Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Cancer

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

A cross-sectional study of high-risk human papillomavirus clustering and cervical outcomes in HIV-infected women in Rio de Janeiro, Brazil

  • Jessica L. Castilho1Email author,
  • José Eduardo Levi2,
  • Paula M. Luz3,
  • Mary Catherine Cambou4,
  • Tazio Vanni5,
  • Angela de Andrade3,
  • Mônica Derrico3,
  • Valdiléa G. Veloso3,
  • Beatriz Grinsztejn3 and
  • Ruth K. Friedman3
Contributed equally
BMC Cancer201515:478

https://doi.org/10.1186/s12885-015-1486-4

Received: 13 January 2015

Accepted: 9 June 2015

Published: 23 June 2015

Abstract

Background

In Brazil, the rate of cervical cancer remains high despite the availability of screening programs. With ongoing vaccine development and implementation, information on the prevalence of specific HPV types is needed, particularly among high-risk populations, such as HIV-infected women.

Methods

We performed a study of HIV-infected women in Rio de Janeiro, Brazil, who underwent cervical HPV genotype testing between 2005-2013. We examined the prevalence of high-risk HPV types and the patterns of high-risk HPV type clustering. Using logarithmic binomial regression, we estimated the risk of abnormal cytology by HPV genotype result.

Results

Of the 562 women included, 498 (89 %) had at least one HPV type detected. 364 women (65 %) had at least one high-risk HPV type detected and 181 (32 %) had more than one high-risk type detected. HPV 58 was the most frequent HPV type detected overall (prevalence 19.8 % [95 % confidence interval 16.4–23.1]), followed by HPV 53 (prevalence 15.5 % [12.5–18.5]) and HPV 16 (prevalence 13 % [10.2–15.8]). Women infected with more than one high-risk HPV type were younger, had lower CD4+ lymphocyte counts, and were more likely to be infected with HPV 16 or 18. In adjusted analyses, presence of more than one high-risk HPV type was associated with a two-fold increased risk of abnormal cytology after adjusting for presence of individual high-risk type, age, and CD4+ lymphocyte count (adjusted prevalence ratios 1.88–2.07, all p <0.001). No single high-risk HPV type was statistically associated with abnormal cytology after adjusting for the presence of more than one high-risk HPV type.

Conclusions

In the largest study of cervical HPV genotypes among HIV-infected women in Latin America, infection by high-risk HPV types other than 16 or 18 and infection by more than one high-risk HPV types were common. Infection by more than one high-risk type was more strongly associated with abnormal cervical cytology than any individual high-risk HPV type, highlighting the need for multi-valent HPV vaccines.

Keywords

HPVWomenHIVCervical cancerEpidemiology

Background

Latin America has one of the highest incidence and mortality rates of cervical cancer in the world [1]. As in other regions, in Latin America, high-risk human papillomavirus (HPV) type 16 has been strongly associated with risk of high-grade cervical dysplasia and cervical cancer [2]. In Brazil, high-risk HPV types have been observed to be highly prevalent in women with both normal and abnormal cervical cytology [3, 4].

For women with HIV infection, the risks and consequences of HPV infection are even greater. Women with HIV infection have higher prevalence of high-risk HPV types, are more likely to be infected with more than one HPV type, and are at increased risk of cervical dysplasia and cervical cancer [511]. HIV-infected women are more likely to have abnormal cervical cytology and dysplasia associated with high-risk HPV types other than 16 or 18 [1214]. Among HIV-infected women in Latin America, prevalence of cervical HPV infection in women with normal cervical cytology has been estimated at 57 %, similar to the prevalence observed in HIV-infected women in Africa (57 %) and higher than that observed in HIV-infected women in Asia (31 %), Europe (32 %), or North America (31 %) [13]. A recent large study of pregnant HIV-infected women in Rio de Janeiro, Brazil, noted an overall cervical HPV prevalence of 84 %, 80 % of whom were infected by high-risk types [15]. While some studies have shown a protective effect, combination antiretroviral therapy (cART) has not consistently been observed to affect rates of cervical intraepithelial neoplasia and only modestly improves HPV infection clearance [7, 1621].

Given their increased risk, HIV-infected women are recommended to receive frequent screening for cervical dysplasia [22]. Vaccines targeting common high-risk HPV types are effective in reducing risk of cervical dysplasia and are immunogenic in HIV-infected women [23, 24]. However, these vaccines are not yet widely available in many places in the world, particularly in low- and middle-income countries [1, 25]. As next-generation HPV vaccines are developed, knowledge of high-risk HPV epidemiology, particularly among high-risk groups such as HIV-infected women, is of critical importance.

To address this need, we performed a prevalence study of cervical HPV infection among a cohort of HIV-infected women in Rio de Janeiro, Brazil. In this study, we describe the prevalence of HPV types, patterns of clustering, and patient clinical and demographic factors associated with high-risk HPV cervical infection and abnormal cytological outcomes.

Methods

To examine the epidemiology of type-specific HPV infections, we performed an analysis of all HIV-infected women followed at the Women’s Cohort of the Instituto Nacional de Infectologia Evandro Chagas (INI), Fundção Oswaldo Cruz, who underwent HPV genotype testing by line assay at cohort entry. This study was approved by institutional ethics review boards of INI and Vanderbilt University.

The Women’s HIV Cohort at INI is an observational study of the natural history of HIV infection in women that began in 1996. After recruitment from the general HIV clinic and signing informed consent, women complete surveys on sexual and gynecologic history and undergo routine cytology-based cervical cancer screening by Papanicolaou (Pap) tests and hybrid capture detection of oncogenic HPV DNA (types 16, 18, 31, 33, 35, 45, 51, 52, 58, and 68). Women with abnormal cytological results are referred for colposcopy and biopsies, as indicated according to the Brazilian Ministry of Health Guidelines. HIV history and pertinent laboratory results are obtained from the HIV clinical database [26].

This study included women who enrolled in the Women’s HIV Cohort between 2005 and 2013. From 2005 through 2013, all women entering the cohort underwent cervical linear-array testing for HPV genotypes along with routine Pap smear testing at cohort entry. Cervical samples were collected using a cervical brush or swab and stored in conservative media (STM, Qiagen, Valencia, CA, USA). DNA was extracted by phenol-chloroform standard method. Five μL aliquots were used for HPV detection and genotyping using the Linear-Array HPV Genotyping Test (Roche Molecular Systems Inc., Alameda, CA, USA) which targets low-risk HPV types (6, 11, 26, 40, 42, 53, 54, 55, 61, 62, 64, 66, 67, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39, and CP6180) and high-risk (oncogenic) HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68). Women with inadequate specimens or failed genotype testing were excluded from the study. HPV type designation of low-risk or high-risk (oncogenic) was performed in accordance to internationally-recognized classification [27]. Cervical cytology analysis was performed at the INI Pathology Laboratory using standardized methods and the Bethesda rating system: atypical squamous cells unknown significance (ASC-US), atypical glandular cells (AGC), low-grade squamous intraepithelial lesion (LSIL), atypical squamous cells – cannot exclude high-grade lesion (ASC-H), high-grade squamous intraepithelial lesion (HSIL), or cancer. For analyses, AG-US and ASC-H results were included with ASC-US.

We first described the distribution of low- and high-risk HPV types observed among all women. For descriptive purposes, overall prevalence rates and 95 % confidence intervals based upon normal distributions were calculated for the most frequently occurring types. We next examined the prevalence of each high-risk HPV type and of more than one high-risk type by cervical cytology outcome (normal, ASC-US, LSIL, and HSIL or cancer), defined as the proportion of women with the cytological outcome who were positive for the high-risk HPV type. To examine patterns of clustering of high-risk HPV types, we graphically examined the relative frequencies of each high-risk HPV pairing observed in women with abnormal cytology.

We compared patient characteristics at the time of HPV testing associated with HPV genotype subsets: women uninfected with HPV, women infected with only low-risk HPV types, women infected with one high-risk HPV type, and women infected with more than one high-risk HPV type. Demographic and social factors included age, race, education, living situation, income, and tobacco use. We also examined sexual and health behavior, as well as HIV clinical variables including CD4+ lymphocyte nadir (defined as lowest recorded CD4+ lymphocyte prior to and up to 90 days after the HPV testing date), current CD4+ lymphocyte count (closest recorded value within one year), current HIV RNA value (up to one year prior), and total months since initiation of combination antiretroviral therapy (cART). Comparisons of HPV genotype group were performed using Wilcoxon rank sum and Fisher exact tests for continuous and categorical variables, respectively.

To study the association of each high-risk HPV type and presence of more than one high-risk type with abnormal cytology outcomes, we calculated prevalence ratios using logarithmic binomial regression. Prevalence ratios for abnormal cytology (defined as cytology results of ASC-US or higher) by demographic (age, race, education), social (tobacco use, presence of HIV-infected sexual partner), and clinical (CD4+ lymphocyte nadir and count, HIV RNA, and cART history) factors were first examined using unadjusted analyses (data not shown). Unadjusted prevalence ratios of each high-risk HPV type and presence of more than one high-risk HPV type for abnormal cytology were calculated. To develop the most parsimonious model possible, demographic and clinical variables highly statistically significantly associated with abnormal cytology (p <0.01) were retained in adjusted models. Final models for each high-risk HPV type included the individual high-risk HPV type, age, CD4+ lymphocyte count, and presence of more than one high-risk HPV. In adjusted analyses, the detection of more than one high-risk HPV type reflects the relative risk of abnormal cytology associated with multiple high-risk HPV types, after accounting for the detection of the individual high-risk type included in the model, age, and CD4+ lymphocyte count. The individual high-risk type included in the model in the adjusted model reflects the risk of abnormal cytology adjusting for background risk associated with co-infections, age, and CD4+ lymphocyte count. To avoid co-linearity, for each model, presence of more than one high-risk type does not by definition include only those co-infections involving individual high-risk HPV of the model. P values were adjusted for multiple comparisons by Bonferroni correction in the final adjusted models (statistically significant threshold of p < 0.004).

Along with HPV types 26, 66, 67, 70, 73, and 82, HPV 53 has been noted to be possibly oncogenic and may not truly represent low-risk infection [28, 29]. As HPV 53 was found to be highly prevalent in our cohort, we examined its prevalence, clustering, and association with abnormal cytology using the same methods as described for the high-risk HPV types.

Statistical analyses and figures were performed using Stata 12.1 (Stata Corporation, College Station, Texas, USA). All p values were two-sided.

Results

From 2005 to 2013, 590 women enrolled in the women’s cohort and underwent HPV linear array genotyping at the time of cervical cancer screening. HPV genotype results for 28 women (4.7 %) failed or were incomplete, resulting in 562 women who were included in our study. Women with failed genotype testing who were excluded were statistically similar to those included with respect to age, race, education, and sexual history (data not shown). Excluded women had similar CD4+ lymphocyte counts at cohort entry compared to women included in the analyses (median 437 vs. 436 cells/mL respectively, p = 0.67). Excluded women had a higher proportion of failed hybrid capture tests (25 vs. 1 %, p < 0.001); however, among women with hybrid capture results, excluded and included women had similar rates of positive hybrid capture results (57 vs. 44 % respectively, p = 0.27). Lastly, excluded and included women had similar proportions of abnormal cervical cytology outcomes (19 vs. 30 % respectively, p = 0.38).

The frequencies of each HPV type observed in the cohort are shown in Fig. 1. Overall, the most frequent HPV type observed was high-risk type 58 (prevalence: 19.8 %, 95 % confidence interval [CI]: 16.4–23.1). After HPV 58, HPV 16 was the second most frequently observed high-risk HPV detected (prevalence: 13 %, 95 % CI: 10.2–15.8). HPV 18 was detected in 10.3 % of women (95 % CI: 7.8–12.8). Infection by more than one high-risk HPV type was observed in 32.2 % of women (95 % CI: 28.3–36.1).
Fig. 1

Prevalence of all HPV types. Includes HPV genotype data on all 562 women

Table 1 describes the demographic, social, and clinical characteristics of women included in analyses according to HPV genotype result. Overall, 364 women (65 %) had at least one high risk HPV type detected and nearly half of those women had more than one high risk type present (n = 181). Women with infection by more than one high-risk type were younger than women with only one high-risk HPV type detected and were more likely to report a known HIV-infected sexual partner. They did not differ in reported condom use, tobacco, or hormonal contraception use. Women with more than one high-risk type had lower CD4+ lymphocyte count nadirs compared to women with no HPV types detected but did not differ from women with only one high-risk HPV type detected. However, women with more than one high-risk type had lower CD4+ lymphocyte counts at the time of HPV testing compared to both HPV negative women and those with only one high-risk type detected. Women with more than one high-risk type had a greater number of low-risk HPV types detected and were more often infected with HPV 16 or 18. Women with any high-risk type more frequently had abnormal cytology, with presence of more than one high-risk type associated with even higher frequency of abnormal cytology.
Table 1

Demographic, social, and clinical characteristics of women by HPV genotype result

 

No HPV

Only low risk HPV

One high risk HPV

More than one high risk HPV

Total

N (%)

64 (11.4)

134 (23.8)

183 (32.6)

181 (32.2)

562

Age in years, median (IQR)

37.4 (30.3–41.3)

38.5 (31.1–45.5)

36.0 (29.9–44.0)

32.7 (26.5–41.3)a

35.8 (29.3–43.6)

Non-white race, n (%)

50 (79.4)

99 (73.9)

129 (71.3)

124 (68.9)

402 (72.0)

Years of formal education, median (IQR)

8 (5–11)

8 (5–11)

8 (5–11)

9 (6–11)b

8 (5–11)

Monthly income (US$), median (IQR)

400 (255–600)

425 (250–750)

400 (232.5–750)

450 (232.5–800)

415 (235–750)

Married/living with partner, n (%)

34 (53.1)

85 (63.4)

100 (54.6)

102 (56.4)

321 (57.1)

Age at sexual debut, median (IQR)

16 (14–18)

16 (15–18)

16 (15–18)

16 (15–18)

16 (15–18)

Number of lifetime sexual partners, median (IQR)

5 (4–12)

5 (3–8)

5 (3–10)

5 (3–9)

5 (3–10)

Condom use with last sexual intercourse, n (%)

37 (57.8)

86 (65.7)

117 (65.4)

118 (66.3)

358 (64.9)

HIV-infected current sexual partner, n (%)

9 (14.1)

38 (28.4)c

28 (15.3)

50 (27.6)c, d

125 (22.2)

Number of pregnancies, median (IQR)

2 (1–4)

3 (2–4)

3 (1–4)

2 (1–3)a

2 (1–4)

Current hormonal contraceptive use, n (%)

16 (25.0)

19 (14.3)

27 (14.8)

33 (18.2)

95 (17.0)

Current tobacco usee, n (%)

10 (15.6)

37 (20.6)

36 (20.2)

31 (23.1)

114 (20.5)

Nadir CD4+ lymphocyte countf, median (IQR)

302 (190–570)

307 (155–500)

255 (128–483)

256 (90–414)b

274 (128–467)

CD4+ lymphocyte count at HPV testg, median (IQR)

528 (326–827)

512 (309–679)

433 (309–631)

398 (251–549)a, b

436 (296–679)

HIV RNA <400 copies/mlh, n (%)

27 (42.2)

63 (47.0)

74 (40.4)

62 (34.3)

226 (40.2)

Total months since cART initiation at HPV test, median (IQR)

1.65 (0–12.5)

2.5 (0–15.1)

3.6 (0–16.9)

2.0 (0–13.5)

2.5 (0–14.13)

Total number of low-risk HPV types detected, median (IQR)

0

1 (1–2)

1 (1–2)

2 (1–3)a

1 (0–2)

HPV 16 or 18 detected, n (%)

0

0

42 (23.0)

82 (45.3)d

122 (22.1)

Cytology results, n (%)

     

Any Abnormal

7 (10.9)

22 (16.4)

53 (24.0)c

84 (46.4)c, d

166 (29.5)

ASC-US or AGC

5 (7.8)

14 (10.5)

19 (10.4)

26 (14.4)

64 (11.4)

LSIL

1 (1.6)

7 (5.2)

30 (16.4)c

47 (26.0)c, d

85 (15.1)

HSIL

1 (1.6)

1 (0.8)

4 (2.2)

10 (5.5)

16 (2.9)

Cancer

0

0

0

1 (0.6)

1 (0.2)

aRank sum test of comparison with one HR HPV group p < 0.05

bRank sum test of comparison with no HPV group p < 0.05

cFisher exact test of comparison with no HPV group p < 0.05

dFisher exact test of comparison with one HR HPV group p < 0.05

eThere were 6 women in total missing tobacco use data

fThere were 5 women in total missing CD4+ lymphocyte nadir data

gThere were a total of 37 women with missing CD4+ lymphocyte data at the time of HPV exam

hThere were 63 women with missing HIV RNA data at the time of HPV exam

Abbreviations used

IQR: interquartile range

cART: combination antiretroviral therapy

ASC-US: atypical squamous cells of unknown significance

AGC: atypical glandular cells

LSIL: low-grade squamous intraepithelial lesion

HSIL: high-grade squamous intraepithelial lesion

The prevalence of high-risk HPV types and presence of more than one high-risk type by cytology result are shown in Fig. 2. Overall, HPV 58 was the most common high-risk HPV type detected in women with normal cytology, ASC-US, LSIL, and HSIL or cervical cancer. HPV 16 was detected in 22 % (95 % CI: 13–31 %) of women with LSIL and 24 % (95 % CI: 10–46 %) of women with HSIL or cancer. HPV 18 was detected in 13 % (95 % CI: 6–20 %) and 18 % (95 % CI: 0–38 %) of women with LSIL and HSIL or cancer, respectively. Prevalence of infection by more than one high-risk type increased from 24 % (95 % CI: 20–29 %) among women with normal cytology to 65 % (95 % CI: 36–89 %) among women with HSIL or cancer.
Fig. 2

Prevalence of high-risk HPV types and presence of more than one high-risk HPV types by cytology. Abbreviations used: HR: high-risk; ASC-US: atypical squamous cells of unknown significance, includes atypical glandular cells (n = 1); LSIL: low-grade squamous intraepithelial lesion; HSIL: high-grade squamous intraepithelial lesion

We next examined the pairing frequencies of high-risk HPV types observed in women with abnormal cytology results (n = 166). Figure 3 displays each high-risk HPV pair observed whereby the size of the circle at the intersection of each high risk HPV type corresponds to the relative frequency of the observed pairing. The circles representing the intersection of each high-risk type and “none” reflect the relative frequencies of each high-risk type occurring in monoinfection. Among women with abnormal cytology, HPV 58 was the most common high-risk type detected in monoinfection and in multiple infections. However, the frequencies of individual high-risk pairings were relatively low and distributed across all high-risk HPV types. The pairing combinations of HPV 58 and 31 (n = 10, prevalence = 6 %), 58 and 56 (n = 9, prevalence = 5 %), and 16 and 56 (n = 8, prevalence = 5 %) were the most frequently observed high-risk HPV pairs. HPV 16 paired most often with HPV 58 (n = 7) and 68 (n = 7). Some high-risk HPV types occurred more frequently in paired infections than monoinfection, including HPV 39 and 68.
Fig. 3

Relative frequencies of high-risk HPV pairings in women with abnormal cytology. Includes results from 166 women with abnormal cervical cytology. Circle size reflects relative frequency of occurrence such that smaller circles reflect less frequent observations. The most frequently observed pairings are labeled (HPV 31 and HPV 58, n = 10 occurrences; HPV 56 and HPV 58, n = 9 occurrences; HPV 56 and HPV 16, n = 8 occurrences). Pair = None refers to HPV type frequency alone, without another high risk HPV type

Results from unadjusted and adjusted logarithmic binomial regression models for abnormal cytology are reported in Table 2. In unadjusted analyses, a number of individual high-risk HPV types were statistically associated with abnormal cytology, including HPV 16, 31, 33, 35, 39, 52, and 68. In addition, age (prevalence ratio [PR] per 5 year increase 0.92 [95 % CI: 0.86–0.98]), CD4+ lymphocyte count (PR per 100 cells/ml increase 0.90 [95 % CI: 0.85–0.95]), and presence of more than one high risk HPV type (PR 2.16 [95 % CI: 1.68–2.76]) were statistically associated with abnormal cytology results in unadjusted analyses. Notably, tobacco use, number of lifetime sexual partners, condom use, HIV RNA, and cART history were not statistically associated with abnormal cytology in unadjusted analyses (data not shown). In adjusted models adjusting for multiple comparisons, the prevalence ratio point estimates for each high-risk HPV type were attenuated and no longer statistically significant, based upon a Bonferroni corrected p value of <0.004 for significance. However, in every adjusted model, presence of more than one HPV type remained strongly associated with an approximate 2-fold increased risk of abnormal cervical cytology, regardless of the individual high-risk HPV type assessed in each model.
Table 2

Unadjusted and adjusted prevalence ratios for abnormal cytology of high-risk HPV types

 

Unadjusted Prevalence Ratio (PR)

Adjusted Prevalence Ratio (aPR)a,b

High risk HPV type

HPV type PR [95 % CI]

P value

HPV type aPR [95 % CI]

P value

More than one high risk HPV aPR [95 % CI]

P value

16

1.48 [1.08–2.01]

0.013

1.14 [0.83–1.54]

0.418

1.94 [1.50–2.52]

<0.001c

18

1.19 [0.81–1.74]

0.369

0.83 [0.57–1.20]

0.321

2.04 [1.57–2.66]

<0.001c

31

1.53 [1.09–2.13]

0.013

0.97 [0.70–1.37]

0.882

1.98 [1.51–2.59]

<0.001c

33

2.13 [1.51–3.02]

<0.001

1.47 [1.10–1.97]

0.009

1.89 [1.45–2.46]

<0.001c

35

1.89 [1.38–2.59]

<0.001

1.20 [0.88–1.64]

0.246

1.88 [1.43–2.48]

<0.001c

39

2.03 [1.43–2.88]

<0.001

1.09 [0.74–1.61]

0.665

1.95 [1.49–2.53]

<0.001c

45

0.80 [0.44–1.50]

0.507

0.58 [0.32–1.06]

0.079

2.07 [1.60–2.68]

<0.001c

51

1.35 [0.93–1.97]

0.116

1.00 [0.70–1.43]

0.993

1.97 [1.52–2.56]

<0.001c

52

2.05 [1.50–2.81]

<0.001

1.35 [1.00–1.84]

0.051

1.89 [1.45–2.46]

<0.001c

56

1.74 [1.27–2.38]

0.001

1.06 [0.76–1.47]

0.726

1.94 [1.48–2.55]

<0.001c

58

1.29 [0.97–1.72]

0.084

0.90 [0.68–1.21]

0.488

2.04 [1.56–2.68]

<0.001c

59

1.34 [0.95–1.89]

0.097

1.00 [0.72–1.38]

0.976

1.97 [1.51–2.57]

<0.001c

68

1.53 [1.09–2.16]

0.015

1.04 [0.74–1.46]

0.834

1.96 [1.50–2.56]

<0.001c

aDue to missing CD4+ lymphocyte values in 37 women, 525 women were included in multivariate models

bAll adjusted models included individual high-risk HPV type, age, CD4+ lymphocyte count at HPV test, and presence of more than one high risk HPV types. CD4+ lymphocyte count and presence of more than one high-risk HPV types remained statistically significant. Age was not statistically significant in multivariate models

cp value significant at Bonferroni threshold (0.004) for correction of multiple comparisons

Abbreviations used

CI: confidence interval

PR: prevalence ratio

aPR: adjusted prevalence ratio

The second most frequently observed type was HPV 53 (prevalence: 15.5 %, 95 % CI: 12.5–18.5 %) and analyses examined its epidemiology given its weakly carcinogenic risk. Of the 87 women infected with HPV 53, 67 (77 %) were also infected with a high-risk HPV type. Thirty-two (19 %) of all women with HPV 53 infection had abnormal cytology; however, 31 of these women were also infected with high-risk HPV types. One woman with HPV 53 infection without co-infection by a high-risk type was found to have ASC-US on cytology. In unadjusted analyses, infection by HPV 53 was associated with increased risk of abnormal cytology (PR = 1.3, 95 % CI: 0.96–1.78). In a model adjusted for age, CD4 lymphocyte count, and co-infection with high-risk types, the association was no longer observed (aPR = 0.90, 95 % CI 0.67–1.21).

Discussion

In this large study of HIV-infected women, we found that infection with high-risk HPV types and infection with multiple high-risk types, in particular, were highly prevalent and associated with abnormal cervical cytology. While HPV 16 infection was common, HPV 58 was the most common HPV type detected overall. Our study highlighted the role of infection by more than one high-risk type. Individual pairing frequencies of high-risk HPV types were relatively low overall; however, the presence of multiple high-risk HPV types was strongly associated with abnormal cytology outcomes, even when adjusting for detection of individual high-risk HPV types.

In this cohort, infection by high-risk HPV types was common, occurring in more than half of all women. Infection with high-risk HPV types was associated with younger age and lower CD4+ lymphocyte counts. These findings are consistent with previous studies of this cohort and other studies of HIV-infected women in Brazil [15, 3033]. Differing from other studies, tobacco use was not associated with high-risk HPV infection or abnormal cervical cytology [32, 34]. Previous work examining risk of high-grade cervical intra-epithelial neoplasia by histopathology among women at our clinic demonstrated an association with tobacco use [35]. The lack of association observed in this analysis may be a result of differing outcome measures.

Additionally, infection with more than one high-risk HPV type was highly prevalent. Women with infections by more than one high-risk type were notably younger and had lower CD4 lymphocyte counts compared to women with high-risk HPV monoinfection. Increased risk of infection by multiple high-risk HPV types has been associated in HIV-infection and younger age [3639]. We also observed higher frequency of known HIV-infected sexual partners among women with multiple high-risk HPV infection compared to those with only one high-risk HPV detected. While the HIV infection status of the partner may have affected sexual practices (though no difference in condom use was reported between the groups), studies of HIV serodiscordant couples have shown HIV infection increases the risk of acquiring HPV infection from uninfected partners in both women and men [40]. The HIV infection status of sexual partners thus may be an important risk factor for HPV infection among HIV-infected women.

In our study, presence of more than one high-risk type was consistently and independently associated with risk of abnormal cytology, after adjusting for presence of individual high-risk types (including HPV 16), age, and CD4+ lymphocyte count. Infection by more than one high-risk HPV type has been associated with increasing risk of cervical intraepithelial neoplasia [38, 41]. A recent study of >59,000 cervical cytology specimens and HPV genotypes from New Mexico demonstrated that, with the exception of HPV 16, HPV infection by more than one high-risk type conferred additional risk of HSIL compared to monoinfection for each high-risk type examined. However, risk was not further increased when more than two high-risk types were detected, suggesting that risk of high-grade cervical outcomes is not synergistically increased with multiple infections [41]. While clustering of high-risk HPV types is common, as observed in our study, patterns of specific pairings tend to be unpredictable. Studies that have statistically examined clustering patterns of high-risk HPV types have generally concluded that specific high risk HPV pairings occur at random [4244]. Nonetheless, the limited sample size of most studies precludes statistical inference regarding patterns of clustering and their impact on the natural history of cervical cancer. This highlights the importance of international collaborative studies and meta-analysis in HIV and HPV research [45].

In this study, high-risk HPV 58 was the most common HPV type detected in all women, including those with multiple high-risk types detected and those associated with abnormal cytology. Worldwide, HPV 16 is the most frequently detected high-risk type, including in HIV-infected women [13]. However, the prevalence of high-risk types other than 16 and 18 is higher in HIV-infected women compared to uninfected women [13, 14]. HPV 58 has been observed at high rates in multiple studies of cervical infection in women in Brazil and has been observed at rates above those of HPV 16 in cohorts of HIV-infected women in Botswana and Zambia [32, 4649]. Globally, HPV 58 is the third most prevalent HPV type detected in cases of cervical cancer [50]. While HPV 58 was the most frequent high-risk HPV type observed in women with abnormal cytology, further study is needed in its association with histological measures of neoplasia, particularly in HIV-infected women. In a longitudinal study of HIV-uninfected women, HPV 58 was not as strongly associated with cervical intraepithelial neoplasia as HPV 16 or 31 [51]. However, the pathogenicity of HPV 58 in HIV-infected women has not been described.

Understanding of epidemiology of specific HPV types, particularly in high-risk populations like HIV-infected women, is of critical importance for HPV vaccine development and implementation. While studies have suggested cost-effectiveness, general access to the HPV vaccines is not currently available in Brazil [25]. Importantly, second-generation HPV vaccines will include coverage for a greater number of high-risk HPV types, including 6,11,16,18, 31, 33, 45, 52, and 58, which could be particularly important in our population where HPV 58 is highly prevalent. Mathematical models of second-generation HPV vaccines have predicted even greater absolute risk reduction of cervical cancer compared to current vaccines. However, models have suggested that these effects may be blunted by infection by more than one high-risk type [52]. This study highlights the need for HPV vaccines that cover for a diversity of high-risk HPV types and also the need for further information about their effectiveness in settings of multiple infection.

Our study has important strengths and limitations. First, this study was designed as a cross-sectional analysis, which limits our ability to draw conclusions regarding causality. Additionally, without longitudinal genotype data available, we did not examine HPV infection clearance or long-term cytological and histological outcomes in this analysis. An important strength of our study is the large cohort of women included for which detailed health and behavioral information was available through questionnaires. This study reflects the largest epidemiologic study of HPV genotypes in HIV-infected women in Latin America. Nonetheless, women who chose to participate in the cohort may differ with those who declined and, given the single-center catchment, results from our study may not be generalizable to other settings. It is notable to highlight that all women who entered the cohort during the period of 2005-2013 underwent HPV genotype testing, thus minimizing the risk of selection bias of those tested. We used any abnormal cytology results as a composite outcome of interest rather than LSIL or HSIL. By including ASC-US outcomes, which are not as strongly associated with cervical intraepithelial neoplasia, we may have diminished the ability to detect risk conferred by specific high-risk HPV types and may have underestimated the effects of infection by more than one high-risk HPV.

Finally, we included in our analyses those high-risk types most strongly considered oncogenic. Recently, a number of HPV types previously considered low-risk have been recognized to have some oncogenic potential, namely HPV 26, 53, 66, 67, 69, 70, 73, and 82 [28, 29, 53]. Detection of these viruses would not have occurred using hybrid capture alone and our study expands the available data about their epidemiology. HPV 53 was the second most common HPV type detected overall and was associated with abnormal cytology in unadjusted analyses. However, only one woman with monoinfection by HPV 53 had abnormal cytology (ASC-US) and the association of HPV 53 with abnormal cytology was markedly attenuated after adjusting for presence of infection by more than one high-risk type. Further study into the persistence, clearance, and long-term outcomes associated with these possibly oncogenic HPV types is needed.

Conclusions

In conclusion, in a large study of HPV epidemiology in a cohort of HIV-infected women in Brazil, we found that infection by high-risk HPV types and infection by more than one high-risk type were highly prevalent. Infection by more than one high-risk type was strongly associated with abnormal cytology, even after adjusting for age, CD4+ lymphocyte count, and specific high-risk HPV types. HPV type 58 was the most common HPV type detected overall and among abnormal cytological outcomes. Further studies on its risk for cervical intraepithelial neoplasia and longitudinal outcomes are needed. The diversity and frequency of infections by more than one high-risk HPV may have important implications on the effectiveness of second-generation HPV vaccines. However, the prevalence of high-risk HPV infections in this high-risk population underscores the importance of all methods of cervical cancer prevention, including regular screening and vaccine availability.

Notes

Declarations

Acknowledgements

We would like to thank the patients of the Women’s HIV Cohort at INI for their time and participation in our study. This work was supported by the National Institutes of Health (T32 AI007474 [JLC], K24 AI65298 [JLC], UO1 AI069923 [JLC, BG, VGV, PML], and R25 MH087222 [MCC]) (United States). PML and BG were also supported by the National Council of Technological and Scientific Development (Brazil), Research Agency of the State of Rio de Janeiro (Brazil), and the Brazilian National STD/AIDS Program (Brazil).

Authors’ Affiliations

(1)
Division of Infectious Diseases, Vanderbilt University School of Medicine
(2)
Virology Lab, Instituto de Medicina Tropical da Universidade de São Paulo
(3)
Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz
(4)
Division of Infectious Diseases and Program in Global Health, David Geffen School of Medicine at UCLA
(5)
Departamento de Ciência e Tecnologia, Ministério da Saúde

References

  1. Villa LL. Cervical cancer in Latin America and the Caribbean: the problem and the way to solutions. Cancer Epidemiol Biomarkers Prev. 2012;21(9):1409–13.View ArticlePubMedGoogle Scholar
  2. Ciapponi A, Bardach A, Glujovsky D, Gibbons L, Picconi MA. Type-specific HPV prevalence in cervical cancer and high-grade lesions in Latin America and the Caribbean: systematic review and meta-analysis. PLoS One. 2011;6(10), e25493.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Ayres AR, Silva GA. Cervical HPV infection in Brazil: systematic review. Rev Saude Publica. 2010;44(5):963–74.PubMedGoogle Scholar
  4. Baldez da Silva MF, Guimaraes V, Silva MA, Amaral CM M d, Becak W, Stocco RC, et al. Frequency of human papillomavirus types 16, 18, 31, and 33 and sites of cervical lesions in gynecological patients from Recife, Brazil. Genet Mol Res. 2012;11(1):462–6.Google Scholar
  5. Brandao Vda C, Lacerda HR, Lucena-Silva N, Ximenes RA. Frequency and types of human papillomavirus among pregnant and non-pregnant women with human immunodeficiency virus infection in Recife determined by genotyping. Mem Inst Oswaldo Cruz. 2009;104(5):755–63.View ArticlePubMedGoogle Scholar
  6. Hanisch RA, Sow PS, Toure M, Dem A, Dembele B, Toure P, et al. Influence of HIV-1 and/or HIV-2 infection and CD4 count on cervical HPV DNA detection in women from Senegal, West Africa. J Clin Virol. 2013;58(4):696–702.Google Scholar
  7. Palefsky JM. Cervical human papillomavirus infection and cervical intraepithelial neoplasia in women positive for human immunodeficiency virus in the era of highly active antiretroviral therapy. Curr Opin Oncol. 2003;15(5):382–8.View ArticlePubMedGoogle Scholar
  8. Dartell M, Rasch V, Munk C, Kahesa C, Mwaiselage J, Iftner T, et al. Risk factors for high-risk human papillomavirus detection among HIV-negative and HIV-positive women from Tanzania. Sex Transm Dis. 2013;40(9):737–43.Google Scholar
  9. McDonald AC, Tergas AI, Kuhn L, Denny L, Wright Jr TC. Distribution of Human Papillomavirus Genotypes among HIV-Positive and HIV-Negative Women in Cape Town. South Africa Front Oncol. 2014;4:48.PubMedGoogle Scholar
  10. Abraham AG, D’Souza G, Jing Y, Gange SJ, Sterling TR, Silverberg MJ, et al. Invasive cervical cancer risk among HIV-infected women: a North American multicohort collaboration prospective study. J Acquir Immune Defic Syndr. 2013;62(4):405–13.Google Scholar
  11. Nicol AF, Grinsztejn B, Friedman RK, Veloso VG, Cunha CB, Georg I, et al. Seroprevalence of HPV vaccine types 6, 11, 16 and 18 in HIV-infected and uninfected women from Brazil. J Clin Virol. 2013;57(2):147–51.Google Scholar
  12. Luque AE, Jabeen M, Messing S, Lane CA, Demeter LM, Rose RC, et al. Prevalence of human papillomavirus genotypes and related abnormalities of cervical cytological results among HIV-1-infected women in Rochester, New York. J Infect Dis. 2006;194(4):428–34.Google Scholar
  13. Clifford GM, Goncalves MA, Franceschi S, Hpv, Group HIVS. Human papillomavirus types among women infected with HIV: a meta-analysis. AIDS. 2006;20(18):2337–44.Google Scholar
  14. McKenzie ND, Kobetz EN, Hnatyszyn J, Twiggs LB, Lucci 3rd JA. Women with HIV are more commonly infected with non-16 and -18 high-risk HPV types. Gynecol Oncol. 2010;116(3):572–7.View ArticlePubMedGoogle Scholar
  15. Meyrelles AR, Siqueira JD, Hofer CB, Costa TP, Azevedo AP, Guimaraes BV, et al. HIV/HPV co-infection during pregnancy in southeastern Brazil: prevalence, HPV types, cytological abnormalities and risk factors. Gynecol Oncol. 2013;128(1):107–12.Google Scholar
  16. Konopnicki D, Manigart Y, Gilles C, Barlow P, de Marchin J, Feoli F, et al. Sustained viral suppression and higher CD4+ T-cell count reduces the risk of persistent cervical high-risk human papillomavirus infection in HIV-positive women. J Infect Dis. 2013;207(11):1723–9.Google Scholar
  17. Kang M, Cu-Uvin S. Association of HIV viral load and CD4 cell count with human papillomavirus detection and clearance in HIV-infected women initiating highly active antiretroviral therapy. HIV Med. 2012;13(6):372–8.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Fife KH, Wu JW, Squires KE, Watts DH, Andersen JW, Brown DR. Prevalence and persistence of cervical human papillomavirus infection in HIV-positive women initiating highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2009;51(3):274–82.View ArticlePubMedPubMed CentralGoogle Scholar
  19. Camargo M, Soto-De Leon SC, Munoz M, Sanchez R, Pena-Herrera D, Pineda-Pena AC, et al. Human papillomavirus detection in women with and without human immunodeficiency virus infection in Colombia. BMC Cancer. 2014;14:451.Google Scholar
  20. Minkoff H, Ahdieh L, Massad LS, Anastos K, Watts DH, Melnick S, et al. The effect of highly active antiretroviral therapy on cervical cytologic changes associated with oncogenic HPV among HIV-infected women. AIDS. 2001;15(16):2157–64.Google Scholar
  21. Rositch AF, Gravitt PE, Tobian AA, Newell K, Quinn TC, Serwadda D, et al. Frequent detection of HPV before and after initiation of antiretroviral therapy among HIV/HSV-2 co-infected women in Uganda. PLoS One. 2013;8(1), e55383.Google Scholar
  22. Franceschi S, Jaffe H. Cervical cancer screening of women living with HIV infection: a must in the era of antiretroviral therapy. Clin Infect Dis. 2007;45(4):510–3.View ArticlePubMedGoogle Scholar
  23. Powell SE, Hariri S, Steinau M, Bauer HM, Bennett NM, Bloch KC, et al. Impact of human papillomavirus (HPV) vaccination on HPV 16/18-related prevalence in precancerous cervical lesions. Vaccine. 2012;31(1):109–13.Google Scholar
  24. Kahn JA, Xu J, Kapogiannis BG, Rudy B, Gonin R, Liu N, et al. Immunogenicity and safety of the human papillomavirus 6, 11, 16, 18 vaccine in HIV-infected young women. Clin Infect Dis. 2013;57(5):735–44.Google Scholar
  25. Vanni T, Mendes Luz P, Foss A, Mesa-Frias M, Legood R. Economic modelling assessment of the HPV quadrivalent vaccine in Brazil: a dynamic individual-based approach. Vaccine. 2012;30(32):4866–71.View ArticlePubMedGoogle Scholar
  26. Grinsztejn B, Bastos FI, Veloso VG, Friedman RK, Pilotto JH, Schechter M, et al. Assessing sexually transmitted infections in a cohort of women living with HIV/AIDS, in Rio de Janeiro, Brazil. Int J STD AIDS. 2006;17(7):473–8.Google Scholar
  27. de Villiers EM, Fauquet C, Broker TR, Bernard HU, zur Hausen H. Classification of papillomaviruses. Virology. 2004;324(1):17–27.View ArticlePubMedGoogle Scholar
  28. Bouvard V, Baan R, Straif K, Grosse Y, Secretan B, El Ghissassi F, et al. A review of human carcinogens–Part B: biological agents. Lancet Oncol. 2009;10(4):321–2.Google Scholar
  29. Schiffman M, Clifford G, Buonaguro FM. Classification of weakly carcinogenic human papillomavirus types: addressing the limits of epidemiology at the borderline. Infect Agents Cancer. 2009;4:8.View ArticlePubMedPubMed CentralGoogle Scholar
  30. Grinsztejn B, Veloso VG, Levi JE, Velasque L, Luz PM, Friedman RK, et al. Factors associated with increased prevalence of human papillomavirus infection in a cohort of HIV-infected Brazilian women. Int J Infect Dis. 2009;13(1):72–80.Google Scholar
  31. Luz PM, Velasque L, Friedman RK, Russomano F, Andrade AC, Moreira RI, et al. Cervical cytological abnormalities and factors associated with high-grade squamous intraepithelial lesions among HIV-infected women from Rio de Janeiro, Brazil. Int J STD AIDS. 2012;23(1):12–7.Google Scholar
  32. Rocha-Brischiliari SC, Gimenes F, de Abreu AL, Irie MM, Souza RP, Santana RG, et al. Risk factors for cervical HPV infection and genotypes distribution in HIV-infected South Brazilian women. Infect Agents Cancer. 2014;9(1):6.Google Scholar
  33. Goncalves MA, Massad E, Burattini MN, Villa LL. Relationship between human papillomavirus (HPV) genotyping and genital neoplasia in HIV-positive patients of Santos City, Sao Paulo, Brazil. Int J STD AIDS. 1999;10(12):803–7.View ArticlePubMedGoogle Scholar
  34. Boldrini NT, Freitas LB, Coutinho AR, Loureiro FZ, Spano LC, Miranda AE. High-grade cervical lesions among women attending a reference clinic in Brazil: associated factors and comparison among screening methods. PLoS One. 2014;9(7), e102169.View ArticlePubMedPubMed CentralGoogle Scholar
  35. de Andrade AC, Luz PM, Velasque L, Veloso VG, Moreira RI, Russomano F, et al. Factors associated with colposcopy-histopathology confirmed cervical intraepithelial neoplasia among HIV-infected women from Rio De Janeiro, Brazil. PloS one. 2011;6(3), e18297.Google Scholar
  36. Correa CM, Teixeira NC, Araujo AC, Carvalho Nde O, Castillo DM, Campos RR, et al. Prevalence and multiplicity of HPV in HIV women in Minas Gerais, Brazil. Revista da Associacao Medica Brasileira. 2011;57(4):425–30.Google Scholar
  37. Vaccarella S, Franceschi S, Snijders PJ, Herrero R, Meijer CJ, Plummer M, et al. Concurrent infection with multiple human papillomavirus types: pooled analysis of the IARC HPV Prevalence Surveys. Cancer Epidemiol Biomarkers Prev. 2010;19(2):503–10.Google Scholar
  38. Pista A, Oliveira A, Verdasca N, Ribeiro F. Single and multiple human papillomavirus infections in cervical abnormalities in Portuguese women. Clin Microbiol Infect. 2011;17(6):941–6.View ArticlePubMedGoogle Scholar
  39. Resende LS, Rabelo-Santos SH, Sarian LO, Figueiredo Alves RR, Ribeiro AA, Zeferino LC, et al. A portrait of single and multiple HPV type infections in Brazilian women of different age strata with squamous or glandular cervical lesions. BMC Infect Dis. 2014;14:214.Google Scholar
  40. Mbulawa ZZ, Johnson LF, Marais DJ, Coetzee D, Williamson AL. The impact of human immunodeficiency virus on human papillomavirus transmission in heterosexually active couples. J Infect. 2013;67(1):51–8.Google Scholar
  41. Wentzensen N, Nason M, Schiffman M, Dodd L, Hunt WC, Wheeler CM, et al. No evidence for synergy between human papillomavirus genotypes for the risk of high-grade squamous intraepithelial lesions in a large population-based study. J Infect Dis. 2014;209(6):855–64.Google Scholar
  42. Carozzi F, Ronco G, Gillio-Tos A, De Marco L, Del Mistro A, Girlando S, et al. Concurrent infections with multiple human papillomavirus (HPV) types in the New Technologies for Cervical Cancer (NTCC) screening study. Eur J Cancer. 2012;48(11):1633–7.Google Scholar
  43. Chaturvedi AK, Myers L, Hammons AF, Clark RA, Dunlap K, Kissinger PJ, et al. Prevalence and clustering patterns of human papillomavirus genotypes in multiple infections. Cancer Epidemiol Biomarkers Prev. 2005;14(10):2439–45.Google Scholar
  44. Vaccarella S, De Vuyst H, Mugo NR, Sakr SR, Plummer M, Heideman DA, et al. Clustering patterns of human papillomavirus infections among HIV-positive women in Kenya. Infect Agents Cancer. 2013;8(1):50.Google Scholar
  45. Vanni T, Mesa-Frias M, Sanchez-Garcia R, Roesler R, Schwartsmann G, Goldani MZ, et al. International scientific collaboration in HIV and HPV: a network analysis. PLoS One. 2014;9(3), e93376.Google Scholar
  46. Macleod IJ, O’Donnell B, Moyo S, Lockman S, Shapiro RL, Kayembe M, et al. Prevalence of human papillomavirus genotypes and associated cervical squamous intraepithelial lesions in HIV-infected women in Botswana. J Med Virol. 2011;83(10):1689–95.Google Scholar
  47. Sahasrabuddhe VV, Mwanahamuntu MH, Vermund SH, Huh WK, Lyon MD, Stringer JS, et al. Prevalence and distribution of HPV genotypes among HIV-infected women in Zambia. Br J Cancer. 2007;96(9):1480–3.Google Scholar
  48. Fernandes JV, Meissner RV, Carvalho MG, Fernandes TA, Azevedo PR, Sobrinho JS, et al. Prevalence of human papillomavirus in archival samples obtained from patients with cervical pre-malignant and malignant lesions from Northeast Brazil. BMC Res Notes. 2010;3(1):96.Google Scholar
  49. Paesi S, Serafini EP, Barea F, Madi SR, Echeverrigaray S. High prevalence of human papillomavirus type 58 in patients with cervical pre-malignant lesions in southern Brazil. J Med Virol. 2009;81(7):1270–5.View ArticlePubMedGoogle Scholar
  50. Li N, Franceschi S, Howell-Jones R, Snijders PJ, Clifford GM. Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: Variation by geographical region, histological type and year of publication. Int J Cancer. 2011;128(4):927–35.Google Scholar
  51. Smelov V, Elfstrom KM, Johansson AL, Eklund C, Naucler P, Arnheim-Dahlstrom L, Dillner J. Long-term HPV type-specific risks for high-grade cervical intraepithelial lesions: A 14-year follow-up of a randomized primary HPV screening trial. Int J Cancer.2015;136(5):1171-80.Google Scholar
  52. Kiatpongsan S, Campos NG, Kim JJ. Potential benefits of second-generation human papillomavirus vaccines. PLoS One. 2012;7(11), e48426.View ArticlePubMedPubMed CentralGoogle Scholar
  53. Arbyn M, Tommasino M, Depuydt C, Dillner J. Are 20 human papillomavirus types causing cervical cancer? J Pathol. 2014;234(4):431–5.View ArticlePubMedGoogle Scholar

Copyright

© Castilho et al. 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Advertisement