Teresa M. Darragh

The natural history of human papillomavirus infection as measured by repeated DNA testing in adolescent and young women

OBJECTIVES The objectives of this study were to describe the early natural history of human papillomavirus (HPV) infection by examining a cohort of young women positive for an HPV test and to define within this cohort (1) the probability of HPV regression, (2) the risk of having a squamous intraepithelial lesion, and (3) factors that were associated with HPV regression. STUDY DESIGN The study was a cohort analytic design. An inception cohort of 618 women positive for HPV participated. HPV testing, cytologic evaluation, and colposcopic evaluation were performed at 4-month intervals. HPV testing was characterized for two groups: low risk (five types rarely associated with cancers) and high risk (nine types most commonly associated with cancers). RESULTS Estimates provided by Kaplan-Meier curves showed that approximately 70% of women were found to have HPV regression by 24 months. Women with low-risk HPV type infections were more likely to show HPV regression than were women with high-risk HPV type infections (log rank test p = 0.002). The relative risk for the development of high-grade squamous intraepithelial lesion (HSIL) was 14.1 (95% confidence interval: 2.3, 84.5) for women with at least three positive tests for high-risk HPV preceding the development of the HSIL compared with that for women with negative tests for high-risk HPV. However, 88% of women with persistent positive HPV tests have not had HSIL to date. No factors associated with high-risk HPV type regression were identified except for a negative association with an incident history of vulvar condyloma (relative risk = 0.5 [95% confidence interval: 0.3 to 0.8]). CONCLUSION Most young women with a positive HPV test will become negative within a 24-month period. Persistent positive tests with oncogenic HPV types represented a significant risk for the development of HSIL. However, we found that most young women with persistent positive HPV tests did not have cytologically perceptible HSIL over a 2-year period. Factors thought to be associated with the development of HSIL were found not to be important in HPV regression.

Anal intraepithelial neoplasia in the highly active antiretroviral therapy era among HIV-positive men who have sex with men.

Objectives:The incidence of anal cancer among men who have sex with men (MSM) has continued to increase since the introduction of highly active antiretroviral therapy (HAART). The prevalence of the putative anal cancer precursor, anal intraepithelial neoplasia (AIN) was high among HIV-positive MSM prior to the availability of HAART but little is known about AIN since HAART was introduced. We characterized the prevalence of AIN among HIV-positive MSM and examined the association between AIN and various factors including use of HAART. Design and methods:A baseline point-prevalence analyses in a prospective cohort study of AIN was performed at a university-based research clinic. A total of 357 HIV-positive MSM with no history of anal cancer completed a questionnaire detailing behaviors and medical history, anal cytology and human papillomavirus (HPV) testing, and high-resolution anoscopy with biopsy for detection of AIN. Results:Eighty-one percent of participants with available CD4+ cell counts at baseline had AIN of any grade; 52% had AIN 2 or 3; and 95% had anal HPV infection. In multivariate analysis, detection of ≥ 6 HPV types [odds ratio (OR), 36; 95% confidence interval (CI), 7.4–171) and use of HAART (OR, 10; 95% CI, 2.6–38) were associated with AIN after adjustment for length of time participants were HIV-positive, CD4+ cell count and HIV viral load. Conclusions:The prevalence of AIN has remained high among HIV-positive MSM after the introduction of HAART. Our data indicate that HAART is not associated with a reduced prevalence of AIN and support measures to prevent anal cancer among HIV-positive MSM whether or not they are using HAART.

Regression of low-grade squamous intra-epithelial lesions in young women.

BACKGROUND The aim of this study was to assess the probability of low-grade squamous intra-epithelial lesion (LSIL) regression in young women, and to examine the factors associated with this regression. METHODS In a longitudinal study of human papilloma virus (HPV) infection, female adolescents aged 13-22 years were examined every 4 months by cytology, colposcopy, and HPV DNA status. Both prevalent and incident LSIL cases were included in the analysis, with regression defined as at least three consecutive normal Pap smears. FINDINGS Median follow-up time from baseline (defined as the time of first LSIL diagnosis) for the 187 women with LSIL was 61 months (IQR 34-80). Median time they had been sexually active at diagnosis was 3.2 years (2.6-6.5). Probability of regression for the entire cohort was 61% (95% CI 53-70) at 12 months and 91% (84-99) at 36 months of follow-up. No associations were found between LSIL regression and HPV status at baseline, sexual behaviour, contraceptive use, substance or cigarette use, incident sexually transmitted infection, or biopsy. Multivariate analysis showed that only HPV status at the current visit was associated with rate of regression, whether infection was caused by one or more viral types (relative hazard=0.3 [95% CI 0.21-0.42], and 0.14 [0.08-0.25], respectively). INTERPRETATION The high rate of regression recorded in this study lends support to observation by cytology in the management of LSIL in female adolescents. Negative HPV status was associated with regression, suggesting that HPV testing could be helpful in monitoring LSIL.

The Lower Anogenital Squamous Terminology Standardization Project for HPV-Associated Lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology.

Abstract The terminology for human papillomavirus (HPV)–associated squamous lesions of the lower anogenital tract has a long history marked by disparate diagnostic terms derived from multiple specialties. It often does not reflect current knowledge of HPV biology and pathogenesis. A consensus process was convened to recommend terminology unified across lower anogenital sites. The goal was to create a histopathologic nomenclature system that reflects current knowledge of HPV biology, optimally uses available biomarkers, and facilitates clear communication across different medical specialties. The Lower Anogenital Squamous Terminology (LAST) Project was cosponsored by the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology and included 5 working groups; 3 work groups performed comprehensive literature reviews and developed draft recommendations. Another work group provided the historical background and the fifth will continue to foster implementation of the LAST recommendations. After an open comment period, the draft recommendations were presented at a consensus conference attended by LAST work group members, advisors, and representatives from 35 stakeholder organizations including professional societies and government agencies. Recommendations were finalized and voted on at the consensus meeting. The final, approved recommendations standardize biologically relevant histopathologic terminology for HPV-associated squamous intraepithelial lesions and superficially invasive squamous carcinomas across all lower anogenital tract sites and detail the appropriate use of specific biomarkers to clarify histologic interpretations and enhance diagnostic accuracy. A plan for disseminating and monitoring recommendation implementation in the practicing community was also developed. The implemented recommendations will facilitate communication between pathologists and their clinical colleagues and improve accuracy of histologic diagnosis with the ultimate goal of providing optimal patient care.

High Prevalence of Anal Human Papillomavirus Infection and Anal Cancer Precursors among HIV-Infected Persons in the Absence of Anal Intercourse

Context Anal cancer is associated with human papillomavirus (HPV) infection and receptive anal intercourse and is more common in HIV-positive than HIV-negative homosexual men. Little is known about HPV infection and anal lesions in HIV-positive men with no history of receptive anal intercourse. Contribution In this cross-sectional study of HIV-positive men, 46% of 50 heterosexual men who reported no history of receptive anal intercourse had anal HPV infection and 36% had anal squamous intraepithelial lesions. Low CD4+ cell counts were associated with an increased risk for anal lesions. Implications Anal HPV infection and precancerous lesions occur without receptive anal intercourse in HIV-positive men. The Editors The incidence of anal cancer among men with a history of receptive anal intercourse before the HIV epidemic was several times higher than the current rate of cervical cancer in women in the United States; the incidence of anal cancer is estimated to be as high as 35 per 100 000 in this population (1, 2). Anal cancer is associated with human papillomavirus (HPV) infection (3, 4). Earlier studies of the risk for anal cancer in HIV-negative populations showed that a history of receptive anal intercourse was an important risk factor (2, 5), presumably because it increased the risk for acquiring anal HPV infection. Both anal squamous intraepithelial lesions (SILs) and anal HPV infection are more common in HIV-positive than in HIV-negative men who have sex with men (6-13). Recent studies estimated that the incidence of anal cancer was twofold higher in HIV-infected than in HIV-negative men who had sex with men (14, 15); in addition, the relative risk for developing anal cancer among HIV-positive men was 37-fold higher than in the general population (16). Human immunodeficiency virus-positive men who had sex with men were at 60-fold higher risk. Human immunodeficiency virus-positive injection drug users were also at increased risk (6-fold), although less so than the HIV-positive men who had sex with men. In HIV-positive men who have sex with men, it is difficult to ascertain the role of anal intercourse as a risk factor for anal HPV infection or anal SIL, given the high prevalence of this behavior in this population. Immunosuppression probably plays a role, as indicated in studies showing an association between anal SIL and low CD4+ cell counts (6, 10, 13). In addition, evidence shows that the risk for anal SIL is increased in renal allograft recipients in the absence of receptive anal intercourse (17-19). Cervical cytologic screening to detect cervical high-grade SIL (HSIL) followed by treatment of the lesions substantially reduces the incidence of cervical cancer. Studies of anal cytologic screening to determine whether the incidence of anal cancer can similarly be reduced have not yet been done. However, according to costbenefit modeling over a wide range of assumptions, anal cytologic screening in HIV-positive men who have sex with men has been projected to be cost-effective for preventing anal cancer (20, 21). In this cross-sectional study, we compared the prevalence of and risk factors for abnormal anal histologic or cytologic findings in HIV-positive men who have sex with men with male HIV-positive injection drug users who reported no history of anal intercourse. This was done to assess the role of HIV-related immunodeficiency in detecting anal HPV infection and anal disease in the absence of anal intercourse. In addition, we sought to determine whether the prevalence of anal HPV infection and anal SIL was high enough in HIV-positive injection drug users to warrant additional studies of potential benefit from anal cytologic screening in this population. Methods Study Design Between June 1999 and October 2000, 120 HIV-seropositive men attending the outpatient clinic of Hpital Europen Georges Pompidou, Paris, France, were recruited in a cross-sectional study of anal HPV infection and anal SIL in HIV-seropositive men. Men were eligible for the study if they had acquired HIV through homosexual or bisexual contact or through injection drug use, were older than 18 years of age, and had absolute CD4+ cell counts less than 500 106 cells/L. Injection drug users who had sex with men were excluded from the study. The patients were recruited from a cohort of 1198 HIV-infected patients who were followed at the Clinical Immunology unit of Hpital Europen Georges Pompidou. All patients were consecutively enrolled into the study. No eligible patient declined participation. The Ethics Review Board of Hpital Piti-Salpetrire, Paris, and the Committee on Human Research of the University of California, San Francisco, approved the protocol and written informed consent documents. Patients provided signed written consent before inclusion in the study. All men were interviewed by using a standardized, comprehensive, self-administered questionnaire that included questions on age, education status, professional activity, tobacco use, route of HIV infection, medical history, history of sexually transmitted diseases, history of HPV-related disease, history of treatment for anal disease, drug use, age at first intercourse, total number of sexual partners, total number of receptive and insertive anal intercourse, and history of commercial sex work with men. The questionnaire was a French translation of a questionnaire used in other published studies conducted at the University of California, San Francisco (10). The questionnaires were self-administered, and the investigators were blinded to the results to better ensure patient privacy and accuracy of the data. Cytologic and Histologic Analyses Patients had a thorough anal examination that included insertion of a Dacron swab (Eurotubo, Rubi, Spain) for anal cytologic and HPV testing. The swab was immediately rinsed in a vial of PreservCyt fixative fluid (Cytyc Corp., Boxborough, Massachusetts). Each vial was used for HPV testing and ThinPrep cytologic screening (Cytyc Corp.). An aliquot was taken from the vial for HPV testing; slides were then prepared from the vial by using the ThinPrep 2000 processor (Cytyc Corp.). When cytologic abnormalities were found, consenting patients underwent anoscopic examination and biopsy with the use of a colposcope (22). Biopsy specimens were fixed in 10% formalin for routine histopathologic examination. Anal cytologic and histologic results were evaluated independently of each other, without knowledge of clinical status and HIV risk group of the patient or HPV results. Anal cytologic results were classified as normal, atypical squamous cell of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (LSIL), or HSIL by using the Bethesda system criteria for evaluation of cervical cytologic results. If both cytologic and histologic results were available for analysis, a patients diagnosis was categorized as the more severe result. Detection of Anal HPV DNA Polymerase chain reaction (PCR) for anal HPV DNA detection was performed in a blinded fashion. To determine specimen adequacy, genomic DNA was isolated from the ThinPrep vial and amplified by using MY09/MY11 consensus HPV L1 primers as well as primers to amplify the human -globin gene (9). After 40 amplification cycles, specimens were probed with a biotin-labeled HPV L1 consensus probe mixture. A separate membrane was probed with biotin-labeled probes for the human -globin gene. We performed type-specific probing for the following HPV types individually: 6; 11; 16; 18; 26; 31; 32; 33; 35; 39; 40; 45; 51; 52; 53; 54; 55; 56; 58; 59; 61; 66; 68; 69; 70; 73; Pap 155; Pap 291; AE2; and a mix containing 2, 13, 34, 42, 57, 62, 64, 67, 72, and W13B. We designated samples that were positive with the consensus probes but negative with the individual type-specific probes as having one or more other types. Polymerase chain reaction can be used to discriminate between low-level HPV infection and high-level HPV infection on the basis of intensity of the PCR signal on Southern blot analysis (23), which was recorded on a scale from 0 (negative) to 5. For the purpose of the analysis, a sample that was positive for more than one HPV high-risk types was categorized as the higher PCR signal from the sample. CD4+ Cell Count and Plasma HIV RNA Viral Load We used the CD4+ cell counts and plasma HIV RNA viral loads closest to the period within 2 months of the anal examination. The nadir CD4+ cell count was defined as the lowest count recorded before the study. Absolute numbers of CD4+ T cells were determined by standard flow cytometry. Plasma HIV RNA levels were determined by the branched-chain DNA signal amplification assay (Quantiplex HIV-RNA, Chiron Diagnostics Corp., Emeryville, California). Statistical Analysis We analyzed data by using StatView 5 software (SAS Institute, Inc., Cary, North Carolina). Because most variables had skewed distribution, data are presented as median and ranges. Differences across HIV risk groups were tested with the Fisher exact test (categorical variables) and the nonparametric Mann-Whitney U test (continuous variables). Patients with HPV infection and histologic or cytologic abnormalities were compared with patients with no evidence of HPV infection or anal disease. To identify risk factors for histologic or cytologic abnormalities, the following dichotomous variables were entered into a logistic regression model: age (<35 vs. 35 years), age at first intercourse (<16 vs. 16 years), number of lifetime sexual partners (<40 vs. 40), number of receptive anal intercourse episodes (<10 vs. 10), current smoking, history of anogenital warts, history of sexually transmitted disease (including anogenital herpes, gonorrhea, and syphilis), CD4+ cell count less than 250 106 cells/L, nadir CD4+ cell count less than 100 106 cells/L, plasma HIV RNA viral load greater than 1.7 log copies/mL, previous AIDS-defining event, current antiretroviral treatment, current protease inhibitor tr

Age-Specific Prevalence of Anal Human Papillomavirus Infection in HIV-Negative Sexually Active Men Who Have Sex with Men: The EXPLORE Study

BACKGROUND In the United States, anal cancer in men who have sex with men (MSM) is more common than cervical cancer in women. Human papillomavirus (HPV) is causally linked to the development of anal and cervical cancer. In women, cervical HPV infection peaks early and decreases after the age of 30. Little is known about the age-specific prevalence of anal HPV infection in human immunodeficiency virus (HIV)-negative MSM. METHODS We studied the prevalence and determinants of anal HPV infection in 1218 HIV-negative MSM, 18-89 years old, who were recruited from 4 US cities. We assessed anal HPV infection status by polymerase chain reaction. RESULTS HPV DNA was found in the anal canal of 57% of study participants. The prevalence of anal HPV infection did not change with age or geographic location. Anal HPV infection was independently associated with receptive anal intercourse (odds ratio [OR], 2.0; P<.0001) during the preceding 6 months and with >5 sex partners during the preceding 6 months (OR, 1.5; P<.0001). CONCLUSIONS Urban, HIV-negative MSM have a stable, high prevalence of anal HPV infection across all age groups. These results differ substantially from the epidemiologic profile of cervical HPV infection in women. This may reflect differences between these populations with respect to the number of new sex partners after the age of 30 and may explain the high incidence of anal cancer in MSM.

Colposcopic appearance of anal squamous intraepithelial lesions: relationship to histopathology.

PURPOSE: The incidence of anal cancer is increased in men with a history of anal receptive intercourse. Analogous to cervical cancer, whose precursor is cervical high-grade squamous intraepithelial lesion (HSIL), anal cancer may be preceded by anal HSIL. Although not yet proven, detection, follow-up, and treatment of HSIL may prevent development of anal cancer. Cervical colposcopic methodology was used to describe anal lesions and to determine if HSIL could be distinguished from low-grade squamous intraepithelial lesion (LSIL). METHODS; The colposcopic characteristics of 385 biopsied anal lesions were described and correlated with results of histopathology in a cohort of 121 human immunodeficiency virus-positive and 31 human immunodeficiency-negative homosexual/bisexual men with anal lesions followed as part of a longitudinal study of anal squamous intraepithelial lesions. Color, contour, surface, and vascular patterns of anal lesions were analyzed and correlated with histologic diagnosis. RESULTS: Sixty-seven percent of biopsies showed LSIL and 26 percent showed HSIL. The positive predictive value for anal HSIL in lesions with characteristics typical of cervical LSIL was 7.7 percent (95 percent confidence interval, 1.8–14), whereas the positive predictive value for anal HSIL in lesions with characteristics typical of cervical HSIL was 49 percent (95 percent confidence interval, 40–58). CONCLUSIONS: The colposcopic appearance of different grades of anal squamous intraepithelial lesions was similar to those described for the cervix. Incorporation of colposcopy into assessment of anal disease could aid in distinguishing anal LSIL from HSIL.

The Lower Anogenital Squamous Terminology Standardization project for HPV-associated lesions: background and consensus recommendations from the College of American Pathologists and the American Society for Colposcopy and Cervical Pathology.

The terminology for human papillomavirus (HPV)-associated squamous lesions of the lower anogenital tract has a long history marked by disparate diagnostic terms derived from multiple specialties. It often does not reflect current knowledge of HPV biology and pathogenesis. A consensus process was convened to recommend terminology unified across lower anogenital sites. The goal was to create a histopathologic nomenclature system that reflects current knowledge of HPV biology, optimally uses available biomarkers, and facilitates clear communication across different medical specialties. The Lower Anogenital Squamous Terminology (LAST) project was co-sponsored by the College of American Pathologists (CAP) and the American Society for Colposcopy and Cervical Pathology (ASCCP) and included 5 working groups; three work groups performed comprehensive literature reviews and developed draft recommendations. Another work group provided the historical background and the fifth will continue to foster implementation of the LAST recommendations. After an open comment period, the draft recommendations were presented at a consensus conference attended by LAST work group members, advisors and representatives from 35 stakeholder organizations including professional societies and government agencies. Recommendations were finalized and voted upon at the consensus meeting. The final approved recommendations standardize biologically-relevant histopathologic terminology for HPV-associated squamous intraepithelial lesions and superficially invasive squamous carcinomas across all lower anogenital tract sites and detail appropriate use of specific biomarkers to clarify histologic interpretations and enhance diagnostic accuracy. A plan for disseminating and monitoring recommendation implementation in the practicing community was also developed. The implemented recommendations will facilitate communication between pathologists and their clinical colleagues and improve accuracy of histologic diagnosis with the ultimate goal of providing optimal patient care.

Anal squamous intraepithelial lesions in HIV-positive and HIV-negative homosexual and bisexual men: prevalence and risk factors.

Anal cancer is more commonly found in homosexual and bisexual men than cervical cancer is in women. Invasive anal cancer may be preceded by anal squamous intraepithelial lesions (ASIL), and treatment of ASIL may prevent the development of anal cancer. We characterized the prevalence and risk factors for ASIL in 346 HIV-positive and 262 HIV-negative homosexual men. Anal cytology, biopsy of visible anal lesions, and human papillomavirus (HPV) tests were performed, and data on HIV serostatus, CD4 count, and medical and lifestyle history were collected. ASIL was diagnosed in 36% of HIV-positive men and 7% of HIV-negative men (relative risk [RR] = 5.7; 95% confidence interval [CI], 3.6-8.9). Among HIV-positive men, the RR for ASIL increased with lower CD4 levels but was elevated even in men with CD4 levels >500/mm3 (RR = 3.8; 95% CI, 2.1-6.7) when compared with HIV-negative men. High-level HPV infection, as measured by detection of both hybrid capture (HC) group A and group B types, was another significant risk factor for ASIL in both HIV-positive men (RR = 8.8; 95% CI, 2.3-35) and HIV-negative men (RR = 20; 95% CI, 5.5-71) when compared with HC-negative men. HIV-negative men with anal HPV infection and HIV-positive men, regardless of CD4 level, are at high risk for ASIL.

High prevalence of anal squamous intraepithelial lesions in HIV-positive men despite the use of highly active antiretroviral therapy.

Background The impact of highly active antiretroviral therapy (HAART) on the natural history of HPV infection and anal squamous intraepithelial lesions (SIL) in HIV-infected men who have sex with men (MSM) is poorly documented. Goal The goal of this study was to evaluate the prevalence of anal HPV infection and SIL inpatients under HAART. Study Design Forty-five HIV-infected protease inhibitor-experienced MSM were enrolled in a cross-sectional study. Each patient provided anal samples for anal cytology, histology, and human papillomavirus (HPV) DNA testing. Results The patients had previously received HAART for a median of 32 months. Anal cytology was abnormal in 32 of 45 (71%) patients, including high-grade SIL in 10 patients (22%), low-grade SIL in 19 patients (42%), and atypical squamous cells of undetermined significance in 3 patients (7%). HPV DNA was detected 36/45 men (80%). The prevalence of anal SIL and HPV infection were similar in patients exhibiting a significant increase in CD4+ cell count after HAART initiation compared with those who did not. Conclusion Our results demonstrate a high prevalence of anal SIL, including high-grade SIL, and anal HPV infection in HIV-infected MSM despite immune restoration under HAART.