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Genital HPV Infection Among Female University Students in Washington State

This study from 2003 explores the incidence and risk factors of genital human papillomavirus (HPV) infection among female university students in Washington State, providing valuable insights into HPV transmission dynamics and associated risk factors.

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Genital HPV Infection Among Female University Students in Washington State

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  1. R.L. Winer, Shu-Kuang Lee, J.P. Hughes, D. E. Adam, N.B. Kiviat, L.A. Koutsky American Journal of Epidemiology, 2003:157(3) Presented by Patrick Heyman Palm Beach Atlantic University Genital Human Papillomavirus Infection: Incidence and Risk Factors in a Cohort ofFemale University Students

  2. Background • Human Papillomavirus (HPV) • Most prevalent STI ~50% of women • Some strains cause genital/anal warts • Some strains cause cervical cancer • Good incidence data is not available • Risk factors are largely unknown

  3. Research Objectives • Determine the cumulative incidence of HPV infection in a group of female university students • Study the relationship of various characteristics on HPV infection in women

  4. Methods • Recruitment • 1990 to 1997 • Letters sent to a “Random sample” of students • Eligible women (Washington residents, planned to stay for three years) • 603 women recruited out of ~3000 eligible women

  5. Methods • Initial visit • Medical and sexual history, social history • Subjects saw nurse practitioner every 4 months • Face-to-face interview • Standardized pelvic examination • Updated behavioral and medical information • New sex partners • Separate cervical and vulvovaginal swabs sent for HPV DNA tests • Saliva tests sent for HPV DNA tests

  6. Methods • Response variable • HPV DNA: yes/no • Generic probe • HPV Types (Strain) • Time until infection • Previously sexually active: from enrollment date • Virgins: from first sexual encounter

  7. Results • 553 enrolled women with adequate samples • 109 (19.7 percent) had HPV DNA at first visit • 444 HPV-DNA negative at enrollment • 4,307 total visits • 41.2 (st dev 16.3) months follow-up • 9.7 (st dev 3.4) visits per person • 4.3 months median time between visits • 19.2 (st dev 0.5) years, mean age at enrollment • 148 virgins, 94 became sexually active • 1.8 (st dev 1.7) mean lifetime number of partners

  8. Cumulative 24 month Incidence • Sexually active at enrollment • 38.8% (95% CI, 33.3% - 45.0%) • Virgins who initiated sexual activity • 38.9% (95% CI, 29.4 – 50.3) • Vulvovaginal swabs + before cervical swabs • No difference • Between years (p = 0.53) • Virgins vs already sexually active (p = 0.35) • 0, 1-2, 3 partners at enrollment (p = 0.28) • Oral: 5/2500 samples

  9. Cumulative Incidence of HPV Among Sexually Active Women Cumulative incidence of human papillomavirus (HPV) infection among women sexually active and HPV negative at enrollment (n = 296) in Washington State, 1990?2000. Vertical bars, 95% confidence intervals at 12, 24, 36, 48, and 60 months.

  10. Cumulative Incidence of HPV Among Virgins at Enrollment

  11. HR after Acquisition of a New Partner

  12. Potential Risk Factors

  13. Other Risk Factors • Non-pentrative sex for virgins • 9.7% vs. 1.3% • Non risk factors • Partner's (age, race, educational level, circumcision status, sexually transmitted disease history) • Partnership (condom use and alcohol consumption) • Tampon use • Cesarean delivery • Nongenital warts

  14. HPV Types

  15. Discussion • End prevalence was similar to three other studies done in young women • Risk after new partner similar to risk for virgins who became sexually active • Risk is greatest 5 – 8 months after acquiring a new partner • Risk decreases after 13 months • Vulvovaginal swabs may be more sensitive

  16. Discussion • Smoking was associated with increased risk even after adjusting for other risk factors • Most other studies do not show a link between smoking and risk for HPV • Perhaps some confounding sexual behavior • Perhaps current smoking is the key, and the visits every four months were more accurate in recording smoking • Oral contraceptives were associated with increased risk, unlike other studies

  17. Discussion • Condoms showed no reduction in risk consistent with six other studies • HPV is transmissible by non-penetrative sex • A very small percentage of non-sexually active have HPV (<2%) in accordance with other studies • Oral-penile sex was frequent, but oral HPV low • Oral HPV infection is low • Or Test to detect it is not sensitive enough

  18. Limitations • Only 20% of recruited women participated • Comparative studies are often clinic based, which show higher infection rates • Unable to “capture all forms of non-penetrative sex” • Reporting bias • Recall bias (four month intervals) • Unable to capture frequency of sexual exposures or concurrent partners

  19. Limitations • HPV DNA testing methods are much better now • Cohort may not generalize to other populations • Regional bias • Healthy, young, university females • Older • Immunocompromised • Higher partner change

  20. Conclusion/Implications for Practice • New partners increase risk of HPV infection • Not knowing your partner's sexual history increases risk • 0 – 12 months after new partner acquisition is the key screening period • Virgins can have HPV • Non-penetrative sex can lead to infection

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