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ObjectivesSelf-collection of cervico-vaginal samples for human papillomavirus (HPV) testing has the potential to make cervical cancer screening more accessible to underscreened women. We evaluated the acceptability and ease of use of home-based HPV self-collection within a diverse population of low-income, infrequently screened women.MethodsParticipants were low-income women from North Carolina who had not received Pap testing in 4 or more years. Eligible women received a self-collection kit containing instructions and a brush for home-based sample collection. A total of 227 women returned a self-collected sample by mail and completed a questionnaire to assess their experiences with HPV self-collection. We described acceptability measures and used logistic regression to identify predictors of overall positive thoughts about the self-collection experience.ResultsNearly all women were willing to perform HPV self-collection again (98%) and were comfortable receiving the self-collection kit in the mail (99%). Overall, 81% of participants reported positive thoughts about home-based self-collection. Women with at least some college education and those who were divorced, separated or widowed were more likely to report overall positive thoughts. Aspects of self-collection that participants most commonly reported liking included convenience (53%), ease of use (32%) and privacy (23%). The most frequently reported difficulties included uncertainty that the self-collection was done correctly (16%) and difficulty inserting the self-collection brush (16%).ConclusionsHome-based self-collection for HPV was a highly acceptable screening method among low-income, underscreened women and holds the promise to increase access to cervical cancer screening in this high-risk population.

Objectives We sought to identify characteristics of parents who believe in sexual disinhibition and that Pap smears can safely be stopped after females receive the human papillomavirus (HPV) vaccine. Methods We surveyed 647 parents of adolescent girls living in areas of North Carolina with elevated rates of cervical cancer. We report data primarily from a survey conducted in October and November 2008. Results Only 16% (101/647) of parents agreed that teenage girls who receive HPV vaccine may be more likely to have sex. Parents who believed in vaccineinduced sexual disinhibition were more likely to be older (OR 1.89, 95% CI 1.09 to 3.26) or report conservative political views (OR 2.26, 95% CI 1.37 to 3.73). Parents were less likely to believe in sexual disinhibition if they had greater knowledge about HPV vaccine (OR 0.52, 95% CI 0.32 to 0.85) or if their daughters had received HPV vaccine (OR 0.31, 95% CI 0.17 to 0.57). While few parents (5%; 30/647) believed that women could safely stop getting regular Pap smears after receiving HPV vaccine, this belief was somewhat more common among racial and ethnic minority parents (16%) and among fathers (13%). Conclusions Few parents believed that HPV vaccine is likely to lead to increased sexual activity among females or reduce the need for vaccinated women to have regular Pap smears in the future. Characterising parents who hold beliefs in behavioural disinhibition is important as clinicians encountering parents in practice may desire information about this population.

Objective: To examine the type specific seroprevalence of herpes simplex virus (HSV) types 1 and 2 infections, stratified by age and gender, and associated risk factors for HSV-2 seropositivity in Poland. Methods: 2257 serum samples of individuals from 15–65 years were randomly selected from serum banks in four different geographical regions of Poland, including the Zachodnio-pomorskie, Warminsko-mazurskie, Lubelskie, and Mazowieckie districts. Type specific serum antibodies to HSV-1 and HSV-2 were detected using HerpeSelect IgG ELISA tests. Results: Overall prevalences of type specific HSV-1 and HSV-2 serum antibodies were 90.4% and 9.3%, respectively. Age standardised HSV-2 seroprevalence was higher in women (9.7%) than men (8.8%) (p = 0.06), and increased notably with age from 4% in 15–24 year olds to 12% in those aged 50–65 years. HSV-1 seroprevalence was consistently higher than HSV-2 seroprevalence in each specific age group, ranging from 74.5% in 15–24 year olds to 98.8% in 50–65 year olds. HSV-2 seroprevalence varied significantly by geographical region, with the highest prevalence in the Zachodnio-pomorskie district (12%). Significant multivariate risk factors for HSV-2 seropositivity included older age, female gender, and geographical place of residence. Conclusion: This large survey found a notably high seroprevalence of HSV-1, even among young female adolescents 15–19 years of age (80%). HSV-2 seropositivity was under 12% in all age groups surveyed in Poland, tending to be among the lowest overall HSV-2 seropositivity rates reported thus far in Europe.

Objectives: To determine seroprevalence and determinants of herpes simplex virus 2 (HSV-2) seropositivity, in a random sample of a population based cohort of 10 049 women of Guanacaste, Costa Rica, using a highly sensitive and specific serological assay. Methods: Seroprevalence was determined by a type specific HSV-2 ELISA assay in an age stratified random sample of 1100 women. Univariate and multivariate logistic regression was used to calculate odds ratios and 95% confidence intervals for risk factors of seropositivity. Results: Overall age adjusted HSV-2 seroprevalence was 38.5% (95% CI, 37.5 to 39.5), and it was strongly associated with increasing age (p Trend ), both among monogamous women and women with multiple sexual partners. A greater number of lifetime sexual partners increased the risk of seropositivity, with a 28.2% (95% CI, 24.4 to 32.2) seroprevalence among monogamous women and 75% (95% CI, 65.6 to 83.0) seroprevalence for those with four or more partners (OR = 7.6 95% CI, 4.7 to 12.4 p Trend ). Barrier contraceptive use was negatively associated with HSV-2 seropositivity (OR 0.54, 95% CI, 0.31 to 0.94). Women with antibodies against HPV 16, 18, or 31 were 1.6 times more likely to be HSV-2 seropositive (OR 1.6, 95% CI, 1.2 to 2.1). Conclusions: HSV-2 infection is highly endemic in Guanacaste, even among lifetime monogamous women, suggesting a role of male behaviour in the transmission of the infection. Until vaccination against HSV-2 is available, education to prevent high risk sexual behaviour and the use of condoms appear as preventive measures against HSV-2.

Objective: To elucidate which anatomical sites need to be sampled to detect human papillomavirus (HPV) infection in the lower male genital tract. Method: In an HPV survey of Mexican soldiers (median age 24 years; range 16–50 years), a cell sample from 2 cm deep into the distal urethra (group 1; n = 168 men), or 0.5 cm deep into the meatus urethralis (group 2; n = 414 men) was collected, along with a sample from the external genitalia. The different samples were tested for 27 HPV types using a polymerase chain reaction based strip assay. Results: HPV DNA was detected more frequently in external genitalia samples (46.4%) than in the urethra (20.8%) or meatus samples (12.1%). Lack of samples from the urethra or meatus would have led to 5.1% and 1.5% false HPV negative results, respectively. The most frequently detected high risk HPV types (HPV 59, 52, 51, and 16) were similar in different sites, whereas low risk types were found rarely in urethra samples. Conclusions: The addition of cell samples from the meatus to those from external genitalia contributed negligibly to the evaluation of the prevalence of HPV in men. HPV detection was slightly improved by the addition of urethra samples, but the gain may not justify the discomfort of the procedure in large epidemiological studies.

The systematic review and meta-analysis by Lissouba and colleagues adds to mounting data showing a strong association between genital human papillomavirus (HPV) infection and the risk of HIV acquisition, with an estimated summary odds ratio of 2.0 (95% confidence interval 1.6 to 2.5) for HIV acquisition associated with any-HPV infection. The strongest reported estimates are specific to clearance of HPV infection, suggesting that the association between HPV and HIV acquisition may not be fully attributable to confounding by other sexually transmitted infections (STIs) or co-transmission.1 ,2 …

Objectives Human papillomavirus self-tests that can be used at home and returned by mail may increase cervical cancer screening rates. Growing evidence suggests that self-test methods could increase screening for high-risk and hard-to-reach populations. The purpose of this study was to identify which self-test device women prefer and why. Methods Four focus groups were conducted with 30 high-risk women in two rural and two urban counties in North Carolina. Women evaluated three self-test devices: the Pantarhei screener (a lavage that releases liquid into the vagina and re-collects fluid), the Qiagen cervical brush (a brush that women insert into the vagina and is turned around to collect cells) and the Fournier cervical self-sampling device (a tampon-like plastic wand). Results The majority of women reported that they would use the brush (70%), followed by the wand (67%) and the lavage (43%). Women from urban areas appeared to prefer the brush, whereas women from rural areas endorsed the wand. Women reported liking the lavage because it seemed easy to use; they liked the wand because of its inviting colour (green), and liked the brush because of its small size and familiarity. Women reported disliking the lavage because the liquid seemed messy and unsanitary, disliked the wand due to the 15–20 recommended turns, and disliked the brush because it was short and the tip seemed abrasive. Conclusions No one device was perfect, although suggestions for an optimal self-test most resembled the brush. These findings can be used to develop an optimal self-test collector for women.

HIV-infected women are living longer and are at a higher risk of acquiring cervical cancer. More data comparing cervical cancer screening and treatment strategies in these women are urgently needed. WHO guidelines on optimal methods to screen and treat cervical cancer are available, but there are limited data to inform their potential modification for HIV-infected women. Even fewer data are available which compare the efficacy of treatment methods (loop electrosurgical excision procedure (LEEP) and cryotherapy) and differences in cervical disease recurrence between HIV-infected and HIV-uninfected women. HPV testing appears to be the most sensitive, although less specific for CIN-2+ detection than either VIA and cytology screening. Several studies of HIV-infected women have shown equivalent sensitivity of VIA and of cytology screening for CIN-2+, although there is variation in results. Consistently across studies, the specificity of cytology appears higher than either VIA or for high-risk HPV testing. Two studies in South Africa and Kenya have suggested that the specificity of HPV testing and VIA for detection of high grade lesions is lower in HIV-infected women with lower CD4 counts; more research is needed to examine if screening test performance varies for HIV-infected women with higher versus lower CD4 counts. More research in HIV-infected women is needed to examine if LEEP and cryotherapy treatment methods are associated with differences in HIV-viral shedding and in HIV transmission during or shortly after treatment. HIV-infected adolescents have found to induce high-levels of neutralizing antibody titers following prophylactic HPV vaccination in bridging studies. Studies are not yet available on HPV vaccine efficacy in HIV infected women against either HPV-infection or clinical disease endpoints.

Background Trichomonas vaginalis (TV) is the most common curable sexually transmitted infection worldwide. True prevalence of TV infection is not well characterised as previous studies mainly used methods with relatively poor sensitivity compared to nucleic acid amplification methods. Our aim was to determine TV prevalence using the APTIMA TV Assay (ATV, Gen-Probe Incorporated) and the frequency of co-infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoea (NG) in the USA among women being screened. Methods Samples from 7593 women aged 18–89 years undergoing routine CT and NG screening at obstetrics/gynaecology, emergency room, hospital in-patient, family practice, family planning, internal medicine, jail, and STD clinic populations in 21 states were collected. Consecutive samples previously tested for CT and NG by the APTIMA COMBO 2 Assay (Gen-Probe Incorporated) were retrospectively tested with the ATV assay. Endocervical, urine, vaginal swab and PreservCyt liquid Pap samples (Hologic Inc.) diluted into APTIMA specimen transport buffer were tested. Results Overall prevalences of TV, CT and NG in surveyed women were 8.7%, 6.7%, and 1.7%, respectively. TV prevalence ranged from 7.5 to 8.6% in women age 18 to 39 yr, and increased to 9.8% in women age 40–44 yr. Highest observed TV prevalences were in women ages 45–49 yr (13.4%) and over 50 yr (13.0%). CT and NG prevalences were less than 2% in the 40+ age group and highest in women less than 30 years of age ranging from 5.2% to 14.3% for CT and 1.3%–3.3% for NG. TV was the more prevalent STD than either CT or NG in all age groups, except the 18-19 yr group (CT: 14.3%; TV: 8.5%). TV prevalence differed by race/ethnicity (20.2% blacks; 5.7% whites; 5.0% Hispanics; 3.8% Asians). TV prevalence was 14.4% in the Southeast, 9.5% in the Southwest and Midwest, and 4.3% in the Northeast and ranged from 5.4% in Family Planning clinics to 22.3% in jails. Co-infections in most age groups were Conclusions TV prevalence was highest in women over 40 years of age, in contrast to CT and NG prevalences which were highest in women under 30 years of age. Co-infection of TV with CT or NG was relatively low. The high TV prevalence in all age groups suggests that all women being screened for CT/NG should also be screened for TV. Routine TV screening should also be considered for at-risk sexually active women of any age.

Genital herpes caused by herpes simplex virus (HSV) infection is one of the most prevalent sexually transmitted infections (STIs) and the most common cause of genital ulcer disease (GUD) in developed and developing countries. The monitoring of HSV-2 seroprevalence in pregnant women can identify women at a higher risk of HIV and of neonatal HSV transmission. Very few data are available on type specific seroprevalence of HSV-2 in China, with only one previous study from southern China. Consequently, we conducted a survey to determine type specific seroprevalence of HSV-2 and associated risk factors in Fuzhou City, eastern China.

Background Prevalence of Mycoplasma genitalium is higher in vulnerable populations of women in low-resource settings; predictors for infection, however, are not well understood. This study aimed to determine the prevalence of Mycoplasma genitalium and its associated risk factors among female sex workers in Nairobi, Kenya. Methods A total of 350 FSW aged 18–50 years old participated in this cross-sectional study from 2009 to 2011. A questionnaire was administered at baseline to obtain information on sociodemographics and sexual behaviours. Physician-collected cervical samples were tested for M. genitalium mRNA and other sexually transmitted infections using transcription-mediated amplification-based APTIMA assays (Hologic/Gen-Probe Inc.). Cervical cytology was conducted using physician-collected specimens and classified according to the Bethesda criteria. Results The median age in the study was 28 (range: 18–48). Prevalence of M. genitalium was 12.7%. In the multivariate model, younger age was associated with a higher risk of M. genitalium, whereby women greater than 30 years old were less likely to have infection (OR [95% confidence interval] = 0.3 [0.1.0.9] versus women less than 30 years old). Women who reported using condoms at least “most of the time” were more likely to be infected with M. genitalium than women who reported using condoms “half the time or less.” Relative to those with normal cytology, women with cytology results of either high-grade squamous intraepithelial lesions or squamous cell carcinoma had a higher prevalence of M. genitalium (23.1% vs. 16.2%), although effect estimates were relatively imprecise. Conclusions Younger women within a vulnerable population appear to be at greater risk of M. genitalium infection. The reverse association between condom use and M. genitalium may be due to social desirability bias. Further investigation of the association between M. genitalium infection and high-grade cervical cytology is warranted.

Background We know little about policy issues at state level that impede cervical cancer efforts in the US. This study identifies and explores state policy issues in cervical cancer to inform future policy and programme strategies. Methods Sixty minute key informant interviews were conducted with 15 professionals working in and around cervical cancer: federal and state government breast and cervical cancer programmes; women’s health and cancer control; national advocacy organisations engaged in sexual health and cancer; legislative affairs; researchers working in cervical cancer intervention and evaluation; state coalitions engaged in cervical cancer efforts; and partners from industry working on diagnostics, therapeutics or vaccines. Results State policy issues included health system complexity; lack of state level cervical cancer programme and policy coordination, and socio-organisational culture issues. System complexity was fueled by disparate and uncoordinated financing, controlled by different state programmes/agencies. A paucity of state level coordination exacerbated by a lack of cervical cancer inter-agency/programme influence prevented comprehensive, streamlined systems of care. Despite recent efforts to coordinate statewide cancer planning, cervical cancer issues and actors were not active in state priority setting. Socio-organisational cultural issues prevented normalisation of HPV vaccine for boys and girls, as well as programme and practitioner adoption of recent screening recommendations focused on identifying and monitoring persistent HPV. Conclusions Critical state policy issues are not ‘big p’ issues or laws, but ‘small p’ issues of implementation and unintended systems outcomes of policy. Cross-agency, statewide planning could streamline systems for comprehensive and coordinated funding and policy. Critical need to address state leadership vacuum for cervical cancer efforts. Increasing the policy acumen and skill set of cervical cancer related programmes and coalitions could facilitate change navigation. Success at this ‘small p’ policy level will help to make big strides toward removing structural barriers to cervical cancer efforts in the U.S.

Background Invasive cervical cancer is the most common cancer is Sub-Saharan Africa partly due to lack of effective screening programmes and the HIV epidemic. The baseline analysis of a South Africa study comparing three cervical cancer screening methods, i.e. cytology, visual inspection with acetic acid (VIA) and HPV testing in HIV-infected women, has been completed and quality assurance of VIA interpretation was evaluated. Methods HIV-infected women, aged 18–65, were recruited from Johannesburg, South Africa and VIA performed with 5% acetic acid. Nurses received a two-week training on the VIA procedure. VIA interpretation by the nurse and recording of a digital image was performed in real time. The study physician reviewed weekly the digital imaging and recorded their own interpretation of the VIA appearance. Women with a positive VIA and 25% of women with a negative VIA had confirmatory colposcopic biopsy. Sensitivity and specificity for VIA interpretation for cervical intraepithelial neoplasia (CIN)-2 + for both the nurse and the doctor were compared retrospectively. Results 1202 HIV infected women with a median age of 37 years and CD4 of 394 cells/mm3 participated. 45% of the women had a positive VIA result. Sensitivity and specificity for VIA to determine CIN 2+, as performed by the nurse and doctor, was 65.4% (59.7–71.1)/68.5% (65.3–71.7) and 75.5% (70.5–80.4)/68.1(65.0–71.3) respectively. There was no statistical difference in the VIA readings comparing the first 600 VIA interpretation to the final 593 VIA readings [nurse (p = 0.613) or doctors (p = 0.624)]. Evaluating the first 300 VIA to the final 300 results was also similar (p = 0.505 for nurse; p = 0.802 for doctors). Conclusion Throughout the study there was no statistical difference in the sensitivity in interpreting VIA. These results show that after two weeks of training, nurses were consistent in their VIA readings and could accurately predict 65.4% of CIN 2+.

Background To determine the efficacy of self-collection for primary screening of an array of sexually transmitted infections. Methods A cross-sectional baseline analysis was conducted on a cohort of 300 female sex workers (FSW) within an outpatient clinic from a suburban/slum area of Nairobi, from December 2009 to June 2010. APTIMA transcription-mediated amplification (TMA) assays (Gen-Probe Incorporated) were used for the detection of Chlamydia trachomatis (CT), Neisseria gonorrhoeae (GC), Trichomonas vaginalis (Trich) and Mycoplasma genitalium (MGen) infections and, were analysed in San Diego, California. The APTIMA COMBO 2 assay (AC2) was used for CT/GC, the APTIMA Trichomonas vaginalis assay for Trich, and an APTIMA Mycoplasma genitalium research assay for Mgen. FSW conducted a self-collected sample in privacy, based on standardised instructions, and then underwent a pelvic exam to obtain a physician-collected sample. Results A total of 299 FSW (mean age of 30) participated, of which 15% were HIV-seropositive. MGen was the most common infection (12.7% in physician; 20.7% in self-collection), followed by Trich (7.7%; 9.7%), CT (4.3%; 5.4%), and GC (2.7%; 3.3%). For all STIs examined, the self-collected samples detected more positive cases than the physician-collected samples. No self-collected sample missed an infection that was picked by the physician sample. κ for agreement between self-collected and physician-collected samples were high for CT: 0.89, GC: 0.89 and Trich: 0.87, and slightly lower for MGen: 0.73. Using physician sampling as the gold-standard, the sensitivity of self-collection was 100% for all STIs. The specificity for self-collection was high for CT, GC, and Trich (99.0%, 99.3% and 97.8% respectively) and slightly lower for MGen (91.6%). Conclusion A single self-collected sample appeared to perform with comparable sensitivity and specificity to that of physician-collected sampling for the detection of Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and Mycoplasma genitalium .

Background African Americans (AAs) make up 12% of the US population, yet they account for about half of all reported chlamydia and syphilis cases, and 70% of gonorrhoea cases. Targeted, culturally sensitive interventions are needed to address these disparities. This study sought to explore how AAs perceive STIs in their communities, and what they feel should be done to address the problem. Methods Triads (n=31) and individual interviews (n=64) were conducted with sexually active, heterosexual AA adults, ages 18-45, in four communities with high STI incidence. Triads were segmented by age, gender, and urban/rural residence. Interviewers (gender/race-matched) used a semi-structured guide to explore awareness and importance of the STI problem in AA communities, perceptions of contributing factors and high-risk groups, and suggested solutions. Discussions were audio-taped and transcribed. A team of three analysts coded transcripts using QSR NVivo8, based on a codebook developed from identified themes. Results A total of 158 adults participated. Overall, STDs were believed or presumed to be very common in AA communities. Many had heard about the disparate STD/HIV rates on the news/TV or in school. Men were more likely to challenge this, reasoning that AAs are heterogeneous and that STIs are more likely influenced by socioeconomic status (SES) than race. Participants identified youth, low SES groups, drug addicts, Sex workers, homosexuals, and men on the down low as highest-risk groups. Promiscuity and a lack of sexual-health education, care for self/others/future, and health-care access were seen as major causes. Other contributing factors were teen pregnancy/family disintegration, gangs, drugs, school dropouts, unemployment, poverty, boredom, hopelessness, male/female ratio, partner concurrency, and the media. Overall, STIs were seen as a relatively low priority. Yet most felt that change is critical and could be promoted through music, mass media, faith-based/community/organizational, electronic and interpersonal channels. Increasing information, education, and healthcare access; and developing parenting, self-esteem boosting, and mentoring programs were suggested. Conclusions STDs among AAs are recognised as a likely consequence of many underlying social, structural and community ills, which must be addressed to reduce STD disparities. Traditional STD prevention efforts must be supported by non-traditional social/structural interventions.