Reproductive & Genital Health & Risk of Cervical Human Papillomavirus Infection: Results from the Ludwig-Mcgill Cohort Study

Background

There are inconsistencies in the literature on reproductive and genital health determinants of human papillomavirus (HPV) infection, the primary cause of cervical cancer. We examined these factors in the Ludwig-McGill Cohort Study, a longitudinal, repeated-measurements investigation on the natural history of HPV infection.

Methods

We analyzed a cohort subset of 1867 women with one complete year of follow-up. We calculated odds ratios (OR) and 95 % confidence intervals (CI) for reproductive and genital health characteristics from questionnaire and laboratory data in relation to 1-year period prevalence of HPV infection. Two outcomes were measured; the first based on phylogenetic grouping of HPV types based on tissue tropism and oncogenicity (Alphapapillomavirus Subgenus 1: species 1, 8, 10 and 13; Subgenus 2: species 5, 6, 7, 9, 11; Subgenus 3: species 3, 4 and 14) and the second based on transient or persistent HPV infections.

Results

Lifetime (Subgenus 3 OR = 2.00, CI: 1.23–3.24) and current (Subgenus 3 OR = 2.00, CI: 1.15–3.47) condom use and use of contraceptive injections (Subgenus 1 OR = 1.96, CI: 1.22–3.16, Subgenus 2 OR = 1.34, CI: 1.00–1.79) were associated with increased risk of HPV infection. Intrauterine device use was protective (Subgenus 1 OR = 0.48, CI: 0.30–0.75, Subgenus 2 OR = 0.78, CI: 0.62–0.98). These factors were not associated with persistence of HPV infection. Tampon use, previous gynecologic infections and cervical inflammation were associated with an overall increased risk of HPV infection.

Conclusions

Cervical HPV infection was associated with reproductive and genital health factors. Further studies are necessary to confirm the low to moderate associations observed.

Associations between reproductive health and vaginal hygiene factors and the 1-year period prevalence of HPV infection by phylogenetic group in the Ludwig-McGill cohort study

Variable	Subgenus 1a (n = 108)		Subgenus 2a (n = 495)		Subgenus 3a (n = 131)
	ORb	95 % CI	ORb	95 % CI	ORb	95 % CI
Reproductive Health Factors
Condom Use
Former vs. Never	1.28	0.79, 2.07	0.90	0.71, 1.15	2.00	1.23, 3.24
Current vs. Never	1.43	0.83, 2.48	1.09	0.82, 1.45	2.00	1.15, 3.47
Oral Contraceptives
< 6 years vs. Never	1.25	0.66, 1.38	0.98	0.71, 1.35	1.40	0.83, 2.37
6+ years vs. Never	1.23	0.60, 2.53	1.00	0.70, 1.43	0.62	0.32, 1.19
Intrauterine Device
Yes vs. No	0.48	0.30, 0.75	0.78	0.62, 0.98	0.73	0.49, 1.08
Tubal Sterilization
Yes vs. No	1.24	0.65, 1.36	0.84	0.59, 1.21	0.65	0.33, 1.30
Contraceptive Injection
Yes vs. No	1.96	1.22, 3.16	1.34	1.00, 1.79	1.34	0.83, 2.17
Natural Products
Yes vs. No	-	-	0.37	0.13, 1.05	0.74	0.17, 3.20
Vaginal Products
Yes vs. No	-	-	0.82	0.37, 1.81	0.32	0.04, 2.40
Genital Health and Hygiene Factors
Menstrual Cloth
Yes vs. No	0.54	0.32, 0.91	0.93	0.74, 1.18	1.02	0.68, 1.53
Hygienic Tampon
Yes vs. No	1.49	0.87, 2.54	1.33	0.98, 1.81	1.30	0.79, 2.14
Douching
Frequent vs. Infrequent	1.20	0.53, 2.69	1.29	0.83, 2.00	0.11	0.02, 0.81
Douching Products
Natural vs. None	0.96	0.60, 1.54	0.92	0.72, 1.17	0.90	0.57, 1.41
Medical vs. None	1.09	0.23, 5.15	0.97	0.46, 2.06	2.75	0.98, 7.73
Unknown vs. None	1.18	0.27, 5.22	0.51	0.21, 1.21	2.92	1.20, 7.12
Genital Discomfort
Yes vs. No	0.96	0.64, 1.45	0.96	0.78, 1.20	0.89	0.60, 1.31
Recent Discomfort
Yes vs. No	0.99	0.65, 1.50	1.11	0.89, 1.38	1.22	0.84, 1.75
Pain or Bleeding
Yes vs. No	2.83	0.59, 13.51	1.14	0.34, 3.75	0.91	0.12, 7.00
Gynecologic Products
Antibiotic
Former vs. Never	3.86	0.86, 17.34	0.83	0.51, 1.33	1.43	0.52, 3.97
Current vs. Never	5.95	1.14, 30.97	0.97	0.53, 1.79	1.84	0.56, 6.02
Antifungal
Former vs. Never	5.14	1.17, 22.52	1.10	0.70, 1.75	1.85	0.68, 5.02
Current vs. Never	1.64	0.22, 12.24	1.06	0.56, 2.02	1.74	0.49, 6.11
Abrasion
Former vs. Never	-	-	1.68	0.40, 7.72	-	-
Current vs. Never	-	-	1.10	0.08, 16.23	-	-
External Products
Former vs. Never	0.75	0.20, 2.84	-	-	-	-
Current vs. Never	1.36	0.48, 3.89	-	-	-	-
Unknown Products
Former vs. Never	2.82	0.64, 12.42	0.96	0.62, 1.49	2.21	0.81, 6.01
Current vs. Never	3.44	0.63, 18.68	1.10	0.60, 2.03	2.82	0.83, 9.53
Home-made Products
Natural vs. None	1.22	0.78, 1.92	0.91	0.72, 1.15	0.98	0.66, 1.47
Medical vs. None	0.80	0.27, 2.40	1.26	0.77, 2.04	0.76	0.29, 2.02
Unknown vs. None	2.75	0.53, 14.15	1.33	0.45, 3.91	5.33	1.80, 15.82
Vaginal Health Characteristics
Cervical Ectropion
Yes vs. No	0.37	0.05, 2.77	0.89	0.42, 1.91	0.74	0.17, 3.10
Gynecologic Surgery
Yes vs. No	2.05	1.11, 3.79	0.90	0.60, 1.37	0.89	0.42, 1.89
Gynecologic Treatment/Infection
Yes vs. No	1.73	1.13, 2.65	1.17	0.92, 1.50	1.26	0.83, 1.89
Previous Gynecologic Infection
HPV vs. None	3.87	2.09, 7.14	2.02	1.27, 3.19	1.21	0.54, 2.71
Non-HPV vs. None	1.33	0.81, 2.19	1.03	0.78, 1.34	1.27	0.82, 1.97
Cytology Observations
Bacterial Infection
Yes vs. No	1.28	0.63, 2.63	1.30	0.88, 1.91	1.31	0.68, 2.52
Fungal Infection
Yes vs. No	1.25	0.61, 2.54	1.29	0.88, 1.87	1.48	0.83, 2.66
General Inflammation
Yes vs. No	2.10	1.37, 3.22	1.53	1.21, 1.94	1.12	0.74, 1.69

a Subgenus 1 (HPVs-6, 11, 32, 40, 42, 44, 54 and 55), Subgenus 2 (HPVs-16, 18, 26 31, 33–35, 39, 45, 51–53, 56, 58, 59, 66–70, 73 and 82) and Subgenus 3 (HPVs-57, 61, 62, 71, 72, 81, 83, 84 and 89) infections were determined based on the phylogenetic classification of HPV types

b Odds ratios were adjusted for age, lifetime number of sexual partners and empirical confounders (identified using a 5 % change in estimate strategy) such as race, marital status, education, age at first intercourse, age at menarche, number of pregnancies, smoking, alcohol drinking and years since last Pap smear

Full article at:   http://goo.gl/bWRJrg

By:  Eileen Shaw, Agnihotram V. Ramanakumar, Mariam El-Zein, Flavia R. Silva, Lenice Galan, Maria L. Baggio, Luisa L. Villa, Eduardo L. Franco, and for the Ludwig-McGill Cohort Study

Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Canada

Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 546 Pine Avenue West, Montreal, QC H2W 1S6 Canada

Ludwig Institute for Cancer Research, São Paulo, Brazil

Molecular Biology Laboratory, Centre of Translational Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil

BMC Infect Dis. 2016; 16: 116. Published online 2016 Mar 8. doi:  10.1186/s12879-016-1446-x

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A Randomized Trial of Human Papillomavirus Self-Sampling as an Intervention to Promote Cervical Cancer Screening among Women with HIV

OBJECTIVE:

Women living with HIV experience higher risk of cervical cancer, but screening rates in the United States are lower than recommended. The purpose of this study was to examine whether an intervention using self-sampling of cervicovaginal cells for human papillomavirus (HPV) with results counseling would increase cervical cytology ("Pap") testing among women with HIV.

MATERIALS AND METHODS:

This was a randomized controlled trial to test the effectiveness of an intervention of self-sampling for HPV and results counseling. Participants were 94 women older than 18 years, with HIV infection, attending an HIV clinic for a primary care visit, whose last cervical cancer screening was 18 months or more before baseline. Women were assigned to the intervention or information-only group. The primary outcome was completion of cervical cytology testing within 6 months of baseline. The secondary outcome was the women's perceived threat of developing cervical cancer.

RESULTS:

A total of 94 women were enrolled and analyzed in the study. The cytology completion rate overall was 35% by 6 months from baseline. There were no differences in comparing HPV-positive with HPV-negative women nor comparing them with the information-only group. In the intervention group, a positive HPV test increased perceived threat of cervical cancer.

CONCLUSIONS:

The intervention did not improve cytology test attendance, although education about HPV and cervical cancer risk as part of study procedures was associated with testing for 35% of this group of women whose previous cytology occurred an average of 3.6 years before the baseline appointment. Self-sampling for HPV testing was feasible.

Purchase full article at:   http://goo.gl/wwMV0l

By:  Murphy J1, Mark H, Anderson J, Farley J, Allen J.

• 1Department of Gynecology and Obstetrics, Johns Hopkins University School of Nursing and 
• 2Johns Hopkins School of Medicine, Baltimore, MD.
• J Low Genit Tract Dis. 2016 Apr;20(2):139-44. doi: 10.1097/LGT.0000000000000195. 

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Social and Structural Determinants of Cervical Health among Women Engaged in HIV Care

Cervical cancer prevention/control efforts among women living with HIV/AIDS (WLH) are socially and structurally challenging. Healthcare access and perceived HIV stigma and discrimination are factors that may challenge risk reduction efforts. This study examined socio-structural determinants of cervical cancer screening among women engaged in HIV care. 

One hundred forty-five WLH seeking health/social services from AIDS Service Organizations in the southeastern US completed a questionnaire assessing factors related to cervical cancer prevention/control. 

• 90% were African American, mean age 46.15 ± 10.65 years. 
• 81% had a Pap test <1 year ago. 
• Low healthcare access was positively associated with having a Pap test <1 year ago. 
• About 36 % reported ≥2 Pap tests during the first year after HIV diagnosis. 
• Lower educational attainment was positively associated with having ≥2 Pap tests. 
• 35% reported more frequent Pap tests after diagnosis. 
• Lower income was moderately associated with more frequent Pap tests post-diagnosis. 

Findings highlight the successes of HIV initiatives targeting socio-economically disadvantaged women and provide evidence that health policy aimed at providing and expanding healthcare access for vulnerable WLH has beneficial health implications.

Purchase full article at:   http://goo.gl/7G4ei9

By:  Bynum SA1, Wigfall LT2,3,4, Brandt HM4,5, Julious CH6, Glover SH2,3, Hébert JR4,7.

• 1Division of AIDS, Behavioral, and Population Sciences, Center for Scientific Review, National Institutes of Health, 6701 Rockledge Drive, Bethesda, MD, 20892, USA. shalanda.bynum@nih.gov.
• 2Institute for Partnerships to Eliminate Health Disparities, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
• 3Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
• 4South Carolina Statewide Cancer Prevention and Control Program, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
• 5Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
• 6Palmetto AIDS Life Support Services, Inc., Columbia, SC, USA.
• 7Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA. 
• AIDS Behav. 2016 Mar 8.

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Rapid Acquisition of HPV Around the Time of Sexual Debut in Adolescent Girls in Tanzania

BACKGROUND:

No reports exist on genotype-specific human papillomavirus (HPV) acquisition in girls after first sex in sub-Saharan Africa, despite high HPV prevalence and cervical cancer incidence.

METHODS:

We followed 503 HP-unvaccinated girls aged 15-16 years in Mwanza, Tanzania, 3-monthly for 18 months with interviews and self-administered vaginal swabs. Swabs were tested for 13 higHRisk and 24 low-risk HPV genotypes. Incidence, clearance and duration of overall HPV and genotype-specific infections were calculated and associated factors evaluated.

RESULTS:

A total of 106 participants reported first sex prior to enrolment (N = 29) or during follow-up (N = 77). One was HIV-positive at the final visit. The remaining 105 girls contributed 323 adequate specimens. Incidence of any new HPV genotype was 225/100 person-years (pys), and incidence of vaccine types HPV-6, -11, -16 and -18 were 12, 2, 2 and 7/100 pys, respectively. Reporting sex in the past 3 months and knowing the most recent sexual partner for a longer period before sex were associated with HPV acquisition. Median time from reported sexual debut to first HPVinfection was 5 months, and infection duration was 6 months.

CONCLUSION:

This is the first description of HPV acquisition after first sex in sub-Saharan Africa where the incidence of cervical cancer is amongst the highest in the world. HPV incidence was very high after first sex, including some vaccine genotypes, and infection duration was short. This very high HPV incidence may help explain high cervical cancer rates, and supports recommendations that the HPV vaccine should be given to girls before first sex.

Below:  Time from sexual debut to first infection with any HPV, any HR HPV or any LR HPV, among 41 girls who reported sexual debut during follow-up and were HPV-naïve at time of reported sexual debut.  Kaplan Meier curves are calculated separately for each HPV group.

Full article at:   http://goo.gl/QhwwIr

   

By:  Houlihan CF1, Baisley K2, Bravo IG3, Kapiga S4, de Sanjosé S5, Changalucha J6, Ross DA2, Hayes RJ2, Watson-Jones D7.

• 1Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK Mwanza Intervention Trials Unit, Mwanza, Tanzania catherine.houlihan@lshtm.ac.uk.
• 2MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
• 3Unit of Infections and Cancer, Institut Català d'Oncologia, Barcelona, Spain.
• 4Mwanza Intervention Trials Unit, Mwanza, Tanzania MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK.
• 5Unit of Infections and Cancer, Institut Català d'Oncologia, Barcelona, Spain CIBER ESP, Barcelona, Spain.
• 6National Institute for Medical Research, Mwanza, Tanzania.
• 7Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK Mwanza Intervention Trials Unit, Mwanza, Tanzania. 
• Int J Epidemiol. 2016 Mar 4. pii: dyv367.

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