Prevalence of oral and anal human papillomavirus infection in Czech predominantly HIV-positive men having sex with men - data from a previously unreported population

Abstract

Background:

HIV-positive men who have sex with men (MSM) are more likely to experience human papillomavirus (HPV) infection. The persistent HPV infection is the major factor in the development of anal and oropharyngeal neoplasms. Data on the prevalence of anal and oral HPV in MSM are almost absent from the countries of Central and Eastern Europe. We conducted a cross-sectional study focused on the prevalence of oral and anal HPV infections and the relationship between current anal and oral HPV intrapersonal infection in a Czech population of predominantly HIV-positive MSM.

Methods:

Oral gargle and anal swab samples from 205 predominantly HIV-positive MSM from the Czech Republic were analysed for HPV infection using PCR. Selected sociodemographic and clinical data were correlated with HPV detection using generalized linear models and multivariate analysis.

Results:

HPV infection was detected in 183 (96.8%) anal and 48 (23.6%) oral samples. The most common type of HR-HPV was HPV16 in both anal (25.4%) and oral (2.5%) samples. Multiple anal HPV infections and the presence of vaccine-targeted HR-HPV types were significantly correlated with abnormal anal cytology and HIV status.

Conclusion:

The prevalence of anal HPV infection in Czech predominantly HIV-positive MSM ranks among the highest reported, while oral HPV prevalence is consistent with MSM populations. Minimal overlap of oral and anal HPV types within a patient was observed.

Keywords

Human papillomavirus human immunodeficiency virus men homosexual Europe

Introduction

The natural history of cervical carcinoma via HPV-driven carcinogenesis is well documented, however data of the role and prevalence of HPV in other anogenital and head and neck neoplasms are attracting the attention of scientific researchers. Since the majority of mucosal HPV infections are a result of sexual transmission, an increased number of sexual partners is a significant risk factor for HPV acquisition.^1–3 Men having sex with men (MSM) generally report a higher number of sexual partners compared to heterosexual peers and an increased incidence of sexually transmitted diseases.⁴

In the population of MSM, the anus and oral cavity are the anatomical locations that are frequently subjected to HPV infections, with both low-risk HPV (LR-HPV) and high-risk HPV (HR-HPV) types.^5,6 Whereas most LR-HPV infections manifest as benign lesions of oral papillomas or ano-genital warts, HR-HPV infections represent true risks for the development of cancer.⁷ A persistent HR-HPV infection is responsible for about 90% of anal cancers, 30%–60% of oropharyngeal cancers and a smaller proportion for pharyngeal (12%) and oral carcinomas (3%).⁸

Mucosal anal and oral HPV infection results predominantly from sexual practices.⁹ Autoinoculation with HPV from one anatomical site to another may also play a role in the acquisition of infection.¹⁰ An oral HPV infection in the MSM population is generally less frequent than an anal one, however, a large heterogeneity in prevalence data exists among individual studies globally.¹¹ A recently published meta-analytical study by Farahmand et al. estimates an overall prevalence of oral HPV infection of 17.3%, (range from 3.8% to 81.9%), and a prevalence of anal HPV infection of 78.4% (range from 29.3% to 98.9%).¹¹ Such clear between-study heterogeneity results from both technical factors, such as the method of HPV detection, and sociodemographic factors.^11,12

The incidence of HPV-induced carcinomas in the MSM population has been growing steadily over the last decades, especially in those who are living with HIV.¹³ A recent meta-analysis reported incidence rates of anal cancer of 85/100 000 for HIV-positive MSM.¹⁴ Data about the incidence of oropharyngeal cancer in HIV-positive MSM are scarce, however, in the USA, a moderately elevated incidence of oropharyngeal cancer was observed in HIV-positive MSM compared with the general population, with a standardized incidence ratio of 1.1.¹⁵ Knowledge about anal and oral HPV prevalence and distribution type for specific populations represents an important base for cancer preventative strategies, including HPV vaccination or risk-assessment-based screening.¹⁶ However, such datasets are laregly missing for Central and Eastern European Countries.¹¹

The Czech Republic is a country with a relatively low level of HIV infection (incidence rate 2.35/100 000) with a recent steep increase in HIV incidence almost exclusively attributed to sexual transmissions between MSM.¹⁷ Data about HPV infections in MSM in the Czech Republic are scarce¹⁸ and no data about HPV-related malignancies are available for this subgroup. In the general Czech population, the incidence rate is 1.5/100 000 for anal cancer, 0.7/100 000 for oropharyngeal cancer, and 4/100 000 for oral cancer. HPV vaccines have been available since 2006 and the HPV vaccination is voluntary. Two doses of available vaccines are fully covered from health insurance for 13-14-year-old girls and boys since 2012 and 2018, respectively. The vaccination coverage in adolescent girls has slightly decreased, from 75% in 2012 to 62% in 2021, whereas the opposite is true for adolescent boys.¹⁹

The aim of our study was therefore to assess the prevalence, characteristics, and predictors of oral and anal mucosal HPV infections in the Czech MSM population, including predominantly HIV positive people, with a focus on the co-occurrence of HPV DNA in the oral and anal cavities.

Materials and methods

Ethics statement and informed consent

The study was approved by the institutional board of Bulovka University Hospital (evidence number 7.6.2016/8097/EK-Z). All participants gave written informed consent before study inclusion.

Study design and population

This clinic-based, prospective cross-sectional study was conducted from May 2017 until December 2020 at Bulovka University Hospital in Prague and laboratory analyses were performed at the Biomedical Center of the Faculty of Medicine in Pilsen, the University Hospital in Pilsen, and the National Reference Laboratory for Papillomaviruses and Polyomaviruses in Prague, Czech Republic. The Dermatovenereology Department and the Infectious Diseases Department of the University Hospital Bulovka are tertiary care centers providing care for more than 2000 HIV-positive patients (approximately half of all patients diagnosed with HIV in the Czech Republic). The cohort consisted of the Czech MSM population, including predominantly HIV positive persons. Patients were offered anal cancer screening as part of their routine check-ups with an HIV specialist or during preventive screening for sexually transmitted infections. All participants were 18 years of age and older and reported receptive anal intercourse. Exclusion criteria were a previous history of anal cancer, Acquired Immune Deficiency Syndrome (CD4 count below 200 cells per cubic millimeter of blood) and reluctance to adhere to the study protocol. Participants with CD4 counts below 200 were excluded from the study because the risk of HPV infection and persistence is higher among them which could affect the results. According to the analysis of the patients in our HIV centre before the start of the study, these patients would be less than 3% of the total patient number in the study which would not allow statistical analysis of this subgroup.

Data collection

Participants in the study completed questionnaires with socio-demographic data. Clinical data were retrieved from the hospital database. Gathered socio-demographic and clinical data included patient’s age, HIV seropositivity, duration of HIV infection, antiretroviral treatment history, CD4+T cell count, lifelong no. of sexual partners, oral/anal sex. practices, number of sex partners in the last 6 months, age of a sexual debut, the period from the last receptive anal intercourse, history of peri– and anal warts, history of sexually transmitted disease (STD), regular use of condom, chemsex practice, and vaccination against HPV before sexual debut.

Collection of anal samples

A moistened Dacron swab was used to collect cells from the anal mucosa. The swab was inserted into the anal canal, about 5–7 cm, and rotated 360° for 30 s. Loosened cells were washed out into preservative media PreservCyt® solution (Hologic, Inc., Marlborough, Massachusetts) immediately after collection.

Collection of oral samples

Oral samples of participants were obtained via a rinse and gargle of 10 mL of phosphate buffered saline for 30 s. The spat-out liquid was collected in a DNase/RNase-free tube and centrifuged for 7 min at 3000 rpm. The pellet was washed twice, with 30 and 10 mL of PBS consecutively, and the cells were resuspended in 5 mL of PBS.

HPV detection and genotyping

Detection of relevant HPV infection and genotyping of HPV was performed by Anyplex II HPV28 (Seegene, Seoul, South Korea) according to the manufacturer’s instructions. Anyplex II HPV28 is a real-time multiplex PCR assay targeting the L1 gene of alpha-papillomaviruses (Alpha-PVs) screening and genotyping 28 HPV types. For Anyplex HPV genotyping, DNA was isolated from 2 mL of anal sample and 1 mL of oral sample using the QIAamp® MinElute® Virus Spin Kit (Qiagen, Hilden, Germany) according to manufacturer’s instructions. The quality of isolated DNA and the absence of PCR inhibitors was checked by amplification of β-globin. Samples that were negative for the presence of the amplified β-globin gene, and at the same time negative for the presence of any HPV type, were excluded from the analysis. To cover a wider spectrum of HPV types while testing, additional laboratory-developed assays were used as previously described¹⁸ and according Tieben et al.²⁰ targeting L1 and E1 genes of HPV respectively. HPV infection was classified as follows: HR-HPV types: HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59; possible high-risk human papillomavirus (pHR-HPV): HPV26, 30, 34, 53, 66, 67, 68, 69, 70, 73, 82, 85, and 97); LR-HPV types: HPV6, 11, 40, 42, 54, 55, 61, 62, 64, 71, 72, 81, 83, 84, 89)²¹; multiple HPV infection: presence of 3 and more HPV types; vaccine-targeted HPV types: HPV6, 11, 16, 18, 31, 33, 45, 52 and 58; vaccine-targeted HR-HPV types: HPV16, 18, 31, 33, 45, 52 and 58; alpha-HPV types: HR-, pHR-, and LR-HPV types.

Statistical analyses

Data were summarized as means and SDs for continuous variables and percentages for categorical variables. The prevalence of any anal HPV infection, HR-HPV infection, possible and probable HR-HPV (pHR-HPV) infection, LR-HPV infection, HPV16, multiple HPV infection, HPV types covered in the 9-valent vaccine (HPV6, 11, 16, 18, 31, 33, 45, 52, and 58), and HR-HPV types covered in the 9-valent vaccine (and also the most common HR-HPV types found in anal cancer, namely HPV 16, 18, 31, 33, 45, 52, and 58) were assessed in anal and oral samples of all participants, HIV-positive participants, and HIV-negative participants.

Selected sociodemographic and clinical data were correlated with HPV detection results from anal and oral samples. Briefly, variables (age, CD4+T cell count, sufficient cellularity of anal sample (based on the 4th ed. of Bethesda classification cellularity criteria²²), regular use of condom, age of sexual debut, HIV seropositivity, duration of HIV infection, last receptive anal intercourse, lifelong number of sexual partners, history of STI, history of peri- and anal warts) influencing the presence of anal HPV16 infection, the presence of vaccine-targeted HR-HPV types (HPV16, 18, 31, 33, 45, 52 or 58), multiple HPV anal infections (presence of 3 or more HPV types), and oral infection with alpha-HPV types were evaluated using generalized linear models (GLM) with consequent multimodel inference using a model. avg function in R 4.0.2 software (R Core Team 2020). Simultaneous occurrences/absences of HPV types covered by the 9-valent vaccine (HPV6, 11, 16, 18, 31, 33, 45, 52 and 58) and the effect of independent variables on its occurrences were assessed for sequential, type-specific anal to oral infection using GLM analyses with the logit link function in R software and detrended canonical analysis (DCA) in Canoco 5 software. For details on statistical analyses see supplementary material.

Results

Cohort characteristics

From the total of 205 MSM, 187 (91.2%) were HIV positive with the duration of HIV infection from one to 264 months, median 54 months. The age of participants ranged from 21 to 67 years, median 37 years (Table 1). 108 (52.7%) participants presented with abnormal findings on anal cytology; out of these, 34 (16.6%) presented cytology with atypical squamous cells of undetermined significance (ASC-US), 63 (30.7%) low-grade squamous intra-epithelial lesions (LSIL), 11 (5.4%) high-grade squamous intra-epithelial lesions (HSIL) or atypical squamous cells, cannot exclude HSIL (ASC-H).

Table 1.

Characteristics of participants.

	All participants (n = 205)	HIV + participants (n = 187)	HIV – Participants (n = 18)
Age, mean (±SD), y	37.7 ± 9.3	37.9 ± 9.2	35.6 ± 9.8
Length of HIV, mean (±SD), m	N/R	66.4 ± 53.7	N/R
Antiretroviral therapy (n, %)	N/R	172 (92.0%)	N/R
CD4+T cell count, mean (±SD), cells/mm3	N/R	847.9 ± 336.4	N/R
Lifelong no. of sexual partners, mean (±SD)	84.5 ± 265.7	89.2 ± 277.6	35.6 ± 33.5
Receptive oral sex (n, %	181 (88.3%)	165 (88.2%)	16 (88.9%)
Insertive oral sex (n, %)	180 (87.8%)	164 (87.7%)	16 (88.9%)
Insertive anal sex (n, %)	161 (78.5%)	144 (77.0%)	17 (94.4%)
No. of sex. partners in last 6 m, mean (±SD)	3.8 ± 5.9	3.8 ± 6.1	3.4 ± 2.3
Age of sexual debut, mean (±SD), y	17.8 ± 4.3	17.6 ± 4.1	19.6 ± 5.8
Last receptive anal intercourse, mean (±SD), d	213.1 ± 506.6	197.4 ± 441.3	375.8 ± 933.0
History of peri– and anal warts (n, %)	71 (34.6%)	64 (34.2%)	7 (38.9%)
Abnormal anal cytology	108 (52.7%)	97 (51.9%)	11 (61.1%)
Normal anal cytology	67 (32.7%)	63 (33.7%)	4 (22.2%)
History of STI (n, %)	156 (76.1%)	146 (78.1%)	10 (55.6%)
Regular use of condoms (n, %)	71 (34.6%)	66 (35.3%)	5 (27.8%)
Chemsex practices (n, %)	74 (36.1%)	73 (39.0%)	1 (5.6%)
HPV vaccination before sex. debut (n, %)	4 (2.0%)	4 (2.1%)	0 (0%)

SD: standard deviation; m: months; y: years; d: days; STI: sexually transmitted infections; N/R: not relevant.

Anal HPV detection and genotyping

From the total of 205 anal samples, 189 (92.9%) DNA isolates had appropriate quality for HPV detection. At least one anal HPV type was found in 183 MSM (183/189, 96.8%) within the range from one to 14 HPV types (mean ± SD, 3.5 ± 2.7) (Table 2).

Table 2.

Anal and oral human papillomavirus detection and genotyping.

	All participants (anal n = 189, oral n = 203)	HIV + participants (anal n = 172, oral n = 186)	HIV -participants (anal n = 17, oral n = 17)
Anal HPV DNA positivity	183 (96.8%)	168 (97.7%)	15 (88.2%)
Anal HPV HR-HPV DNA positivity	140 (74.1%)	131 (76%)	9 (52.9%)
Anal pHR-HPV DNA positivity	17 (9.0%)	15 (8.7%)	2 (11.8%)
Anal LR-HPV DNA positivity	26 (13.8%)	22 (12.8%)	4 (36.4%)
Anal HPV16 DNA positivity	48 (25.4%)	42 (24.4%)	6 (35.3%)
Anal multiple types HPV DNA positivity	152 (80.4%)	142 (82.5%)	10 (58.8%)
Anal vaccine-targeted HPV types positivity	143 (75.7%)	130 (75.6%)	13 (76.5%)
Anal vaccine-targeted HR-HPV DNA positivity	114 (60.3%)	106 (61.6%)	8 (47.1%)
The most common anal HPV type (frequency)	HPV42 (51)	HPV42 (47)	HPV16, HPV6 (6; 6)
Oral HPV DNA positivity	48 (23.6%)	46 (24.7%)	2 (11.8%)
Oral Alpha-HPV DNA positivity	29 (14.3%)	27 (14.5%)	2 (11.8%)
Oral HPV HR-HPV DNA positivity	13 (6.4%)	13 (7.0%)	0 (0%)
Oral pHR-HPV DNA positivity	4 (2.0%)	4 (2.2%)	0 (0%)
Oral LR-HPV DNA positivity	12 (5.9%)	10 (5.4%)	2 (11.8%)
Oral HPV16 DNA positivity	5 (2.5%)	5 (2.7%)	0 (0%)
Oral multiple types HPV DNA positivity	5 (2.5%)	5 (2.7%)	0 (0%)
Oral vaccine-targeted HPV types positivity	13 (6.4%)	12 (6.5%)	1 (5.9%)
Oral vaccine-targeted HR-HPV DNA positivity	10 (4.9%)	10 (5.4%)	0 (0%)
The most common oral HPV type (frequency)	HPV16 (5)	HPV16 (5)	HPV6, HPV94 (1; 1)

HR-HPV: high-risk human papillomavirus (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59); pHR-HPV: possible high-risk human papillomavirus (HPV26, 30, 34, 53, 66, 67, 68, 69, 70, 73, 82, 85, and 97); LR-HPV: low-risk human papillomavirus (HPV6, 11, 40, 42, 54, 55, 61, 62, 64, 71, 72, 81, 83, 84, 89)21; multiple types of HPV DNA (presence of 3 and more HPV types); vaccine-targeted HPV types (HPV6, 11, 16, 18, 31, 33, 45, 52 and 58); vaccine-targeted HR-HPV types (HPV16, 18, 31, 33, 45, 52 and 58); alpha-HPV types (HR-, pHR-, and LR-HPV types).

The most often detected HPV types in the anal canal were HPV42 in 51 samples (27.0%), HPV16 and HPV6 both in 48 samples (25.4%), HPV68 in 34 samples (18.0%), and HPV11 in 33 samples (17.5%). None of the tested independent variables had a significant influence on the presence of HPV16 in the anal smear (Table 3, Supplementary material, Table S1–2). The presence of vaccine-targeted HR-HPV types (HPV16, 18, 31, 33, 45, 52 or 58) was correlated with the abnormal cytology result (Table 3, GLM analyses, z = 1.01, p = .003, supplementary material Table S3–4). The combination of abnormal anal cytology and the simultaneous presence of anal vaccine-targeted HR-HPV types were significantly more often than other categories (post hoc Tukey tests; normal cytology vs abnormal cytology: z = 3.28, p = .003, Supplementary material Figure S1). The number of anal HPV types was significantly affected by the presence of HIV infection (GLM analyses, z = 2.53, p = .011), its duration (GLM analyses, z = 2.43, p = .015), result of anal cytology (GLM analyses, z = 5.42, p < .001) and a history of peri- and anal warts (GLM analyses, z = 2.60, p = .009) (Table 3, Supplementary material, Table S5–6) (Figure 1).

Table 3.

Generalized linear models analyses of the effect of independent variables on the presence of HPV16 in anal smears, the presence of vaccine-targeted high-risk human papillomavirus types in anal smears, the number of anal HPV types, and the presence of oral alpha-HPV types. Statistically significant results (p ˂ .05) are in bold. HPV: human papillomavirus

Independent variable	Anal HPV16 (P)	Anal vaccine HR-HPV (P)	number of anal HPV types (P)	Oral Alpha-HPV (P)
Age (years)	0.811	0.684	0.985	0.869
Abnormal anal cytology (Y/N)	0.835	0.003	<0.001	N/T
HIV seropositivity (Y/N)	0.833	0.681	0.011	N/T
Length of HIV infection (months)	0.909	0.919	0.015	N/T
CD4+T cell count cells/mm3	0.967	0.786	0.844	N/T
History of peri– and anal warts (Y/N)	0.604	0.996	0.009	0.984
Sufficient cellularity of anal sample (Y/N)	0.869	0.313	0.280	N/T
History of STI (Y/N)	0.935	0.907	0.703	N/T
Regular use of condoms (Y/N)	0.662	0.981	0.927	N/T
Age of sexual debut (years)	0.811	0.801	0.635	0.700
Lifelong no. of sexual partners	0.908	0.789	0.706	0.970
Last receptive anal intercourse (days)	0.662	0.960	0.941	N/T
Passive oral sex. practices (Y/N)	N/T	N/T	N/T	0.874

vaccine-targeted HR-HPV types (HPV16, 18, 31, 33, 45, 52 and 58); alpha-HPV types (HR-, pHR-, and LR-HPV types), HR-HPV: high-risk human papillomavirus (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59); pHR-HPV: possible high-risk human papillomavirus (HPV26, 30, 34, 53, 66, 67, 68, 69, 70, 73, 82, 85, and 97); LR-HPV: low-risk human papillomavirus (HPV6, 11, 40, 42, 54, 55, 61, 62, 64, 71, 72, 81, 83, 84, 89)²¹; STI: sexually transmitted infections.

Figure 1.

The effect of a) HIV seropositivity, b) anal cytology, c) presence of peri- and anal warts and d) duration of HIV infection on the number of anal HPV types detected in patients: (a) Patients with HIV infection were more likely to present with multiple anal HPV infections. (b) An increased number of anal HPV types was found in patients with abnormal anal cytology compared to normal anal cytology (post hoc Tukey test, z = 5.19, p < 0.001) and cytologically not analysable samples (z = −5.56, p < 0.001). (c) An increased number of anal HPV types was found in patients with peri- and anal warts compared to those without warts. (d) The number of anal HPV types slightly decreased with the duration of HIV infection. (e) HIV duration was positively correlated with the age of patients (simple regression, R2 = 0.15, ß = 0.39, F = 34.3, p < 0.001). In box and whisker-plots: small squares – medians, boxes – 25–75% of data, whiskers – non-outlier range, NA – not analysable. In regressions: solid line – fitted curve, dotted lines – 95% confidence limits. HPV: human papillomavirus; HIV: human immunodeficiency virus.

Oral HPV detection and genotyping

From the total of 205 oral samples, 203 (99.0%) DNA isolates had appropriate quality for HPV detection. At least one oral HPV type was found in 48 MSM (48/203, 23.6%) within the range from one to 4 HPV types (mean ± SD, 0.3 ± 0.5) (Table 2). The most often detected HPV types in oral samples were HPV16 in 5 samples (2.5%), HPV5, HPV36 and HPV105 all in 4 samples (2.0%), and HPV56 in 3 samples (1.5%). None of the independent variables tested had a significant influence on the presence of oral alpha-HPV (Table 3, Supplementary material, Table S7–8).

Anal and oral HPV co-occurrence

The simultaneous occurrence of the same HPV type in oral and anal samples was exceptional but was recorded in 10 patients. In the case of HPV6, 11, 18, 52 and 58 detections, the absence of this simultaneous occurrence was statistically significant (GLM analyses, p = .015, 0.049, 0.038, and 0.045, respectively, supplementary material Table S9–14) (Figure 2).

Figure 2.

Projection scores for presence of chosen vaccine-targeted anal (filled circles) and oral (empty circles) HPVs. Using multivariate detrended canonical analysis analysis, the disconnection between the presence of the same type of anal and oral HPV was confirmed. Whereas anal HPV types formed a clear group in the central part of the ordination space, the same oral HPV types were randomly distributed around this anal HPV group. Further, it was found that some oral HPV types were more often simultaneously present in one patient than others (e.g., HPV6 and 45 or HPV16, 33 and 52). I. and II. ordination axes together explained 19.0% of variability. HPV: human papillomavirus.

Discussion

A persistent HPV infection is a major cause of anal squamous carcinoma, with HPV16 being the most carcinogenic type in the anus.^23,24 Incidence of anal cancer is highest in HIV-positive MSM.¹⁴ The results of our study show that the Czech MSM population may be at risk for HPV-induced malignancies and benign lesions, especially in the anal region. The prevalence of anal HPV for Czech MSM reaches the highest numbers in comparison to data published worldwide; 97.4% for HIV-positive MSM and 88.2% for HIV-negative. The recent meta-analyses by Marra et al. and Farahmand et al. reported an anal HPV prevalence of 79% and 86.2% (HIV-positive MSM) and 47% and 63.8% (HIV-negative MSM), respectively.^11,25

The increased rate of anal HPV positivity in our study probably was due to other aspects, technical as well as sociodemographic. We have excluded 16 negative samples with undetectable human β-globin sequence from the analysis, which may have contained a PCR inhibitor or had not been collected properly. Some studies did not exclude such samples or performed HPV detection without an internal control of the amplification/reaction, e.g., HC2 technique.²⁶ Further, targeting more than one HPV gene for PCR detection increased the rate of positivity. In the meta-analysis by Farahmand, studies using both L1 and E6 genes for PCR detection had a higher positivity compared to those targeting the L1 gene or E1 gene alone.¹¹ In our study, we used 3 systems of PCR detection for every sample (for details see MαM section). Therefore, the positivity rate was higher than it would be using only the commercial assay (HPV28 only detected HPV in 92,5% HIV-positive and 76.5% in HIV-negative MSM).

The most often reported sociodemographic factors associated with the high prevalence of anal HPV are immunosuppression, and sexual behaviors such as practicing anal intercourse, having multiple sexual partners, or never using a condom for anal sex.^6,27,28 Previous studies have demonstrated a high prevalence of anal HPV infection among men who have sex with men, particularly those HIV seropositive .^29,30 Meta-analysis by Farahmand et al.¹¹ also showed differences in the prevalence of anal HPV based on study location. While in Asia, the pooled prevalence of anal HPV infection in MSM is around 70% and in the USA or Australia around 80%, in mainland western Europe it reaches most often 84% or more. The very high prevalence of anal HPV infection in the Czech MSM is consistent with rare data from other eastern European countries. In a Hungarian study of 92 MSM, the estimated prevalence of anal HPV infection was 97.5% in HIV-positive and 58.3% in HIV-negative individuals,³¹ and in a Slovenian study of 136 MSM, the reported anal HPV prevalence was 95% in HIV-positive and 75% in HIV-negative men.³² We have not revealed the major factor influencing the high anal HPV prevalence, however, a very low number of the Czech MSM were vaccinated against HPV before sexual debut (2%) and only 34.6% reported regular use of condoms.

An increased risk of anal cancer in MSM is associated with anal HPV16 and multiple HPV infections.²⁵ In our study, anal HPV16 infection was detected in 24.4% of HIV-positive and 35.3% of HIV-negative MSM. In the meta-analysis from 2012 by Machalek et al., the prevalence of HPV16 was 35.4% (HIV-positive MSM) and 12.5% (HIV-negative MSM).²⁷ Marra et al. reported similar numbers of HPV16 prevalence in their recent meta-analysis, 30% in HIV-positive MSM and 14% in HIV-negative MSM.²⁵ HIV-positivity did not affect the prevalence of HPV16 in our participants, contrary to the findings of others.²⁵ This may be due to the low number and overall increased HPV positivity of HIV-negative MSM from our study group. None of the other variables tested statistically influenced anal HPV16 positivity in our study group. However, abnormal cytological findings were associated with the presence of vaccine-targeted HR-HPV types. Multiple anal HPV infections are common in MSM. We also recorded multiple HPV type positivity in 82.5% of HIV-positive and 58.8 of HIV-negative Czech MSM, which is comparable with other European studies: In Hungary 82.5% and 49.9% ,³¹ in Slovenia 95.0% and 59.5%,³² in Italy 87.1% and 53.3%³³ in HIV-positive and HIV-negative MSM, respectively. According to our data, the increased number of anal HPV types was statistically correlated with the presence of HIV infection and the history of peri- and anal warts. The higher acquisition and persistence rate of HPV in HIV-positive patients probably results from altered cellular immunity. Multiple infections were also statistically more frequent in MSM with abnormal anal cytology, which is consistent with other studies.^34,35

The most often reported factors associated with the high prevalence of oral mucosal HPV are sexual behavior (namely a higher number of sexual partners and receptive oral sex), age, male gender, HIV seropositivity, and smoking habits.^13,36 The oral Alpha-HPV prevalence (HR-, pHR-, and LR-HPV types) in our study was 14.5% in HIV-positive and 11.8% in HIV-negative MSM, which is slightly lower in comparison to data from recent meta-analyses: 22.5% and 14.5%,¹¹ 28.9%, and 17.1%³⁷ in HIV-positive and HIV-negative MSM, respectively. From a technical point of view, a sampling strategy substantially affects oral HPV positivity rate with oral mucosa scraping being the most efficient method.³⁸ However, the gargling collection method used in our study is less invasive and shows oral as well as oropharyngeal HPV infection and it was established by other authors to be effective.³⁹ In our study, most of the participants (88.3%) acknowledged receptive oral sex practices. Unfortunately, we had no records of the number of their oral sex partners. Thus, no association of an oral HPV infection has been found with tested variables in our study group, and even HIV positivity did not significantly predict a higher risk of oral HPV infection, in contrast to other studies.^40,41The low figure of HIV-negative participants might have influenced this observation; however, we cannot exclude a local variation as the number of studies analysing oral HPV prevalence in MSM in Europe is still low and such studies are absent in Central and Eastern European countries.¹¹

In 19 Czech MSM, an oral Beta-PVs infection was revealed, which accounts for almost 40% of all detected oral HPV types. Gheit et al.⁴² described more than a twofold prevalence of oral Beta-PVs in comparison to Alpha-PVs in their study population of MSM. Our finding was rather incidental because HPV detection methods were not fully focused on identification of Beta-PVs and amplifies only a limited number of Beta-PVs.²¹ In the anal canal of our participants, only Alpha-PVs were detected. This might have resulted from a preferential amplification of Alpha-PVs by our detection systems. Similarly, Bollati et al. recorded the lowest proportion of Beta-PVs (3%) in the anal canal of the general population with Alpha-PVs being the most prevalent (59%), followed by Gamma-PVs (35%).⁴³

The MSM population is at an elevated risk of multi-site HPV infection.⁴⁴ Sequential infection from one site to another has been demonstrated on the cervix and in the anus of women⁴⁵ and also on genitals and the oral epithelium.¹⁰ We have observed scarce simultaneous detection of the same HPV type in the anal canal and oral cavity from the same individual. In the case of HPV6, 11, 18 and 58 detections, the absence of this simultaneous occurrence was statistically significant (p = .015–.045). A similar finding was reported by Vergori et al.⁴⁶ and Parisi et al.,⁴⁷ both for the groups of Italian predominantly HIV-positive MSM. However, our finding does not exclude the sequential acquisition from the anal canal to the oral cavity as longitudinal data are needed to confirm or disprove that.

A persistent HR-HPV infection of the anal canal and oropharynx leads to a high risk of carcinoma development, particularly in HIV positive people where the risk is significantly elevated for almost all HPV-related cancers.¹³ HPV vaccines are the most efficient, prevention against HPV induced benign and malignant diseases. A gender-neutral vaccination (GNV) strategy with the 9vHPV (nonavalent HPV vaccine) was established to reduce the burden of HPV-related disease in MSM elsewhere.^48,49 In the population of Czech MSM, the prevalence of HPV and HR-HPV types covered by a 9vHPV was 75.7% and 60.3% in the anal canal and 6.4% and 4.9% in the oral samples. Therefore, we assume that vaccination of young boys with a 9vHPV could offer protection against the most common high-risk HPV types and reduce the incidence of malignant as well as benign HPV-induced lesions substantially, also in the Czech MSM community. Our results are in an agreement with others.⁵⁰

Limitations

Limited oral sex behaviour information and a small number of HIV-negative MSM might have influenced our study findings.

Conclusion

The prevalence of anal HPV infection in Czech predominantly HIV-positive MSM ranks among the highest reported. HIV-positive Czech MSM compared to HIV-negative MSM were statistically more likely to be diagnosed with multiple anal HPV infections – a factor associated with an increased risk of anal cancer. The prevalence of oral HPV infection is among the global average in MSM populations. Detection of the same HPV type in the anal canal and oral cavity was exceptional in our study group. HR-HPV types covered by a nonavalent vaccine were frequently detected in both anal (78.1%) and oral (27.1%) HPV-positive specimens. Gender-neutral vaccination could reduce the incidence of HPV-induced lesions in the Czech MSM population.

Key messages

• The prevalence of anal HPV infection in Czech predominantly HIV-positive MSM ranks among the highest reported, whereas oral infection belongs to the average in MSM populations.

• The presence of the same HPV type in the anal canal and the oral cavity within the same individual is rare in Czech MSM.

• HIV-positive Czech MSM are at increased risk of developing anal cancer compared to HIV-negative MSM due to more frequent anal multiple HPV infections.

Supplemental Material

Supplemental material - Prevalence of oral and anal human papillomavirus infection in Czech predominantly Human immunodeficiency virus-positive men having sex with men - data from a previously unreported population

Supplemental material for Prevalence of oral and anal human papillomavirus infection in Czech predominantly Human immunodeficiency virus-positive men having sex with men - data from a previously unreported population by Jana Nemcova, Jan Riegert, Katerina Cerna, Filip Rob, Jana Smahelova, Jana Tresnak Hercogova, Petr Martinek and Ondrej Ondic in International Journal of STD & AIDS

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Ministerstvo Zdravotnictví Ceské Republiky (AZV17-31777a).

ORCID iDs

Jana Nemcova

Filip Rob

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