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Journal of Clinical Virology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners Laura Lorenzon a,∗ , Irene Terrenato b , Maria Gabriella Donà c , Livia Ronchetti d , Francesca Rollo d , Ferdinando Marandino d , Mariantonia Carosi d , Maria Grazia Diodoro d , Steno Sentinelli d , Paolo Visca d , Giuseppe Vocaturo e , Paola Bellardini f , Amina Vocaturo d,1 , Maria Benevolo d,1 a Surgical and Medical Department of Translational Medicine, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Sant’Andrea Hospital, Rome, Italy b Biostatistics Unit, Scientific Direction, “Regina Elena” National Cancer Institute, Rome, Italy c STI Unit, “San Gallicano” Dermatological Institute, Rome, Italy d Pathology Department, “Regina Elena” National Cancer Institute, Rome, Italy e Oncologic Gynecology Department, “Regina Elena” National Cancer Institute, Rome, Italy f Screening Program, Latina, Italy
a r t i c l e
i n f o
Article history: Received 26 August 2013 Received in revised form 29 March 2014 Accepted 6 April 2014 Keywords: Human papillomavirus HPV concordance HPV transmission Sexually transmitted disease Male infection
a b s t r a c t Background: HPV is one of the most common sexually transmitted infections. However little is known about its prevalence in the male population and concordance with female partners. Objectives: This cross-sectional study aimed to: (a) investigate HPV prevalence and genotype distribution among a series of stable male sexual partners of CIN/HPV positive women and (b) assess HPV infection and type-specific concordance between partners. Study design: 378 stable and monogamous male partners of CIN/HPV positive women were selected. Of these, 238 cases were enrolled at the same time as their female partner. All the subjects were tested by the Linear Array HPV genotyping assay. Results: Overall, 153/378 men (40.5%) and 122/238 women (51.3%) were positive for at least one of the 37 HPV types detectable by the assay used. Among the HPV-positive participants, 69 of the 378 men (18.2%) and 54 of the 238 women (22.7%) harboured multiple genotypes. 75 couples (31.5%) were concordantly HPV positive, while 102 couples (42.9%) were concordantly negative (Kappa value: 0.491, p < 0.0001). Among the couples in which both partners were HPV positive, 68% harboured at least one genotype in common. Results from a GEE model evidenced that when the male partner tested HPV positive for at least one genotype, this had a significant effect on the positivity of their relative female partner (p < 0.0001). Conclusions: We evidenced a high prevalence of HPV male infections and a moderate concordance between partners. However, we observed a significant HPV type-specific correlation between partners, which is unlikely to be coincidental. © 2014 Elsevier B.V. All rights reserved.
Abbreviations: HR, high risk; LR, low risk; HPV, human papillomavirus; LSIL, low grade squamous intra-epithelial lesion; HSIL, high grade squamous intra-epithelial lesion; CIN, cervical intra-epithelial neoplasia; ASCUS, atypical squamous cells of undetermined significance; NILM, negative for intraepithelial lesion or malignancy; CS, clinical status; GEE, generalized estimating equation. ∗ Corresponding author at: Surgical and Medical Department of Translational Medicine, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Sant’Andrea Hospital, Via di Grottarossa 1035-39, 00189 Rome, Italy. Tel.: +39 0633775989; fax: +39 0633775322. E-mail addresses: [email protected], [email protected] (L. Lorenzon). 1 Both the authors contributed equally to the study. http://dx.doi.org/10.1016/j.jcv.2014.04.003 1386-6532/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
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1. Background Persistent infections by high-risk (HR) HPV genotypes are known to be the necessary cause of cervical cancer. However, the number of HR HPV-related cancers has been extended to other female and male tumours (e.g. oropharynx, vulva, anus, vagina and penis carcinomas) [1,2]. Despite these findings, to date, only a few studies have analysed the prevalence of HPV infections in the male genitals [3–6], where the virus usually remains latent or produces sub-clinical lesions [7,8]. In addition, studies investigating HPV infection in the male population have reported discordant data. In fact, the comparisons have been hampered by methodological differences in the sampling sites, in collection techniques, in the population enrolled and in the methods used for HPV detection [4,9–11]. Therefore, studies are needed which aim to outline HPV infection in males and to investigate sexual partners in order to understand the role of men in HPV transmission. To date, only a limited number of couple-based studies have investigated man–woman HPV-concordance and the results are very discordant, mostly due to the criteria adopted in order to define enrolment criteria, HPV infection status (positive or negative) and type-specific concordance [12–16]. Moreover, the vast majority of studies failed to consider the minimum duration of the relationship [17,18]. 2. Objectives On the basis of the background mentioned above, we conducted this study in order to: (a) describe HPV prevalence and genotype distribution among a selected series of clinically healthy Italian men who were active, stable and monogamous sexual partners of women that had been previously or presently affected by CIN and/or HPV positive and (b) investigate HPV infection status and genotype concordance between partners in a subset of this cohort. Furthermore, we investigated the probability of a woman being infected by a certain HPV genotype in relationship with the HPV positivity of her matched male partner. 3. Study design 3.1. Study population From November 2005 to March 2010, 441 heterosexual couples were referred to the Day Clinic of the Pathology Department of the Regina Elena National Cancer Institute of Rome for routine HPV testing. Among them, 330 agreed to participate in this study (response rate: 75%). Both partners were interviewed individually and face-to-face to ascertain the following inclusion criteria: (a) having been engaged in a stable monogamous relationship (vaginal sexual intercourse) for at least 12 months; (b) no use of a condom for at least the 12 months preceding enrolment. In addition, the female partner had to have been previously (in the past 3 years) or presently affected by a CIN lesion and/or HPV positive at the cervix while the male partner had to have been free of sexually transmitted diseases in the 12 months preceding the enrolment and with no current external genital warts. Based on these criteria, 238 out of the 330 couples (72%) were enrolled. Additionally, during the same period, 236 men, referred to the Day Clinic of the Pathology Department of the Regina Elena National Cancer Institute for HPV testing, came without their partner. 184 of these agreed to participate in this study (response rate: 80%) and 140 of these (74%) fulfilled the above-mentioned inclusion criteria, which were ascertained through face-to-face interviews.
In conclusion, the study population consisted of 238 matched couples (238 males and 238 females), plus 140 males that met the inclusion criteria (total: 378 males and 238 females). The histological diagnosis was known for 66 women, of which 61 had a CIN1 and 5 had a CIN2/3. The histological diagnoses prior to enrolment were available for 109 women and were as follows: 84 CIN1 and 25 CIN2/3. Overall, the data collected regarding the socio-demographic, behavioural and clinical factors of the participants and of the couples met the majority of the indications suggested by Reiter [19], except for the lack of information regarding the number of lifetime sexual partners, age at first intercourse and marital status. The study was approved by the Ethics Committee of the Regina Elena National Cancer Institute and written informed consent was obtained from all the participants. 3.2. Specimen collection All the patients enrolled in the present study were instructed not to have sexual intercourse in the week before the sample collections in order to avoid contamination. (a) Men. A single cytobrush was used to collect exfoliated cells from different penile areas: the dorsal and ventral area of the penile shaft, external and internal surface of the prepuce, coronal sulcus, glans and distal urethra. The cells were collected in a ThinPrep vial/patient (Hologic), and stored at 4 ◦ C until processing. The men were invited not to wash their external genitalia the morning of the collection in order to increase the number of the cells in the sample. (b) Women. Cervicovaginal samples were collected by a cytobrush and an Ayre spatula (Hologic), and stored in a ThinPrep vial at 4 ◦ C until use. 3.3. HPV DNA detection and genotyping All the 20 ml of the male samples were centrifuged and the resulting pellet was re-suspended and utilized for DNA extraction (AmpliLute Liquid Media Extraction kit – Roche Diagnostics). The amplification and detection were performed by the Linear Array HPV Genotyping Test (Roche Diagnostics) [20]. The hybridization steps were carried out using the Profiblot T48 (Tecan, Roche Diagnostics). This assay detects 37 anogenital HPV types. For the purposes of this study, samples were considered to be: HR-HPV positive when positive for any of the 13 genotypes classified as carcinogenic or probably carcinogenic (including 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68), LR-HPV positive when positive for any of the 9 genotypes classified as low risk (types 6, 11, 40, 42, 54, 61, 72, 81 and CP6108), while the other genotypes (including 26, 53, 55, 62, 64, 66, 67, 69, 70, 71, 73, 82, 83, 84 and IS39) were considered other HPV [21,22]. 3.4. Statistical methods The differences in the rate of HPV positivity, the HR and nononcogenic HPV distribution and the rate of multiple infections were tested by the Mann–Whitney test. The agreement between male and female HPV status was estimated by using the raw agreement and the Cohen’s Kappa statistic, which was interpreted on the basis of the Landis and Koch classification criteria [23]. A Chi-square test was used to evaluate HPV concordance and distribution in positive couples. To assess the HPV-type-specific relationship between man and his relative partner, taking potential co-infections into account, we conducted a generalized estimating equation (GEE) model [24]. The GEE model was used, clustered by couple ID and run in a
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
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multivariate mode by adjusting for male status (positive at any genotypes vs. negative) and for the serial correlation within subjects variable, that is, the different HPV-genotypes ranked by the observed incidence in the male distribution using HPV83, one of the less frequent, as reference category. The dependent variable was binomial (female HPV status: positive at any genotypes vs. negative) and therefore, the logit link function was used. A p-value 1 HPV type
4. Results
Men n 378 n (%)
Women n 238 n (%)
p-Value#
153 (40.5) 87 (23.0) 72 (19.0) 62 (16.4) 69 (18.2)
122 (51.3) 84 (35.3) 40 (16.8) 40 (16.8) 54 (22.7)
0.009 0.0009 0.482 0.895 0.180
Men n 69 n (%)
4.1. Patient characteristics and HPV distribution 378 men (mean age: 39 years ± 10.2, range 18–68) were enrolled. 238 of them (mean age 40 ± 10.0, range 19–67) were enrolled together with their female partner. The 238 women had a mean age of 37 years ± 9.7 (range 18–65). All patients were Caucasians, had attended high school or a higher institution, and thus were considered to be of an intermediate socio-economic status. None of the men were circumcised. Table 1 shows the absolute HPV positivity in penile and cervicovaginal specimens. The data are displayed according to oncogenic risk and number of HPV types. 153 men (40.5%) and 122 women (51.3%) were positive for at least one of the 37 HPV types. We observed a statistically significant difference when comparing the male and female populations (p 0.009). In particular, 87 men (23.0%) and 84 women (35.3%) were infected with at least one HR HPV genotype (p 0.0009).
Women 54 n (%)
(b) n of HPV types in patients positive for more than 1 HPV type 34 (49.3) 27 (50.0) 2 24 (34.8) 11 (20.4) 3 7 (10.1) 15 (27.8) 4 4 (5.8) 1 (1.8) 5 a Any HPV: positive for any HPV among the 37 types detectable by the Linear Array test. Any HR: positive for any HPV among the 13 types classified as carcinogenic/probably carcinogenic. Any LR: positive for any HPV of the 9 types classified as low-risk. Other HPVs: positive for any of the types other than HR and LR. >1 HPV type: positive for more than 1 HPV type. # p-Values were calculated by the Mann–Whitney non-parametric test comparing male and female populations
Table 2 HPV genotype distribution in the study populations. Both relative and absolute percentages are given. “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy. HPV type
16 CP6108 53 6 42 31 62 59 84 73 51 81 54 18 58 61 52 66 55 56 39 82 40 45 67 11 33 35 70 71 83 26, 64, 68, 69, 72 and IS39 a
Men n (%)a
Women n (%)a
N = 153 (HPV-positive)
N = 378
N = 122 (HPV-positive)
N = 238
34 (22.2) 23 (15.0) 22 (14.4) 21 (13.7) 18 (11.8) 16 (10.5) 14 (9.2) 12 (7.8) 12 (7.8) 11 (7.2) 10 (6.5) 10 (6.5) 9 (5.9) 8 (5.2) 7 (4.6) 7 (4.6) 5 (3.3) 5 (3.3) 4 (2.6) 4 (2.6) 3 (2.0) 3 (2.0) 2 (1.3) 2 (1.3) 2 (1.3) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 0
9.0 6.1 5.8 5.6 4.8 4.2 3.7 3.2 3.2 2.9 2.6 2.6 2.4 2.1 1.9 1.9 1.3 1.3 1.1 1.1 0.8 0.8 0.5 0.5 0.5 0.3 0.3 0.3 0.3 0.3 0.3 0
36 (29.5) 11 (9.0) 16 (13.1) 3 (2.5) 15 (12.1) 19 (15.6) 8 (6.6) 5 (4.1) 6 (4.9) 7 (5.7) 9 (7.4) 4 (3.3) 7 (5.7) 7 (5.7) 8 (6.6) 9 (7.4) 6 (4.9) 6 (4.9) 5 (4.1) 7 (5.7) 5 (4.1) 1 (0.8) 1 (0.8) 3 (2.5) 3 (2.5) 1 (0.8) 5 (4.1) 3 (2.5) 1 (0.8) 1 (0.8) 3 (2.5) 0
15.1 4.6 6.7 1.3 6.3 8.0 3.4 2.1 2.5 2.9 3.8 1.7 2.9 2.9 3.4 3.8 2.5 2.5 2.1 2.9 2.1 0.4 0.4 1.3 1.3 0.4 2.1 1.3 0.4 0.4 1.3 0
Total sum of the percentages of patients exceeds 100% due to patients with more than one HPV type. Bold numbers refer to the most frequently detected types.
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
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Table 3 HPV status concordance between partners of 238 sexually active couples in “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy.
Table 5 HPV status and type specific relationship between sexual partners: results from GEE analysis in “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy.
Female/male HPV status
n (%)
Variable
OR
95% CI
Positive/positive Negative/negative Positive/negative Negative/positive Total
75 (31.5) 102 (42.9) 47 (19.7) 14 (5.9) 238 (100.0)
Male partnera
25.43
15.88
40.73
ARTICLE IN PRESS
JCV-3001; No. of Pages 6
Journal of Clinical Virology xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners Laura Lorenzon a,∗ , Irene Terrenato b , Maria Gabriella Donà c , Livia Ronchetti d , Francesca Rollo d , Ferdinando Marandino d , Mariantonia Carosi d , Maria Grazia Diodoro d , Steno Sentinelli d , Paolo Visca d , Giuseppe Vocaturo e , Paola Bellardini f , Amina Vocaturo d,1 , Maria Benevolo d,1 a Surgical and Medical Department of Translational Medicine, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Sant’Andrea Hospital, Rome, Italy b Biostatistics Unit, Scientific Direction, “Regina Elena” National Cancer Institute, Rome, Italy c STI Unit, “San Gallicano” Dermatological Institute, Rome, Italy d Pathology Department, “Regina Elena” National Cancer Institute, Rome, Italy e Oncologic Gynecology Department, “Regina Elena” National Cancer Institute, Rome, Italy f Screening Program, Latina, Italy
a r t i c l e
i n f o
Article history: Received 26 August 2013 Received in revised form 29 March 2014 Accepted 6 April 2014 Keywords: Human papillomavirus HPV concordance HPV transmission Sexually transmitted disease Male infection
a b s t r a c t Background: HPV is one of the most common sexually transmitted infections. However little is known about its prevalence in the male population and concordance with female partners. Objectives: This cross-sectional study aimed to: (a) investigate HPV prevalence and genotype distribution among a series of stable male sexual partners of CIN/HPV positive women and (b) assess HPV infection and type-specific concordance between partners. Study design: 378 stable and monogamous male partners of CIN/HPV positive women were selected. Of these, 238 cases were enrolled at the same time as their female partner. All the subjects were tested by the Linear Array HPV genotyping assay. Results: Overall, 153/378 men (40.5%) and 122/238 women (51.3%) were positive for at least one of the 37 HPV types detectable by the assay used. Among the HPV-positive participants, 69 of the 378 men (18.2%) and 54 of the 238 women (22.7%) harboured multiple genotypes. 75 couples (31.5%) were concordantly HPV positive, while 102 couples (42.9%) were concordantly negative (Kappa value: 0.491, p < 0.0001). Among the couples in which both partners were HPV positive, 68% harboured at least one genotype in common. Results from a GEE model evidenced that when the male partner tested HPV positive for at least one genotype, this had a significant effect on the positivity of their relative female partner (p < 0.0001). Conclusions: We evidenced a high prevalence of HPV male infections and a moderate concordance between partners. However, we observed a significant HPV type-specific correlation between partners, which is unlikely to be coincidental. © 2014 Elsevier B.V. All rights reserved.
Abbreviations: HR, high risk; LR, low risk; HPV, human papillomavirus; LSIL, low grade squamous intra-epithelial lesion; HSIL, high grade squamous intra-epithelial lesion; CIN, cervical intra-epithelial neoplasia; ASCUS, atypical squamous cells of undetermined significance; NILM, negative for intraepithelial lesion or malignancy; CS, clinical status; GEE, generalized estimating equation. ∗ Corresponding author at: Surgical and Medical Department of Translational Medicine, Faculty of Medicine and Psychology, University of Rome “La Sapienza”, Sant’Andrea Hospital, Via di Grottarossa 1035-39, 00189 Rome, Italy. Tel.: +39 0633775989; fax: +39 0633775322. E-mail addresses: [email protected], [email protected] (L. Lorenzon). 1 Both the authors contributed equally to the study. http://dx.doi.org/10.1016/j.jcv.2014.04.003 1386-6532/© 2014 Elsevier B.V. All rights reserved.
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
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1. Background Persistent infections by high-risk (HR) HPV genotypes are known to be the necessary cause of cervical cancer. However, the number of HR HPV-related cancers has been extended to other female and male tumours (e.g. oropharynx, vulva, anus, vagina and penis carcinomas) [1,2]. Despite these findings, to date, only a few studies have analysed the prevalence of HPV infections in the male genitals [3–6], where the virus usually remains latent or produces sub-clinical lesions [7,8]. In addition, studies investigating HPV infection in the male population have reported discordant data. In fact, the comparisons have been hampered by methodological differences in the sampling sites, in collection techniques, in the population enrolled and in the methods used for HPV detection [4,9–11]. Therefore, studies are needed which aim to outline HPV infection in males and to investigate sexual partners in order to understand the role of men in HPV transmission. To date, only a limited number of couple-based studies have investigated man–woman HPV-concordance and the results are very discordant, mostly due to the criteria adopted in order to define enrolment criteria, HPV infection status (positive or negative) and type-specific concordance [12–16]. Moreover, the vast majority of studies failed to consider the minimum duration of the relationship [17,18]. 2. Objectives On the basis of the background mentioned above, we conducted this study in order to: (a) describe HPV prevalence and genotype distribution among a selected series of clinically healthy Italian men who were active, stable and monogamous sexual partners of women that had been previously or presently affected by CIN and/or HPV positive and (b) investigate HPV infection status and genotype concordance between partners in a subset of this cohort. Furthermore, we investigated the probability of a woman being infected by a certain HPV genotype in relationship with the HPV positivity of her matched male partner. 3. Study design 3.1. Study population From November 2005 to March 2010, 441 heterosexual couples were referred to the Day Clinic of the Pathology Department of the Regina Elena National Cancer Institute of Rome for routine HPV testing. Among them, 330 agreed to participate in this study (response rate: 75%). Both partners were interviewed individually and face-to-face to ascertain the following inclusion criteria: (a) having been engaged in a stable monogamous relationship (vaginal sexual intercourse) for at least 12 months; (b) no use of a condom for at least the 12 months preceding enrolment. In addition, the female partner had to have been previously (in the past 3 years) or presently affected by a CIN lesion and/or HPV positive at the cervix while the male partner had to have been free of sexually transmitted diseases in the 12 months preceding the enrolment and with no current external genital warts. Based on these criteria, 238 out of the 330 couples (72%) were enrolled. Additionally, during the same period, 236 men, referred to the Day Clinic of the Pathology Department of the Regina Elena National Cancer Institute for HPV testing, came without their partner. 184 of these agreed to participate in this study (response rate: 80%) and 140 of these (74%) fulfilled the above-mentioned inclusion criteria, which were ascertained through face-to-face interviews.
In conclusion, the study population consisted of 238 matched couples (238 males and 238 females), plus 140 males that met the inclusion criteria (total: 378 males and 238 females). The histological diagnosis was known for 66 women, of which 61 had a CIN1 and 5 had a CIN2/3. The histological diagnoses prior to enrolment were available for 109 women and were as follows: 84 CIN1 and 25 CIN2/3. Overall, the data collected regarding the socio-demographic, behavioural and clinical factors of the participants and of the couples met the majority of the indications suggested by Reiter [19], except for the lack of information regarding the number of lifetime sexual partners, age at first intercourse and marital status. The study was approved by the Ethics Committee of the Regina Elena National Cancer Institute and written informed consent was obtained from all the participants. 3.2. Specimen collection All the patients enrolled in the present study were instructed not to have sexual intercourse in the week before the sample collections in order to avoid contamination. (a) Men. A single cytobrush was used to collect exfoliated cells from different penile areas: the dorsal and ventral area of the penile shaft, external and internal surface of the prepuce, coronal sulcus, glans and distal urethra. The cells were collected in a ThinPrep vial/patient (Hologic), and stored at 4 ◦ C until processing. The men were invited not to wash their external genitalia the morning of the collection in order to increase the number of the cells in the sample. (b) Women. Cervicovaginal samples were collected by a cytobrush and an Ayre spatula (Hologic), and stored in a ThinPrep vial at 4 ◦ C until use. 3.3. HPV DNA detection and genotyping All the 20 ml of the male samples were centrifuged and the resulting pellet was re-suspended and utilized for DNA extraction (AmpliLute Liquid Media Extraction kit – Roche Diagnostics). The amplification and detection were performed by the Linear Array HPV Genotyping Test (Roche Diagnostics) [20]. The hybridization steps were carried out using the Profiblot T48 (Tecan, Roche Diagnostics). This assay detects 37 anogenital HPV types. For the purposes of this study, samples were considered to be: HR-HPV positive when positive for any of the 13 genotypes classified as carcinogenic or probably carcinogenic (including 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68), LR-HPV positive when positive for any of the 9 genotypes classified as low risk (types 6, 11, 40, 42, 54, 61, 72, 81 and CP6108), while the other genotypes (including 26, 53, 55, 62, 64, 66, 67, 69, 70, 71, 73, 82, 83, 84 and IS39) were considered other HPV [21,22]. 3.4. Statistical methods The differences in the rate of HPV positivity, the HR and nononcogenic HPV distribution and the rate of multiple infections were tested by the Mann–Whitney test. The agreement between male and female HPV status was estimated by using the raw agreement and the Cohen’s Kappa statistic, which was interpreted on the basis of the Landis and Koch classification criteria [23]. A Chi-square test was used to evaluate HPV concordance and distribution in positive couples. To assess the HPV-type-specific relationship between man and his relative partner, taking potential co-infections into account, we conducted a generalized estimating equation (GEE) model [24]. The GEE model was used, clustered by couple ID and run in a
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
G Model
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L. Lorenzon et al. / Journal of Clinical Virology xxx (2014) xxx–xxx
multivariate mode by adjusting for male status (positive at any genotypes vs. negative) and for the serial correlation within subjects variable, that is, the different HPV-genotypes ranked by the observed incidence in the male distribution using HPV83, one of the less frequent, as reference category. The dependent variable was binomial (female HPV status: positive at any genotypes vs. negative) and therefore, the logit link function was used. A p-value 1 HPV type
4. Results
Men n 378 n (%)
Women n 238 n (%)
p-Value#
153 (40.5) 87 (23.0) 72 (19.0) 62 (16.4) 69 (18.2)
122 (51.3) 84 (35.3) 40 (16.8) 40 (16.8) 54 (22.7)
0.009 0.0009 0.482 0.895 0.180
Men n 69 n (%)
4.1. Patient characteristics and HPV distribution 378 men (mean age: 39 years ± 10.2, range 18–68) were enrolled. 238 of them (mean age 40 ± 10.0, range 19–67) were enrolled together with their female partner. The 238 women had a mean age of 37 years ± 9.7 (range 18–65). All patients were Caucasians, had attended high school or a higher institution, and thus were considered to be of an intermediate socio-economic status. None of the men were circumcised. Table 1 shows the absolute HPV positivity in penile and cervicovaginal specimens. The data are displayed according to oncogenic risk and number of HPV types. 153 men (40.5%) and 122 women (51.3%) were positive for at least one of the 37 HPV types. We observed a statistically significant difference when comparing the male and female populations (p 0.009). In particular, 87 men (23.0%) and 84 women (35.3%) were infected with at least one HR HPV genotype (p 0.0009).
Women 54 n (%)
(b) n of HPV types in patients positive for more than 1 HPV type 34 (49.3) 27 (50.0) 2 24 (34.8) 11 (20.4) 3 7 (10.1) 15 (27.8) 4 4 (5.8) 1 (1.8) 5 a Any HPV: positive for any HPV among the 37 types detectable by the Linear Array test. Any HR: positive for any HPV among the 13 types classified as carcinogenic/probably carcinogenic. Any LR: positive for any HPV of the 9 types classified as low-risk. Other HPVs: positive for any of the types other than HR and LR. >1 HPV type: positive for more than 1 HPV type. # p-Values were calculated by the Mann–Whitney non-parametric test comparing male and female populations
Table 2 HPV genotype distribution in the study populations. Both relative and absolute percentages are given. “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy. HPV type
16 CP6108 53 6 42 31 62 59 84 73 51 81 54 18 58 61 52 66 55 56 39 82 40 45 67 11 33 35 70 71 83 26, 64, 68, 69, 72 and IS39 a
Men n (%)a
Women n (%)a
N = 153 (HPV-positive)
N = 378
N = 122 (HPV-positive)
N = 238
34 (22.2) 23 (15.0) 22 (14.4) 21 (13.7) 18 (11.8) 16 (10.5) 14 (9.2) 12 (7.8) 12 (7.8) 11 (7.2) 10 (6.5) 10 (6.5) 9 (5.9) 8 (5.2) 7 (4.6) 7 (4.6) 5 (3.3) 5 (3.3) 4 (2.6) 4 (2.6) 3 (2.0) 3 (2.0) 2 (1.3) 2 (1.3) 2 (1.3) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 1 (0.7) 0
9.0 6.1 5.8 5.6 4.8 4.2 3.7 3.2 3.2 2.9 2.6 2.6 2.4 2.1 1.9 1.9 1.3 1.3 1.1 1.1 0.8 0.8 0.5 0.5 0.5 0.3 0.3 0.3 0.3 0.3 0.3 0
36 (29.5) 11 (9.0) 16 (13.1) 3 (2.5) 15 (12.1) 19 (15.6) 8 (6.6) 5 (4.1) 6 (4.9) 7 (5.7) 9 (7.4) 4 (3.3) 7 (5.7) 7 (5.7) 8 (6.6) 9 (7.4) 6 (4.9) 6 (4.9) 5 (4.1) 7 (5.7) 5 (4.1) 1 (0.8) 1 (0.8) 3 (2.5) 3 (2.5) 1 (0.8) 5 (4.1) 3 (2.5) 1 (0.8) 1 (0.8) 3 (2.5) 0
15.1 4.6 6.7 1.3 6.3 8.0 3.4 2.1 2.5 2.9 3.8 1.7 2.9 2.9 3.4 3.8 2.5 2.5 2.1 2.9 2.1 0.4 0.4 1.3 1.3 0.4 2.1 1.3 0.4 0.4 1.3 0
Total sum of the percentages of patients exceeds 100% due to patients with more than one HPV type. Bold numbers refer to the most frequently detected types.
Please cite this article in press as: Lorenzon L, et al. Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners. J Clin Virol (2014), http://dx.doi.org/10.1016/j.jcv.2014.04.003
G Model JCV-3001; No. of Pages 6
ARTICLE IN PRESS
4
L. Lorenzon et al. / Journal of Clinical Virology xxx (2014) xxx–xxx
Table 3 HPV status concordance between partners of 238 sexually active couples in “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy.
Table 5 HPV status and type specific relationship between sexual partners: results from GEE analysis in “Prevalence of HPV infection among clinically healthy Italian males and genotype concordance between stable sexual partners”, 2014 Italy.
Female/male HPV status
n (%)
Variable
OR
95% CI
Positive/positive Negative/negative Positive/negative Negative/positive Total
75 (31.5) 102 (42.9) 47 (19.7) 14 (5.9) 238 (100.0)
Male partnera
25.43
15.88
40.73
