Epidemiology of HPV Genotypes among HIV Positive Women in Kenya: A Systematic Review and Meta-Analysis

Abstract

BackgroundThere is a scarcity of data on the distribution of human papillomavirus (HPV) genotypes in the HIV positive population and in invasive cervical cancer (ICC) in Kenya. This may be different from genotypes found in abnormal cytology. Yet, with the advent of preventive HPV vaccines that target HPV 16 and 18, and the nonavalent vaccine targeting 90% of all ICC cases, such HPV genotype distribution data are indispensable for predicting the impact of vaccination and HPV screening on prevention. Even with a successful vaccination program, vaccinated women will still require screening to detect those who will develop ICC from other High risk (HR) HPV genotypes not prevented by current vaccines. The aim of this review is to report on the prevalence of pHR/HR HPV types and multiple pHR/HR HPV genotypes in Kenya among HIV positive women with normal, abnormal cytology and ICC.MethodsPUBMED, EMBASE, SCOPUS, and PROQUEST were searched for articles on HPV infection up to August 2nd 2016. Search terms were HIV, HPV, Cervical Cancer, Incidence or Prevalence, and Kenya.ResultsThe 13 studies included yielded a total of 2116 HIV-infected women, of which 89 had ICC. The overall prevalence of pHR/HR HPV genotypes among HIV-infected women was 64% (95%CI: 50%-77%). There was a borderline significant difference in the prevalence of pHR/HR HPV genotypes between Female Sex workers (FSW) compared to non-FSW in women with both normal and abnormal cytology. Multiple pHR/HR HPV genotypes were highly prominent in both normal cytology/HSIL and ICC. The most prevalent HR HPV genotypes in women with abnormal cytology were HPV 16 with 26%, (95%CI: 23.0%-30.0%) followed by HPV 35 and 52, with 21% (95%CI: 18%-25%) and 18% (95%CI: 15%-21%), respectively. In women with ICC, the most prevalent HPV genotypes were HPV 16 (37%; 95%CI: 28%-47%) and HPV 18 (24%; 95%CI: 16%-33%).ConclusionHPV 16/18 gains prominence as the severity of cervical disease increases, with HPV 16/18 accounting for 61% (95%CI: 50.0%-70.0%) of all ICC cases. A secondary prevention program will be necessary as this population harbors multiple pHR/HR HPV co-infections, which may not be covered by current vaccines. A triage based on FSW as an indicator may be warranted.

Public health approach to prevent cervical cancer in HIV-infected women in Kenya: Issues to consider in the design of prevention programs

“…Our meta-analysis demonstrated a high burden of HR-HPV genotypes with 64% (95%CI: 50%–77%) in a general HIV population in Kenya ( Menon et al, 2016a ), significantly higher than a recent meta-analysis on pooled HPV prevalence in the general female population in eastern Africa (42.2%) ( Ogembo et al, 2015 ). This finding suggests that a compromised immune system may be a risk factor for HR-HPV acquisition.…”

“…A borderline statistically significant difference in our recent meta-analysis in Kenya between pooled estimates of HR-HPV genotypes in FSW and the general HIV population suggested that a cost-effective approach for cervical cancer prevention may warrant a triage based on this risk factor ( Menon et al, 2016a ). Moreover, our study found that of the 192 HIV-infected FSW, 27.1% (95% CI: 20.9–34.0%) had abnormal cytology ( Menon et al, 2017b ).…”

“…In light of the financial constraints that preclude universal screening, as well as the high pooled prevalence of pHR/HR-HPV genotypes among the HIV-infected population of 64% (95%CI: 50%–77%) ( Menon et al, 2016a ), enhanced screening may need to be devised for certain groups.…”

“…Whilst immunogenicity trials have shown the effectiveness of a two-dose HPV vaccine against HPV 16 and HPV 18 in HPV-naive girls aged 9–14 ( Markowitz, 2016 ), the WHO still recommends that immunocompromised/HIV-infected girls aged 9–14 be administered a third dose ( World Health Organization, 2017a ). However, this will not obviate the need for secondary prevention in Kenya, where our recent meta-analysis (2016) on the distribution of pHR/HR HPV genotypes in HIV-infected women in Kenya found a pooled estimated prevalence of HPV 16 and 18 of 61% in HIV-infected women with ICC ( Menon et al, 2016a ). This finding underscores a need for a broader primary prevention program than the quadrivalent vaccine (Gardasil™) that protects against HPV genotypes 6, 11, 16 and 18 that is currently being rolled out ( Garland & Smith, 2010 ).…”

Prevention of human papillomavirus (HPV)-related tumors in people living with human immunodeficiency virus (HIV)

“…The prevalence of HPV varied according to geographical location, but was generally at least twofold higher among WLWH compared to HIV-negative women: 62% vs. 24% in sub-Saharan Africa, 30% vs. 14% in Europe, and 30% vs. 5% in North America [6,7]. A metaanalysis among WLWH from Kenya estimated the prevalence of hrHPVs among WLWH to be as high as 64%, with HPV16/18 accounting for 61% of invasive cervical carcinoma (ICC) cases [8]. Similarly, the most recent meta-analysis of data from highincome Western countries showed a 46% vs. 29% prevalence of cervical hrHPV infection in WLWH and in the general US female population, respectively [9] (Figure 1).…”