In the 3 multivariable models evaluating factors associated with any HPV infection, HPV-16 and/or -18 infection, and HPV-6, -11, -16, and/or -18 infection, no independent predictors were identified. In the model evaluating factors associated with high-risk HPV infection, 3 variables were retained: race/ethnicity, HIV VL, and frequency of vaginal sexual intercourse in the past 90 days (Table 4). Non-Hispanic black participants had approximately 7 times the odds of high-risk HPV infection compared with Hispanic participants, participants who had an HIV VL ≥400 copies/mL had approximately 3.5 times the odds of infection compared with those with a lower HIV VL, and participants who reported 6 or more (vs. 0) episodes of vaginal sexual intercourse over the prior 90 days had almost 6 times the odds of high-risk HPV.
In this study, we determined rates of type-specific HPV infection for 41 HPV types, HPV serology for the 4 vaccine types, and factors associated with HPV infection in HIV+ adolescent and young adult women receiving the first quadrivalent HPV vaccine dose. The effectiveness of vaccinating HIV+ young women is uncertain in the absence of information about HPV exposure at the time of vaccination, as young women who have been infected with vaccine-type HPV at the time of vaccination are not expected to derive as much clinical benefit from vaccination as those who were not infected. HIV+ young women may be at relatively high risk for previous or current HPV infection because of their sexual behaviors and may be at a higher risk for persistent HPV infection and progression to CIN because of their compromised immune status.
We found that the prevalence of overall and type-specific HPV, including HPV-16 and -18, were high in this sample. Almost 75% of participants were positive for at least one HPV type, 12% were positive for HPV-16, and 5% were positive for HPV-18. In comparison, the overall prevalence of HPV in a representative sample of US women 14–59 years of age was 24.5% among 14- to 19-year olds and 44.8% among 20- to 24-year olds.32 HPV-16 was detected in only 1.5% of all women and HPV-18 in 0.8% of all women. Interestingly, however, the rates of HPV found in our study are comparable to those found in several other studies that enrolled HIV-negative adolescent and young adult women who were similar to the young women in our study in terms of demographic characteristics.30,33,34 For example, in a previous study of predominantly low-income, African American, HIV-negative, but at-risk young women 13- to 26-years of age receiving primary care in an urban hospital-based teen health center, 68% were HPV-positive, 17% HPV-16 positive, and 12% HPV-18 positive.30 The similarities in rates of HPV likely reflect similar demographic characteristics (eg, high poverty rates) and sexual behaviors that are established risk factors for HPV.32,35–37 In contrast, several studies involving adult women and one involving adolescent women have demonstrated substantially higher rates of HPV in HIV+ compared with HIV− women.2–4,22 These higher HPV rates could reflect riskier sexual behaviors, higher incident detection of HPV infection, higher rates of HPV persistence, or more common reactivation of previously acquired latent HPV.4 The relatively high HPV rates in HIV+ women could also reflect alterations in viral-host interactions that increase the risk of HPV acquisition or persistence in HIV-infected individuals.3,38,39
The high prevalence of overall and type-specific HPV identified in our participants has implications for vaccination recommendations in HIV+ young women. First, it points to the importance of vaccination before acquisition of HPV, when vaccination is most effective. Our findings provide compelling support for recommendations to target vaccination to girls 11- to 12-years of age or younger, when they are unlikely to have initiated sexual intercourse.40,41 Second, the findings support the importance of continued cervical cancer screening after vaccination, whether by Papanicolaou or HPV testing, to prevent cervical cancer in those young women who were already infected at the time of vaccination. HIV+ women, compared with HIV− women, may have a higher incidence, persistence, or recurrence of HPV-related anogenital dysplasia and cancer, 4,42–45 or develop dysplasias or cancers that are more aggressive and less responsive to treatment.9,13
Although the prevalence of overall and type-specific HPV was relatively high compared with the general population, a significant proportion were negative for vaccine-type HPVs at the time of vaccination: 89% were negative for HPV-16 and 95% were negative for HPV-18. Furthermore, more than 50% of participants were both HPV DNA negative and seronegative for HPV-16, and almost 75% for HPV-18. These results indicate that a substantial proportion of these HIV+ young women had neither evidence of current HPV-16 or -18 infection nor past exposure and would therefore likely benefit from vaccination, if the HPV vaccine is demonstrated to be effective at preventing HPV infection and disease in HIV+ individuals.
Identification of factors associated with HPV in HIV+ young women may be helpful in guiding the design of HPV prevention strategies or vaccination guidelines in this population. Even in this relatively homogeneous population in terms of their high levels of exposure to genital HPV, 3 variables were significantly associated with high-risk HPV: non-Hispanic black ethnicity, HIV VL, and frequency of vaginal intercourse in the past 90 days. The presence of HIV-1 viremia, but not CD4 cell count, was associated with high-risk HPV detection: associations between HIV VL, CD4, and HPV infection have been inconsistent in previous studies. In a study of 1778 HIV+ adult women in the Women's Interagency HIV Study (WIHS), CD4 was inversely associated with HPV and HIV VL positively associated with HPV (P < 0001).2 Overall, women with highest prevalence of HPV were those with a CD4 <200 cells/mm3, regardless of HIV VL. Among women with CD4 >200 cells/mm3, a higher prevalence of HPV was found among those women with a higher HIV VL (>20,000 copies/mL) compared to a lower HIV VL (<20,000 copies/mL). The lowest prevalence of HPV was found in women with a CD4 >500 cells/mm3 and HIV VL <4000 copies/mL. This interaction was also evident in a subsequent prospective analysis of WIHS data, in which investigators found that the interaction between CD4 and HIV VL was significantly associated with both prevalent and incident HPV infection. A high HIV VL was strongly associated with prevalent and incident HPV in women with a high (>500 cells/mm3) or moderate (200–500 cells/mm3) CD4, but not a low CD4 (<50 cells/mm3 for prevalent HPV, <200 cells/mm3 for incident HPV).4 The investigators also found that CD4/HIV VL strata were more strongly associated with incident HPV than persistent HPV in more immune compromised HIV+ women. In contrast to the WIHS analyses, several studies of HIV+ adults demonstrated no association between CD4 and HPV detection.46,47 It is possible that the relatively small numbers of HIV+ women and high proportion of women who were HPV-positive in these studies limited the power to detect associations between CD4+ count and HPV. Similarly, in a study of HIV+ adolescent girls neither CD4 nor HIV VL were associated with HPV infection.3 The lack of an association between CD4 and HPV in that study, as in our study, may have been because of the relatively small number of participants and/or the lack of variation in CD4+ count: in our study, only 1% of participants had a CD4 <200 mm3 and 13% had a CD4 <350 mm3. The positive association between HIV VL and HPV in the WIHS and our study raises the question as to whether improved control of HIV replication either through treatment with antiretroviral medications or from immune-mediated mechanisms of the host could prevent HPV infection and subsequent adverse outcomes. It is also possible that the fact that HPV was associated with HIV VL but not CD4 could be related to immune dysregulation; that is, the higher levels of immune activation that are noted among untreated HIV+ individuals.
Frequency of vaginal sexual intercourse with a male partner in the past 90 days was also positively associated with high-risk HPV in the multivariable model. The association between sexual behaviors and HPV is well established in adolescents and adults,4,32,35,37,48–50 and points to the importance of effective strategies to promote safer sexual behaviors among HIV+ young women to prevent STI acquisition and HIV transmission.51
Finally, non-Hispanic black participants had substantially higher odds of high-risk HPV than Hispanic participants in the multivariable model. Racial and ethnic differences in HPV prevalence have been shown in previous studies and are concerning in that they may account in part for disparities in cervical cancer incidence and mortality.52 In a nationally representative sample of US women, black women had significantly higher rates of HPV (39.2%) compared with White (24.2%) and Hispanic (24.3%) women.32 In a study of college women, HPV prevalence rates were highest in black women, lower in Hispanic women, and lowest in white women,53,54 whereas in a study of urban adolescents, black race but not Hispanic ethnicity was associated with HPV infection.37 The elevated risk in black participants may be related to complex interactions between race, ethnicity, and poverty.36 In the study of US women noted previously, poverty was strongly associated with high-risk HPV infection, and among participants living below the poverty line, Mexican American ethnicity was inversely associated with high-risk HPV, whereas among participants living above the poverty line, black race was positively associated with high-risk HPV.36 These interactions between race/ethnicity, poverty, and HPV infection deserve further exploration because they have implications for the design of interventions to decrease existing disparities in HPV-related disease.52
Limitations of this study include the relatively small sample size, which limited the power to detect associations between demographic, virologic, immunologic, and behavioral factors and HPV infection. In addition, behavioral data were self-reported, which may affect their validity. Importantly, serology has limited sensitivity for detection of previous HPV infection and thus seropositivity rates may underestimate previous exposure to HPV. Seropositivity may indicate infection at sites other than the cervix; for example, the anus. Furthermore, women with more advanced immune compromise may not generate as high an immune response to natural infection, which may affect baseline serology results. The cross-sectional design of this study limits the ability to detect persistent and incident HPV infection. Lastly, the population consisted of all high-risk young women with high levels of sexual exposure and those willing to enroll in a vaccination study; these factors may increase or decrease the risk of HPV, which limits the generalizability of the results. However, the clinical sites in the Adolescent Medicine Trials Network are generally the largest of the clinics offering comprehensive services to HIV+ youth in the United States, and thus likely to be representative of HIV+ youth in care. In conclusion, the high rates of HPV identified in this cohort of HIV+ young women provide strong support for targeting HPV vaccination to girls 11- to 12-years of age or younger to maximize the health benefits of vaccination. The data also support vaccination of sexually experienced HIV+ young women, as the majority was HPV DNA negative and seronegative for high-risk vaccine-type HPV infection at the time of vaccination.
The study was scientifically reviewed by the Adolescent Medicine Trials Network's (ATN's) Therapeutic Leadership Group. Network, scientific, and logistical support was provided by the ATN Coordinating Center (C. Wilson and C. Partlow) at The University of Alabama at Birmingham. Network operations and analytic support was provided by the ATN Data and Operations Center at Westat, Inc (J. Korelitz and B. Driver). The following ATN sites participated in this study: Children's National Medical Center (D'Angelo, Hagler, and Trexler), Children's Hospital of Philadelphia (Douglas, Tanney, and DiBenedetto), John H. Stroger Jr Hospital of Cook County and the Ruth M. Rothstein CORE Center (Martinez, Bojan, Jackson, and Henry-Reid), University of Puerto Rico (Febo, Ayala-Flores, and Fuentes-Gomez), Montefiore Medical Center (Futterman, Enriquez-Bruce, and Campos), Tulane University Health Sciences Center (Abdalian, Kozina, and Baker), University of Miami School of Medicine (Friedman, Maturo, and Major-Wilson), Children's Diagnostic and Treatment Center (Puga, Leonard, and Inman), St. Jude's Children's Research Hospital (Flynn and Dillard), Children's Memorial (Garofalo, Brennan, and Flanagan), University of South Florida, Tampa (Emmanuel, Straub, Lujan-Zilberman, Julian, and Rebolledo), Children's Hospital of Los Angeles (Belzer, Flores, and Tucker), Mount Sinai Medical Center (Steever and Geiger), and University of Maryland (Peralta and Gorle).
The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck & Co, Inc. The comments and views of authors B. G. Kapogiannis and C. Worrell do not necessarily represent the views of the National Institute of Child Health and Human Development.
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