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- Ejaz, Muslima, et al.
(author)
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Anal human papillomavirus infection among men who have sex with men and transgender women living with and without HIV in Pakistan : findings from a cross-sectional study
- 2021
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:11
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Journal article (peer-reviewed)abstract
- OBJECTIVES: The aim of this study was to determine the prevalence of infection, genotypes and risk factors for human papillomavirus (HPV) among men who have sex with men (MSM) and transgender women living with and without HIV in Pakistan. Anal infection with HPV is very common worldwide among MSM, particularly among MSM living with HIV. The high prevalence of HIV among MSM and male-to-female transgendered individuals in Pakistan is a significant health concern since access to screening and health-seeking is often delayed in this stigmatised key population.DESIGN: This cross-sectional study was conducted between March 2016 and November 2017.PARTICIPANTS, SETTING AND DATA COLLECTION: This study recruited MSM and transgender-women who self-reported to have had anal sex in the last 6 months, and were at least 18 years of age, from the sexual health and antiretroviral therapy centres. Structured questionnaires were administered, and blood samples were obtained to confirm HIV status. Anal swabs were collected for HPV-DNA detection and typing.MAIN OUTCOME MEASURES: The primary outcome was the prevalence of 'HPV-DNA infection'. The prevalence ratios (PR) were calculated using Cox proportional hazard model algorithms to analyse the association between exposure variables and HPV-infection.RESULTS: Complete data were available for 298 MSM and transgender women (HIV +n=131; HIV-n=167). The overall HPV-DNA prevalence was 65.1% and was higher in participants living with HIV as compared with HIV-negative (87% vs 48%; χ2p≤0.001). Likewise, 28.9% of participants living with HIV were infected with two or more than two types of HPV as compared with 18.8% participants without HIV(χ2 p≤0.001). The most frequent HPV type was HPV6/11 (46.9%), followed by HPV16 (35.1%), HPV18 (23.2%) and HPV35 (21.1%). HIV status (PR 2.81, 95% CI 2.16 to 3.82) and never condom use (PR 3.08, 95% CI 1.69 to 5.60)) were independently associated with prevalence of 'anal-HPV16 infection' when adjusting for confounding for age, other sexual and behavioural factors, for example, smoking and alcohol consumption.CONCLUSION: High prevalence of HPV indicates a substantial future risk of anal cancer in Pakistani MSM and transgender women, and particularly in those living with HIV. Current findings support anal Pap-smear HPV screening for this particular group and vaccination efforts for future generations.
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| 2. |
- Ejaz, Muslima, et al.
(author)
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Human papillomavirus-associated anal squamous intraepithelial lesions in men who have sex with men and transgender women living with and without HIV in Karachi Pakistan : implications for screening and prevention
- 2021
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In: BMC Infectious Diseases. - : BioMed Central. - 1471-2334. ; 21:1
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Journal article (peer-reviewed)abstract
- BACKGROUND: Anal squamous intraepithelial lesions (ASIL), strongly related to human papilloma virus (HPV) infection, is more prevalent among men who have sex with men (MSM). However, no such data are available for Pakistan yet, and neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. The purpose of this first ever study was to assess the prevalence of HPV-related anal cytological abnormalities among MSM and transgender women living with and without HIV infection in Pakistan.METHODS: We conducted a cross-sectional study from March 2016 to November 2017 at sexual health centers run by the Perwaaz Trust and the National AIDS Control Program in Karachi. The study enrolled MSM and transgender women aged greater-than-and-equal-to-18-years who reported anal sex in the preceding 6 months. We collected two anal samples for liquid-based cytology and HPV type testing by PCR, and socio-demographic and behavioral data were collected through face-to face interviews. ASIL and its associations with biological and behavioral risk factors were analyzed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs).RESULTS: Out of 271 qualifying participants, 79% were MSM and 21% transgender women. The mean age was 28.8 (± 8) years. Almost 35% (93/271) of the study population had ASIL detected, ASIL was significantly more common among participants living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p ≤ 0.001). Among ASIL, 66% (61/93) had low-grade squamous intraepithelial lesions (LSIL), and 3.6% (3/93) had high-grade squamous intraepithelial lesions (HSIL). The overall, HPV16 positivity was 35.5% (33/93) among all abnormal anal lesions and all 3 HSIL were HPV16 positive, however, HPV16 positivity could show its association with ASIL detection in univariate model only (PRcrude: 2.11(1.39-3.18)). Moreover, any HR-HPV type (PR 3.04; 95% CI 1.75-5.26), concurrent sexually transmitted infection (STI) (2.13; (1.28-3.55)) and HIV + /HPV + coinfection (1.75; (1.07-2.88)) remained independently associated with ASIL in the multivariate model.CONCLUSIONS: Abnormal anal cytology among MSM and transgender is prevalent enough to consider optimal screening regimens. Further studies are required to see if periodic anal cytology can be made part of HIV care and treatment programs among MSM in Pakistan.
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| 3. |
- Ejaz, Muslima
(author)
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Human papillomavirus in men who have sex with men, transgender women and people living with HIV in Pakistan
- 2022
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Doctoral thesis (other academic/artistic)abstract
- Background: Anal infection with human papillomavirus (HPV) and associated anal squamous intraepithelial lesions (ASIL), are more prevalent among men who have sex with men (MSM) particularly among MSM and transgender women living with HIV The high prevalence of HIV among MSM and transgender women in Pakistan is a significant health concern and access to screening and health-seeking is often delayed due to stigmatization and discrimination. Anal Papanicolaou (Pap) screening may have utility in the identification of these lesions and is a cost- effective modality for anal cancer prevention among MSM, but no such data are available for Pakistan. Similarly, neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. To design HPV associated health interventions, HPV knowledge and positive attitudes towards uptake of HPV prevention is crucial. This thesis aimed to assess the burden of HPV and HPV related precancerous lesions in Pakistan, to explore knowledge, attitudes and perceived self- risk for HPV and associated illnesses, and to understand the policy perspective and health systems’ capacity and readiness to integrate an HPV preventive care model into existing HIV care and treatment program in Pakistan. Methods: Cross-sectional studies (paper I and II) were conducted between March 2016 to November 2017 at a sexual health centre run by a local community-based organization and the the center for HIV treatment in Karachi to estimate burden of anal type-specific HPV infection and anal intraepithelial lesions. We recruited 320 MSM and transgender women aged ≥ 18-years who reported anal sex in the preceding 6 months. Anal samples negative for β globin or with insufficient biological material for cytological analyses were excluded. We collected two anal samples for liquid-based cytology and HPV type testing by PCR. Socio-demographic and behavioural data were collected through face-to face interviews. The prevalence of HPV16 DNA infection, ASIL and associated risk factors were analysed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs). Study III was conducted between March to August 2019 and recruited 48 MSM and transgender women for focus group discussions from community-based organization. For study IV a total of 18 key informants, at different levels of seniority, were recruited from governmental and non- governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives were recruited. Both qualitative studies employed content analysis to identify the manifest and latent themes. Results: In study I, we observed a 65.1% of overall HPV-DNA prevalence and was higher in participants living with HIV as compared to HIV negative (87% versus 48%; ?2p=<0.001). Likewise, in study II, almost 35% of the study participants had ASIL. ASIL was significantly more common among those living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p = <0.001). HPV16 was the most common oncogenic HPV type found both in the anal canal (35.1%) and in anal lesions (35.5%), again individuals living with HIV had the highest burden. HIV-status (Prevalence ratio (PR) 2.81; 95% confidence interval (CI) 2.16-3.82) and never-condom-use (PR:3.08; 95% CI 1.69-5.60)) were independently associated with prevalence of “Anal-HPV16 infection” whereas, any HR-HPV type (PR 3.04; 95% CI 1.75-5.26), concurrent sexually transmitted infection (STI) (PR 2.13; CI (1.28–3.55)) and HIV+/HPV+ coinfection (PR 1.75; CI (1.07-2.88)) remained independently associated with ASIL in the multivariate model. Study III identified three themes in the focus group discussions. 1) Knowledge and risk perceptions about STIs and HPV, 2) Beliefs and attitudes towards HPV prevention, 3) Participant’s recommendations for HPV vaccination and anal Pap screening. The overall knowledge of HPV was poor though, and none of the participants had heard about HPV prevention including vaccination and anal Pap screening for men but expressed a positive attitude towards prevention. In study IV, participants unanimously favoured integration of HPV preventive services into the existing HIV program, but also identified several service delivery barriers including shortage of trained workforce, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet the needs of these key-populations. Conclusions: The findings of this thesis reaffirm the high burden of HPV and associated anal precancerous lesions in MSM and transgender women living with HIV. Current findings support anal Pap-smear HPV screening for this particular group and vaccination efforts for future generations. Educational interventions should be culturally tailored to address the knowledge gaps among key-populations. Moreover, integration of anal cancer screening is dependent on political will, financing, anti-stigma and discrimination interventions, and health system efficiency.
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