HPV prevalent in a key population in India – potential for vaccination

Prevalence of anal HPV infection among HIV-positive men who have sex with men in India.

Hernandez AL, Karthik R, Sivasubramanian M, Raghavendran A, Gnanamony M, Lensing S, Lee JY, Kannangai R, Abraham P, Mathai D, Palefsky JM. J Acquir Immune Defic Syndr. 2016 Apr 1;71(4):437-43. doi: 10.1097/QAI.0000000000000855.

Background: India has a large population of HIV-positive individuals, including men who have sex with men (MSM), and the incidence of human papillomavirus (HPV)-related cancers is high. In developed countries, HIV-positive MSM exhibit the highest prevalence of anal HPV infection and incidence of anal cancer. Little is known about anal HPV infection in HIV-positive Indian MSM.

Methods: We evaluated 300 HIV-positive MSM from 2 cities in India. Men were tested for anal HPV infection using L1-HPV DNA polymerase chain reaction with probes specific for 29 types and a mixture of 10 additional types. CD4 level and plasma HIV viral load were measured. Participants completed an interviewer-administered questionnaire including a sexual history.

Results: The prevalence of anal HPV was 95% (95% confidence interval: 91% to 97%). The 3 most common types were HPV 35 (20%), HPV 16 (13%), and HPV 6/11 (13%). History of taking antiretroviral medications decreased risk of anal HPV 16 infection [relative risk (RR): 0.6 (0.4-1.0)]. Having an increased number of vaginal sex partners lowered risk of any anal HPV infection. Ever having receptive sex increased risk of any anal HPV [RR: 1.2 (1.1-1.4)] and anal HPV 16 [RR: 6.5 (1.8-107)].

Conclusions: Almost all Indian HIV-positive MSM had anal HPV infection. The prevalence of HPV 16 was lower and the prevalence of other oncogenic HPV types was higher than in similar populations in North America and Europe. Vaccine-based prevention strategies for HPV infection in India should consider potential differences in HPV type distribution among HIV-infected MSM when designing interventions.

Abstract access   [1]

Editor’s notes: This is the first report of anal human papilloma virus (HPV) prevalence and associated risk factors among HIV-positive gay men and other men who have sex with men in India. The incidence of HPV-associated anogenital disease is high in Indian men and women. Given that Indian men who are HIV-positive have an increased risk of anal cancer compared to HIV negative men, data on HPV infection in this population is warranted.

The authors report a high prevalence of any HPV type (95%) and any oncogenic HPV type (49%), similar to reports among other HIV-positive gay men and other men who have sex with men in northern America and Europe. An important distinction within this cohort is that many of these men self-identify as bisexual. Just under half (47%) reported being married and two-thirds (62%) reported having at least one female sex partner in their lifetime. This finding has important implications for HPV transmission between gay men and other men who have sex with men and female partners, given the high HPV prevalence in this population. HPV vaccination of key populations has the potential to reduce this transmission.

HPV vaccination in HIV-negative men and women with evidence of prior infection has been shown to confer protection against infection from other HPV types. Men in this cohort had an average of 1.7 oncogenic HPV infections, and so a broader spectrum vaccine such as the 9-valent vaccine which targets seven of the oncogenic HPV types (16/18/31/33/45/52/58) could still protect against acquisition of other vaccine types. Notably, the most common oncogenic type detected was HPV35 which, although not targeted by any of the currently available vaccines, is implicated in cervical cancer. While HPV16 and 18 are the types most commonly found in anal cancer in the general population and in cervical cancer among HIV-positive and negative women, little is known about the association of HPV types with anal disease in people living with HIV. Additional studies are necessary to firstly determine the incidence of anal cancer among HIV-positive gay men and other men who have sex with men in India, and secondly to evaluate which HPV types are linked to anal disease in order to estimate the fraction of disease that could be prevented through vaccination. Further, HPV vaccination of gay men and other men who have sex with men in India could confer additional protection to their female partners through a reduction in transmission of oncogenic HPV types, resulting in a consequent reduction in cervical disease attributed to these HPV types.   

Comorbidity [3], Epidemiology [4]
Asia [5]
India [6]
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