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R.L. Winer, Shu-Kuang Lee, J.P. Hughes, D. E. Adam, N.B. Kiviat, L.A. Koutsky

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 of Female University Students.

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R.L. Winer, Shu-Kuang Lee, J.P. Hughes, D. E. Adam, N.B. Kiviat, L.A. Koutsky

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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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