the anus compared with the general population of women. Anal high-grade squamous intraepithelial lesions (HSILs) precede anal cancer, and accurate studies of HSIL prevalence among WLHIV in the United States are lacking. METHODS The AIDS Malignancy Consortium 084 study was a multicenter national trial to evaluate the prevalence of and risk factors for anal HSIL in a US cohort. Eligible participants were WLHIV aged ≥18 years with no history of anal HSIL. Study participants had an examination including collection of cervical/vaginal and anal specimens, followed by high-resolution anoscopy with biopsy. RESULTS We enrolled 256 women with evaluable anal pathology. The mean age was 49.4 years, 64% women were non-Hispanic black, 67% were former or current smokers, and 56% reported ever having anal sex with a man. The median CD4 T-cell count was 664 cells/μL. The prevalence of anal histologic HSIL (hHSIL) was 27% (95% confidence interval [CI], 22%-33%). There was a strong concordance (240/254) between local and consensus pathologists for hHSIL vs less than hHSIL (κ = 0.86 [95% CI, .79-.93]). Current CD4 count of ≤200 cells/μL was the strongest predictor of consensus anal hHSIL diagnosis (adjusted odds ratio [aOR], 10.34 [95% CI, 3.47-30.87]). History of anoreceptive intercourse was also associated with hHSIL (aOR, 2.44 [95% CI, 1.22-4.76]). CONCLUSIONS The prevalence of anal hHSIL in WLHIV in the United States was 27% in this study where all participants received high-resolution anoscopy and biopsy.
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Affiliation(s)
- Elizabeth A Stier
- Obstetrics and Gynecology, Boston University School of Medicine, Massachusetts
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock
| | - Teresa M Darragh
- Department of Pathology, Mount Zion Medical Center, University of California, San Francisco (UCSF)
| | - Ashish A Deshmukh
- Department of Management Policy and Community Health, School of Public Health, University of Texas Health Science Center at Houston
| | - Mark H Einstein
- Department of Obstetrics/Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark
| | | | - Naomi Jay
- Anal Neoplasia Clinic, Research, and Education Center, San Francisco, California
| | - J Michael Berry-Lawhorn
- Anal Neoplasia Clinic, Research, and Education Center, San Francisco, California.,Division of Hematology Oncology, UCSF
| | - Timothy Wilkin
- Clinical Trials Unit, Department of Medicine, Cornell University, New York, New York
| | | | - Luis F Barroso
- Department of Internal Medicine, Infectious Diseases, Wake Forest University Health Sciences, Winston-Salem, North Carolina
| | - Ross D Cranston
- University of Vic, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Rebecca Levine
- Department of Surgery, Montefiore Medical Center, Bronx, New York
| | - Humberto M Guiot
- Department of Medicine and Department of Microbiology and Medical Zoology, University of Puerto Rico School of Medicine, San Juan
| | - Audrey L French
- Division of Infectious Diseases, CORE Center/Stroger Hospital of Cook County, Chicago, Illinois
| | - Deborah Citron
- Department of Pathology, Baylor College of Medicine, Houston, Texas
| | - M Katayoon Rezaei
- Department of Pathology, George Washington University, Washington, District of Columbia
| | | | - Elizabeth Chiao
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine.,Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Nowak RG, Ravel J, Bentzen SM, Schumaker LM, Ambulos NP, Ndembi N, Dauda W, Mitchell A, Mathias TJ, Crowell TA, Baral SD, Blattner WA, Charurat ME, Palefsky JM, Cullen KJ. High-Risk Human Papillomavirus Persistence and Anal Microbiota Among Nigerian Men Who Have Sex With Men Living With or At Risk for HIV. JCO Glob Oncol 2020. [DOI: 10.1200/go.20.22000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Noninvasive therapies, such as probiotics that promote local immunity and reduce persistence of high-risk human papillomavirus (HR-HPV), would circumvent challenges in implementing anal cancer screening where same-sex behavior is stigmatized and criminalized. We describe the persistence of HR-HPV and its relationship with the anal microbiota among Nigerian men who have sex with men (MSM). METHODS Anal swabs from HIV-uninfected and -infected MSM who were enrolled in the TRUST/RV368 cohort were HPV genotyped at enrollment and at 3 and 12 months. Participants who presented with the same type(s) of HR-HPV across all visits were categorized as having persistent infections. The anal microbiota composition at baseline of HR-HPV–positive individuals was evaluated. Unsupervised K-means clustering of the 15 most abundant bacterial taxa identified 2 microbial clusters (MC-1 and MC-2). Unadjusted associations of 12-month HR-HPV persistence was evaluated by MC membership and HIV status using χ2 tests and logistic regression. RESULTS One hundred nine HIV-infected and 41 HIV-uninfected participants—contributing 284 baseline HR-HPV infections—were observed for a median of 12 months (interquartile range, 11.5-12.6 months). MC-1 was dominated by Prevotella and MC-2 consisted of a diverse set of anaerobic bacteria ( Finegoldia, Corynebacterium, Peptoniphilus, and Anerococcus). At 12 months, 45% (67 of 150) of MSM had 86 persistent HR-HPV and 55% (83 of 150) cleared all baseline HR-HPV. HPV16 (21%), HPV45 (13%), and HPV51 (12%) were the most persistent. Persistence of any HR-HPV was nonsignificantly higher in MC-1 (odds ratio [OR], 1.6; 95% CI, 0.8 to 3.1). Persistent HPV16 was more abundant in MC-2 versus MC-1 (OR, 3.9; 95% CI, 1.2 to 12.0), whereas HPV45 and HPV51 were similarly distributed across both MCs. Compared with HIV-uninfected, persistence (OR, 1.6; 95% CI, 0.8 to 3.3) and MC-2 membership (OR, 1.3; 95% CI, 0.8 to 2.0) were nonsignificantly higher among HIV-infected participants. CONCLUSION Anal HPV16 has the highest annual persistence and is associated with a low Prevotella anal microbiota, a potentially modifiable cofactor.
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Affiliation(s)
- Rebecca G. Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD
| | - Søren M. Bentzen
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Lisa M. Schumaker
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Nicholas P. Ambulos
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | | | - Wuese Dauda
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Andrew Mitchell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - Trevor J. Mathias
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
| | - Trevor A. Crowell
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | | | - William A. Blattner
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - Manhattan E. Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD
| | - Joel M. Palefsky
- Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Kevin J. Cullen
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD
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Nowak RG, Ndembi N, Dauda W, Jibrin P, Bentzen SM, Nnaji CH, Olaomi O, Darragh TM, Madukwe J, Crowell TA, Baral SD, Blattner WA, Charurat ME, Palefsky JM, Cullen KJ. Implementation of and Early Outcomes From Anal Cancer Screening at a Community-Engaged Health Care Facility Providing Care to Nigerian Men Who Have Sex With Men. J Glob Oncol 2020; 5:1-11. [PMID: 31322994 PMCID: PMC6690628 DOI: 10.1200/jgo.19.00102] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Anal cancer risk is substantially higher among HIV-infected men who have sex with men (MSM) as compared with other reproductive-age adults, but screening is rare across sub-Saharan Africa. We report the use of high-resolution anoscopy (HRA) as a first-line screening tool and the resulting early outcomes among MSM in Abuja, Nigeria. METHODS From August 2016 to August 2017, 424 MSM enrolled in an anal cancer screening substudy of TRUST/RV368, a combined HIV prevention and treatment cohort. HRA-directed biopsies were diagnosed by histology, and ablative treatment was offered for high-grade squamous intraepithelial lesions (HSIL). HRA proficiency was assessed by evaluating the detection of squamous intraepithelial lesions (SIL) over time and the proportion biopsied. Prevalence estimates of low-grade squamous intraepithelial lesions and HSIL with 95% CIs were calculated. Multinomial logistic regression was used to identify those at the highest risk of SIL. RESULTS Median age was 25 years (interquartile range [IQR], 22-29), median time since sexual debut was 8 years (IQR, 4-12), and 59% (95% CI, 54.2% to 63.6%) were HIV infected. Rate of detection of any SIL stabilized after 200 screenings, and less than 20% had two or more biopsies. Preliminary prevalence estimates of low-grade squamous intraepithelial lesions and HSIL were 50.0% (95% CI, 44.7% to 55.3%) and 6.3% (95% CI, 4.0% to 9.3%). HIV infection, at least 8 years since anal coital debut, concurrency, and external warts were independently statistically associated with SIL. CONCLUSION Proficiency with HRA increased with experience over time. However, HSIL detection rates were low, potentially affected by obstructed views from internal warts and low biopsy rates, highlighting the need for ongoing evaluation and mentoring to validate this finding. HRA is a feasible first-line screening tool at an MSM-friendly health care facility. Years since anal coital debut and external warts could prioritize screening.
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Affiliation(s)
| | | | - Wuese Dauda
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | | | | | | | | | | | | | - Trevor A Crowell
- Walter Reed Army Institute of Research, Silver Spring, MD.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD
| | - Stefan D Baral
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | | | - Kevin J Cullen
- University of Maryland School of Medicine, Baltimore, MD
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Nowak RG, Schumaker LM, Ambulos NP, Ndembi N, Dauda W, Nnaji CH, Mitchell A, Mathias TJ, Jibrin P, Darragh TM, Olaomi O, Crowell TA, Baral SD, Charurat ME, Bentzen SM, Palefsky JM, Cullen KJ. Multiple HPV infections among men who have sex with men engaged in anal cancer screening in Abuja, Nigeria. Papillomavirus Res 2020; 10:100200. [PMID: 32492573 PMCID: PMC7287273 DOI: 10.1016/j.pvr.2020.100200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 02/08/2023]
Abstract
Background Anal precancers and cancers can be detected during screening with high-resolution anoscopy (HRA). The sensitivity of HRA depends on the burden and duration of human papillomavirus (HPV) among those screened as well as anoscopist proficiency, which is highly correlated with prior screening experience. Our objective was to compare the identification and type of HPV and the likelihood of HRA-detected precancer for men who have sex with men (MSM) undergoing their first HRA-screening in Nigeria. Methods MSM were recruited from an HIV test-and-treat cohort, TRUST/RV368, into a new anal cancer screening program. Anal swabs obtained during screening underwent Ion Torrent next-generation sequencing using barcoded HPV PCR broad-spectrum primers 5+/6+ to detect up to 161 HPVs. All high-risk (HR) HPVs and the most abundant low-risk (LR)-HPVs were evaluated as type-specific infections with some categorized as belonging to a multiple infection. HRA screening results included benign, low-grade squamous intraepithelial lesions (LSIL), or HSIL as detected by cytology or histology. Multivariable logistic regression was used to assess the association of HPV and other cofactors with any SIL. Results Among 342 MSM, 60% were HIV-infected, 89% were under 35 years of age, and 51% had 8 or more years since anal coital debut. Of those with SIL, 89% had LSIL and only 11% had HSIL. Prevalence of any HPV and high-risk (HR)-HPV was 92% and 74%, respectively. The most prevalent genotypes in rank order were HPV6 (31%), HPV16 (23%), HPV42 (20%), HPV11 (18%), HPV45 (18%), and HPV51 (17%). For multiple HR-HPVs, 31% had a single HR-HPV, 32% had 2-3, and 10% had 4 or more. Low-risk HPVs, type 6 and/or 11, were common (42%) and were significantly associated with SIL (adjusted odds ratio [aOR]:1.8, 95% confidence interval [CI]: 1.1–3.1) together with perianal warts (aOR:6.7, 95% CI: 3.3–13.5). In contrast, HR-HPV and multiple HR-HPVs were not significantly associated with SIL (all p > 0.05). Conclusions Detection of HSIL was low. Although HR-HPV was abundant, HSIL development also depends on the duration of HR-HPV infections and the anoscopist's level of experience. As our cohort ages and the anoscopist becomes more skilled, detection of HSIL will likely improve.
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Affiliation(s)
- Rebecca G Nowak
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Lisa M Schumaker
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas P Ambulos
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Wuese Dauda
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | | | - Andrew Mitchell
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Trevor J Mathias
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Teresa M Darragh
- Department of Pathology, University of California, San Francisco, CA, USA
| | | | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA; Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Stefan D Baral
- Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Manhattan E Charurat
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Søren M Bentzen
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Kevin J Cullen
- University of Maryland Marlene and Stewart Greenebaum Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Goldstone SE, Lensing SY, Stier EA, Darragh T, Lee JY, van Zante A, Jay N, Berry-Lawhorn JM, Cranston RD, Mitsuyasu R, Aboulafia D, Palefsky JM, Wilkin T. A Randomized Clinical Trial of Infrared Coagulation Ablation Versus Active Monitoring of Intra-anal High-grade Dysplasia in Adults With Human Immunodeficiency Virus Infection: An AIDS Malignancy Consortium Trial. Clin Infect Dis 2020; 68:1204-1212. [PMID: 30060087 DOI: 10.1093/cid/ciy615] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 07/26/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Anal high-grade squamous intraepithelial lesions (HSILs) ablation may reduce the incidence of invasive cancer, but few data exist on treatment efficacy and natural regression without treatment. METHODS An open-label, randomized, multisite clinical trial of human immunodeficiency virus (HIV)-infected adults aged ≥27 years with 1-3 biopsy-proven anal HSILs (index HSILs) without prior history of HSIL treatment with infrared coagulation (IRC). Participants were randomized 1:1 to HSIL ablation with IRC (treatment) or no treatment (active monitoring [AM]). Participants were followed every 3 months with high-resolution anoscopy. Treatment participants underwent anal biopsies of suspected new or recurrent HSILs. The AM participants underwent biopsies only at month 12. The primary end point was complete clearance of index HSIL at month 12. RESULTS We randomized 120 participants. Complete index HSIL clearance occurred more frequently in the treatment group than in the AM (62% vs 30%; risk difference, 32%; 95% confidence interval [CI], 13%-48%; P < .001). Complete or partial clearance (clearance of ≥1 index HSIL) occurred more commonly in the treatment group (82% vs 47%; risk difference, 35%; 95% CI, 16%-50%; P < .001). Having a single index lesion, compared with having 2-3 lesions, was significantly associated with complete clearance (relative risk, 1.96; 95% CI, 1.22-3.10). The most common adverse events related to treatment were mild or moderate anal pain and bleeding. No serious adverse events were deemed related to treatment or study participation. CONCLUSION IRC ablation of anal HSILs results in more clearance of HSILs than observation alone.
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Affiliation(s)
- Stephen E Goldstone
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shelly Y Lensing
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Elizabeth A Stier
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
| | - Teresa Darragh
- Department of Pathology, University of California, San Francisco
| | - Jeannette Y Lee
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Naomi Jay
- Department of Medicine, University of California, San Francisco
| | | | - Ross D Cranston
- Fundació Lluita contra la Sida, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Ronald Mitsuyasu
- David Geffen School of Medicine at University of California, Los Angeles (UCLA), UCLA Center for Clinical AIDS Research and Education
| | - David Aboulafia
- Division of Hematology and Oncology, Virginia Mason Medical Center and the University of Washington, Seattle, WA
| | - Joel M Palefsky
- Department of Pathology, University of California, San Francisco
| | - Timothy Wilkin
- Division of Infectious Diseases, Weill Cornell Medicine, New York, New York
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Kelly H, Chikandiwa A, Alemany Vilches L, Palefsky JM, de Sanjose S, Mayaud P. Association of antiretroviral therapy with anal high-risk human papillomavirus, anal intraepithelial neoplasia, and anal cancer in people living with HIV: a systematic review and meta-analysis. Lancet HIV 2020; 7:e262-e278. [PMID: 32109408 DOI: 10.1016/s2352-3018(19)30434-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effect of antiretroviral therapy (ART) on the natural history of anal high-risk HPV and anal lesion progression is not well established. We reviewed the association of ART and other HIV-related factors on anal HPV infection, anal intraepithelial neoplasia (AIN), and anal cancer among people living with HIV. METHODS For this systematic review and meta-analysis, we searched MEDLINE and EMBASE for studies published between Jan 1, 1996, and Oct 30, 2019, that reported the association of HIV-related exposures (ART or highly active ART [HAART], HIV-RNA plasma viral load [PVL], and nadir or current CD4 cell count) with outcomes of anal high-risk HPV prevalence, incidence, and persistence; prevalence, incidence, progression, or regression of anal histological and cytological abnormalities; and anal cancer incidence. Effect estimates were extracted whenever available; otherwise, they were calculated from raw data. We assessed the risk of bias of included studies using the Newcastle-Ottawa scale, and random-effects meta-analyses were done to examine heterogeneity using the I2 statistic. This study is registered on the PROSPERO database, CRD42018007271. FINDINGS We identified 6777 studies, of which 5377 were excluded before full-text review. 122 studies providing estimates for 130 distinct populations matched the inclusion criteria. The populations comprised 417 006 people living with HIV (women, men who have sex with men, and men who have sex with women). 41 (32%) population estimates were not stratified by sex or sexual orientation. People living with HIV receiving ART had 35% lower high-risk HPV prevalence than ART-naive people (crude odds ratio [OR] 0·65, 95% CI 0·54-0·79; I2 12·1%, p=0·31) in 18 studies, and prolonged ART use was associated with a 10% reduction per year in high-risk HPV prevalence in two studies (adjusted OR 0·90, 0·85-0·95; I2 0%, p=0·88). People living with HIV with undetectable PVL had lower HSIL-AIN2+ prevalence than those with detectable PVL (crude OR 0·84, 0·72-0·98; I2 0%, p=0·80) in 16 studies, particularly if sustained for more than 1 year (crude OR 0·62, 0·47-0·81; I2 0%, p=0·51). ART was not associated with anal cancer incidence when adjusted for years living with HIV in three studies (adjusted hazard ratio [HR] 1·11, 95% CI 0·68-1·80; I2 0%, p=0·57), but ART users with sustained undetectable HIV PVL had 44% lower risk of anal cancer than those without (adjusted HR 0·56, 0·44-0·70; I2 0%, p=0·94) and for each increase in nadir CD4 cell counts of 100 cells per μL, there was a 40% decrease in anal cancer incidence (crude HR 0·60, 0·46-0·78; I2 21·7%, p=0·26). INTERPRETATION Effective ART use and early initiation at high nadir CD4 counts might reduce anal high-risk HPV infection and anal cancer risk. Although most studies were cross-sectional in design and few adjusted for potential confounders, this analysis provides comprehensive estimates of the effect of ART and HIV-related factors on the natural history of anal HPV-related disease in people living with HIV. FUNDING EU Marie Skłodowska-Curie Actions programme.
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Affiliation(s)
- Helen Kelly
- Cancer Epidemiology Research Program, Catalan Institute of Oncology, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.
| | - Admire Chikandiwa
- Wits Reproductive Health and HIV Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laia Alemany Vilches
- Cancer Epidemiology Research Program, Catalan Institute of Oncology, Institut d'Investigació Biomèdica de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Joel M Palefsky
- Department of Infectious Diseases, School of Medicine, University of California, San Francisco, CA, USA
| | - Silvia de Sanjose
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Barcelona, Spain; PATH, Seattle, WA, USA
| | - Philippe Mayaud
- Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
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44
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Nowak RG, Nnaji CH, Dauda W, Mitchell A, Olaomi O, Jibrin P, Crowell TA, Baral SD, Ndembi N, Charurat ME, Palefsky JM, Bentzen SM, Cullen KJ. Satisfaction with high-resolution anoscopy for anal cancer screening among men who have sex with men: a cross-sectional survey in Abuja, Nigeria. BMC Cancer 2020; 20:98. [PMID: 32024521 PMCID: PMC7003335 DOI: 10.1186/s12885-020-6567-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 01/21/2020] [Indexed: 12/22/2022] Open
Abstract
Background Men who have sex with men (MSM) living with HIV are at increased risk for anal cancer. We evaluated satisfaction with first-time anal cancer screening using high resolution anoscopy (HRA) as a cross sectional survey among men who have sex with men (MSM) attending a community-engaged clinic in Abuja, Nigeria. Methods Between March and August 2017, 342 MSM underwent screening and 307 (89%) completed a satisfaction survey that evaluated 8 domains related to expectations, convenience, staff interpersonal skills, physical surroundings, technical competence, pain/discomfort, general satisfaction, and intention to re-screen if symptomatic. The 22-item questionnaire used 5-point Likert scales ranging from 1 (strongly disagree) to 5 (strongly agree). For each domain, responses to specific items were averaged, aggregated, and converted to a 100-point scaled score (SS) with 25 and 75 corresponding to disagree and agree, respectively. Results Median age was 24 years (interquartile range [IQR]: 22–28), median years since anal coital debut was 7 (IQR: 4–12), and 58% (95% confidence interval [CI]: 52–64%) were living with HIV. Despite respondents reporting pre-procedure anxiety (SS:73), most were comfortable with the setting and procedure and reported overall satisfaction (SS:74–76). Willingness to undergo future screening had the lowest score (SS:69) within the general satisfaction domain. The lowest scoring domains were pain/discomfort (SS:57) and agreement to re-screen if symptomatic (SS:59), which correlated with lower overall satisfaction (p < 0.001). Domain responses did not differ by HIV infection after adjusting for multiple comparisons (p > 0.006) or number of anal biopsies (all p > 0.05). Conclusions Overall, HRA was satisfactory for those naïve to screening but moving forward necessitates monitoring levels of discomfort with pain scales and normalizing dialogue around clinical symptoms of anal cancer and overall anal health to sustain future screening.
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Affiliation(s)
- Rebecca G Nowak
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, 725 W. Lombard Street, Baltimore, MD, 21201, USA. .,Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA. .,University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | | | - Wuese Dauda
- Institute of Human Virology Nigeria, Abuja, Nigeria
| | - Andrew Mitchell
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, 725 W. Lombard Street, Baltimore, MD, 21201, USA
| | | | | | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Stefan D Baral
- Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Manhattan E Charurat
- Division of Epidemiology and Prevention, Institute of Human Virology, University of Maryland School of Medicine, 725 W. Lombard Street, Baltimore, MD, 21201, USA
| | - Joel M Palefsky
- Department of Medicine, University of California, San Francisco, CA, USA
| | - Søren M Bentzen
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.,University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kevin J Cullen
- University of Maryland Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
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45
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Walhart T, Isaacson-Wechsler E, Ang KH, Arkin M, Tugizov S, Palefsky JM. A Cell-Based Renilla Luminescence Reporter Plasmid Assay for High-Throughput Screening to Identify Novel FDA-Approved Drug Inhibitors of HPV-16 Infection. SLAS Discov 2020; 25:79-86. [PMID: 31361520 PMCID: PMC6925341 DOI: 10.1177/2472555219860771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Like cervical cancer, anal cancer is caused by human papillomavirus (HPV). HPV is the most common sexually transmitted agent and is found in the anal canal of almost all HIV-positive men who have sex with men (MSM). Rates of HPV anal cancer are disproportionately higher in this population. Although the nanovalent HPV vaccine is efficacious in protecting against oncogenic HPV types, a substantial proportion of MSM remains unvaccinated and anal HPV infection continues to be an important public health burden. Therefore, it is important to identify strategies to prevent HPV infection. We report on two promising and interlinked strategies: (1) the development of a cell-based Renilla luminescence reporter assay using HPV-16 pseudovirions that encapsidate SV40-driven Renilla luminescence reporter expression plasmid and (2) use of this assay for high-throughput screening (HTS) of FDA- and internationally approved drugs to identify those that could be repurposed to prevent HPV infection. We conducted a screen of 1906 drugs. The assay was valid with a Z' of 0.67 ± 0.04, percent coefficient of variance of 10.0, and signal-to-background noise window of 424.0 ± 8.0. Five drugs were chosen for further analyses based on selection parameters of ≥77.0% infection of HPV-16 pseudovirion-driven Renilla expression with <20.0% cytotoxicity. Of these, the antifungal pentamidine and a gamma-amino butyric acid receptor agonist securinine exhibited ≥90.0% infection with <10.0% cytotoxicity. This luminescent cell-based reporter expression plasmid assay for HTS is a valid method to identify FDA- and internationally approved drugs with the potential to be repurposed into prevention modalities for HPV infection.
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Affiliation(s)
- Tara Walhart
- Department of Community Health Systems, School of Nursing, University of California, San Francisco, CA, USA
- Department of Infectious Disease, Palefsky Laboratory, School of Medicine, University of California, San Francisco, CA, USA
| | - Erin Isaacson-Wechsler
- Department of Infectious Disease, Palefsky Laboratory, School of Medicine, University of California, San Francisco, CA, USA
| | - Kean-Hooi Ang
- Department of Pharmaceutical Chemistry, Small Molecule Discovery Center, University of California, San Francisco, CA, USA
| | - Michelle Arkin
- Department of Pharmaceutical Chemistry, Small Molecule Discovery Center, University of California, San Francisco, CA, USA
| | - Sharof Tugizov
- Department of Infectious Disease, Palefsky Laboratory, School of Medicine, University of California, San Francisco, CA, USA
| | - Joel M. Palefsky
- Department of Infectious Disease, Palefsky Laboratory, School of Medicine, University of California, San Francisco, CA, USA
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46
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Vonsky M, Shabaeva M, Runov A, Lebedeva N, Chowdhury S, Palefsky JM, Isaguliants M. Carcinogenesis Associated with Human Papillomavirus Infection. Mechanisms and Potential for Immunotherapy. Biochemistry (Mosc) 2019; 84:782-799. [PMID: 31509729 DOI: 10.1134/s0006297919070095] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Human papillomavirus (HPV) infection is responsible for approximately 5% of all cancers and is associated with 30% of all pathogen-related cancers. Cervical cancer is the third most common cancer in women worldwide; about 70% of cervical cancer cases are caused by the high-risk HPVs (HR HPVs) of genotypes 16 and 18. HPV infection occurs mainly through sexual contact; however, viral transmission via horizontal and vertical pathways is also possible. After HPV infection of basal keratinocytes or ecto-endocervical transition zone cells, viral DNA persists in the episomal form. In most cases, infected cells are eliminated by the immune system. Occasionally, elimination fails, and HPV infection becomes chronic. Replication of HPVs in dividing epithelial cells is accompanied by increased expression of the E6 and E7 oncoproteins. These oncoproteins are responsible for genomic instability, disruption of the cell cycle, cell proliferation, immortalization, and malignant transformation of HPV-infected cells. Besides, E6 and E7 oncoproteins induce immunosuppression, preventing the detection of HPV-infected and transformed cells by the immune system. HPV integration into the genome of the host cell leads to the upregulation of E6 and E7 expression and contributes to HPV-associated malignization. Prophylactic HPV vaccines can prevent over 80% of HPV-associated anogenital cancers. The vaccine elicits immune response that prevents initial infection with a given HPV type but does not eliminate persistent virus once infection has occurred and does not prevent development of the HPV-associated neoplasias, which necessitates the development of therapeutic vaccines to treat chronic HPV infections and HPV-associated malignancies.
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Affiliation(s)
- M Vonsky
- Institute of Cytology, Russian Academy of Sciences, St. Petersburg, 194064, Russia. .,Almazov National Medical Research Center, St. Petersburg, 197341, Russia
| | - M Shabaeva
- Pavlov First St. Petersburg State Medical University, St. Petersburg, 197022, Russia.
| | - A Runov
- Institute of Cytology, Russian Academy of Sciences, St. Petersburg, 194064, Russia.,Almazov National Medical Research Center, St. Petersburg, 197341, Russia.,Gamaleya Federal Research Center for Epidemiology and Microbiology, Moscow, 123098, Russia
| | - N Lebedeva
- Gamaleya Federal Research Center for Epidemiology and Microbiology, Moscow, 123098, Russia. .,Moscow Regional Center of AIDS and Infectious Diseases Prevention and Treatment, Moscow, 129110, Russia
| | - S Chowdhury
- University of California, San Francisco School of Medicine, San Francisco, CA 94143, USA
| | - J M Palefsky
- University of California, San Francisco School of Medicine, San Francisco, CA 94143, USA.
| | - M Isaguliants
- Gamaleya Federal Research Center for Epidemiology and Microbiology, Moscow, 123098, Russia. .,Chumakov Federal Scientific Center for Research and Development of Immune-and-Biological Products, Russian Academy of Sciences, Moscow, 108819, Russia.,Karolinska Institutet, Department of Microbiology, Tumor and Cell Biology, Stockholm, SE-171 77, Sweden.,Riga Stradins University, Department of Pathology, Riga, LV-1007, Latvia
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47
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Manyere NR, Dube Mandishora RS, Magwali T, Mtisi F, Mataruka K, Mtede B, Palefsky JM, Chirenje ZM. Human papillomavirus genotype distribution in genital warts among women in Harare-Zimbabwe. J OBSTET GYNAECOL 2019; 40:830-836. [PMID: 31790323 DOI: 10.1080/01443615.2019.1673710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study aimed to determine the prevalence of HPV genotypes in genital warts among women in Harare, Zimbabwe. Women aged 18-45 years attending gynaecology and genitourinary clinics with a clinical diagnosis of genital-warts were recruited. HPV-DNA was extracted from tissue biopsies. HPV-DNA testing and typing was done by Southern Dot Blot Hybridisation. A hundred samples from 100 women were analysed. Median age of participants was 30.3 years (range 18-45 years). Seventy-eight percent of participants were HIV infected. HPV prevalence was 98%. Low risk genotypes predominated at 86% prevalence. The most prevalent genotypes were 11 (47%), 6 (42%) and 16 (14%). This is the first study on HPV genotype distribution among women with genital warts in Zimbabwe. The high prevalence of HR-HPV 16 in clinically benign lesions shows that warts should have histological analysis to exclude pre-malignancy and malignancy.Impact statementWhat is already known on this subject? Genital warts (GWs), also known as condylomata acuminata (EAC), are a clinical manifestation of persistent infection with 'low risk' or non-oncogenic HPV genotypes. HPV 6 and 11 are examples of low risk genotypes, and both are associated with 90% of GWs. Data on HPV genotypes causing genital warts in the population under study are scarce.What do the results of this study add? A high prevalence (98%) of HPV DNA in genital warts, confirms that the biopsied lesions were HPV related. Over and above the high prevalence of low risk HPV 11 (47%) and HPV 6 (42%), the women had 14% prevalence of HPV 16, an oncogenic genotype, in genital warts. Seventy-eight percent of the participants were HIV infected. The HIV infected women had a 33.3% prevalence of HR-HPV as compared to the 15.8% prevalence in the HIV uninfected women.What are the implications of these findings for clinical practice and/or further research? The population under study will benefit more if an HPV vaccine that includes anti-HPV 6 and 11 is used. The high prevalence of the HR-HPV in apparently benign lesions shows that warts should have histological analysis to exclude vulvar cancer and vulvar intraepithelial neoplasia. All women presenting with genital warts should be offered an HIV test.
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Affiliation(s)
- N R Manyere
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - R S Dube Mandishora
- Department of Medical Microbiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - T Magwali
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - F Mtisi
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre (UZCHS-CTRC), University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - K Mataruka
- University of Zimbabwe College of Health Sciences Clinical Trials Research Centre (UZCHS-CTRC), University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - B Mtede
- Program Quality Improvement, Elizabeth Glaser Pediatric AIDS Foundation, Harare, Zimbabwe
| | - J M Palefsky
- Department of Medicine, UCSF School of Medicine, Med Sci San Francisco, CA, USA
| | - Z M Chirenje
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.,University of Zimbabwe College of Health Sciences Clinical Trials Research Centre (UZCHS-CTRC), University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
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48
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Castle PE, Burk RD, Massad LS, Eltoum IE, Hall CB, Hessol NA, Anastos K, Xie X, Minkoff H, Xue X, D'Souza G, Flowers L, Colie C, Rahangdale L, Fischl MA, Palefsky JM, Strickler HD. Epidemiological evidence that common HPV types may be common because of their ability to evade immune surveillance: Results from the Women's Interagency HIV study. Int J Cancer 2019; 146:3320-3328. [PMID: 31577842 DOI: 10.1002/ijc.32693] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/23/2019] [Accepted: 08/30/2019] [Indexed: 01/25/2023]
Abstract
Infection by human papillomavirus (HPV) type 16, the most oncogenic HPV type, was found to be the least affected by HIV-status and CD4 count of any of the approximately 13 oncogenic HPV types. This relative independence from host immune status has been interpreted as evidence that HPV16 may have an innate ability to avoid the effects of immunosurveillance. However, the impact of immune status on other individual HPV types has not been carefully assessed. We studied type-specific HPV infection in a cohort of 2,470 HIV-positive (HIV[+]) and 895 HIV-negative (HIV[-]) women. Semi-annually collected cervicovaginal lavages were tested for >40 HPV types. HPV type-specific prevalence ratios (PRs), incidence and clearance hazard ratios (HRs), were calculated by contrasting HPV types detected in HIV[+] women with CD4 < 200 to HIV[-] women. HPV71 and HPV16 prevalence had the weakest associations with HIV-status/CD4 count of any HPV, according to PRs. No correlations between PRs and HPV phylogeny or oncogenicity were observed. Instead, higher HPV type-specific prevalence in HIV[-] women correlated with lower PRs (ρ = -0.59; p = 0.0001). An alternative (quadratic model) statistical approach (PHIV+ = a*PHIV- + b*PHIV- 2 ; R2 = 0.894) found similar associations (p = 0.0005). In summary, the most prevalent HPV types in HIV[-] women were the types most independent from host immune status. These results suggest that common HPV types in HIV[-] women may have a greater ability to avoid immune surveillance than other types, which may help explain why they are common.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Xiaonan Xue
- Albert Einstein College of Medicine, Bronx, NY
| | | | - Lisa Flowers
- Emory University School of Medicine, Atlanta, GA
| | | | - Lisa Rahangdale
- University of North Carolina School of Medicine, Chapel Hill, NC
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49
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Faber MT, Frederiksen K, Palefsky JM, Kjaer SK. Risk of Anal Cancer Following Benign Anal Disease and Anal Cancer Precursor Lesions: A Danish Nationwide Cohort Study. Cancer Epidemiol Biomarkers Prev 2019; 29:185-192. [PMID: 31597665 DOI: 10.1158/1055-9965.epi-19-0601] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/16/2019] [Accepted: 09/26/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Human papillomavirus (HPV) is associated with the majority of anal high-grade intraepithelial neoplasia (AIN) and anal cancers. Little is known about the risk of anal cancer following a diagnosis of benign anal disease and AIN. METHODS Using data from nationwide, population-based Danish registries, a cohort of 126,174 individuals with either non-neoplastic anal disease or AIN 1 to 3 during 1970 to 2016 was followed until first occasion of anal cancer. Information on HIV status was obtained from the Danish HIV Cohort Study. The absolute risk of anal cancer was estimated using the Aalen-Johansen estimator taking into account censoring at emigration and end of follow-up and competing risk at time of death. Standardized incidence ratios (SIR) for anal cancer among individuals with non-neoplastic anal disease, including inflammatory lesions, hemorrhoids, and polyps, were estimated in Poisson models. Sex-, age-, and calendar period-specific national population rates were estimated using the Danish National Pathology Registry. RESULTS Anal cancer risk increased with increasing severity of lesions, reaching 4% 5 years after diagnosis of AIN3. Even among those with non-neoplastic anal lesions, particularly inflammatory lesions, anal cancer risk was significantly higher than expected from Danish national anal cancer rates (SIR = 2.8; 95% confidence intervals, 2.3-3.2). The absolute 5-year risk of anal cancer following AIN3 was considerably higher among HIV-positive (14.1%) than HIV-negative (3.2%) individuals. CONCLUSIONS Anal cancer risk increases with increasing severity of lesions and is especially high among HIV-positive individuals. IMPACT Vaccination against HPV is important in the prevention of both high-grade AIN and anal cancer.
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Affiliation(s)
- Mette T Faber
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Copenhagen, Denmark
| | - Kirsten Frederiksen
- Danish Cancer Society Research Center, Statistics and Pharmacoepidemiology, Copenhagen, Denmark
| | - Joel M Palefsky
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Susanne K Kjaer
- Danish Cancer Society Research Center, Virus, Lifestyle and Genes, Copenhagen, Denmark. .,Department of Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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50
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Kojic EM, Conley L, Bush T, Cu-Uvin S, Unger ER, Henry K, Hammer J, Escota G, Darragh TM, Palefsky JM, Brooks JT, Patel P. Prevalence and Incidence of Anal and Cervical High-Risk Human Papillomavirus (HPV) Types Covered by Current HPV Vaccines Among HIV-Infected Women in the SUN Study. J Infect Dis 2019; 217:1544-1552. [PMID: 29452366 DOI: 10.1093/infdis/jiy087] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Background Nonavalent (9v) human papilloma virus vaccine targets high-risk human papillomavirus (HR-HPV) types 16, 18, 31, 33, 45, 52, 58, and low-risk 6, 11. We examined prevalence, incidence, and clearance of anal and cervical HR-HPV in HIV-infected women. Methods The SUN Study enrolled 167 US women in 2004-2006. Anal and cervical specimens were collected annually for cytology and identification of 37 HPV types: 14 HR included: 9v 16, 18, 31, 33, 45, 52, 58; non-9v 35, 39, 51, 56, 59, 66, 68. Results Baseline characteristics of 126 women included: median age 38 years; 57% non-Hispanic black; 67% HIV RNA < 400 copies/mL; 90% CD4 counts ≥200 cells/mm3. HPV prevalence at anus and cervix was 90% and 83%; for 9v HR-HPV types, 67% and 51%; non-9v HR-HPV, 54% and 29%, respectively. The 9v and non-9v HR-HPV incidence rates/100 person-years were similar (10.4 vs 9.5; 8.5 vs 8.3, respectively); 9v clearance rates were 42% and 61%; non-9v 46% and 59%, in anus and cervix, respectively. Conclusions Anal HR-HPV prevalence was higher than cervical, with lower clearance; incidence was similar. Although prevalence of non-9v HR-HPV was substantial, 9v HR-HPV types were generally more prevalent. These findings support use of nonavalent vaccine in HIV-infected women.
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Affiliation(s)
- Erna Milunka Kojic
- Division of Infectious Diseases, Mount Sinai St Luke's and West Hospitals, New York
| | - Lois Conley
- Divisions of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tim Bush
- Divisions of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Elizabeth R Unger
- Division of High-Consequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Keith Henry
- Hennepin County Medical Center, Minneapolis, Minnesota
| | - John Hammer
- Denver Infectious Disease Consultants, Rose Medical Center, Colorado
| | - Gerome Escota
- Washington University School of Medicine, St Louis, Missouri
| | | | | | - John T Brooks
- Divisions of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Pragna Patel
- Divisions of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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