1. Persistence of HPV in a cohort of female adolescents Erika Samoff, Emilia H. Koumans, Lauri E. Markowitz, Maya Sternberg, Mary K. Sawyer, David Swan, John R. Papp, William Secor, Elizabeth R. Unger Centers for Disease Control (CDC), Emory University Dept. of Pediatrics

2. Background HPV and Cervical Cancer HPV is necessary but not sufficient to cause cervical cancer Other sexually transmitted infections may affect HPV persistence and development of cancer C. trachomatis has been associated with cervical cancer

3. Background HPV Persistence Persistence of HPV infection is associated with development of cervical cancer Concurrent infection (HPV and another genital tract infection) may alter host ability to clear virus Infection with >1 HPV type may affect the probability of persistence

4. Study objective To assess whether concurrent infection with C. trachomatis, other organisms, or additional HPV types are associated with HPV persistence.

5. Methods Study Population Adolescent primary care clinic in public hospital, Atlanta GA Inclusion: –Adolescent (age 12-19) –Sexually active Exclusion –HIV-infected –Pregnant Female

6. Methods Data collection and laboratory methods Study visits –Behavioral and exposure data –Urine, vaginal, and cervical samples –6 month intervals Laboratory analyses –HPV: Roche line-blot assay (37 HPV types) –C. trachomatis and N. gonorrheae: Nucleic acid amplification tests –T. vaginalis: wet mount –Bacterial vaginosis: Gram stain scored with Nugent’s criteria

7. Methods HPV Persistence Analysis population –Study participants with detection of HPV and a following visit separated by at least 6 months Persistent outcome –detection of the same HPV type at a pair of sequential visits separated by at least 6 months Unit of analysis was pairs of visits (high risk and low risk) Coinfection was assessed at the initial of the pair of visits

8. Methods HPV persistence HPV 6 Woman 1 Woman 2 Visit 1 Visit 2 Visit 3 HPV 16 HPV 18

9. Methods Regression Analysis Associations with persistence measured using logistic regression Generalized estimating equations –allows for analysis of correlated data –exchangeable correlation structure –robust standard errors

10. Results Study Population N=282 (at least 2 study visits) MedianRange Age16.513.3-19.9 Lifetime sex partners41-150 Duration of follow-up (months)96-42 Months between visits 6 5-8* *90% of visits; range for all visits: 5-41 months

11. Results Cumulative HPV detection N% Low-risk HPV type144/28251 High-risk HPV type203/28272 >1 HPV type135/28248

12. Results Cumulative detection of other genital tract infections N% C. trachomatis121/28243 N. gonorrheae56/28220 T. vaginalis65/28223 Bacterial vaginosis138/28249

13. Results HPV persistence N% Low-risk persistence13/7118 High-risk persistence77/18143

14. Results: Univariate Logistic Regression Associations with high-risk HPV persistence Coinfection at index visitOR (95% C.I.) C. trachomatis2.1 (1.1-3.9) N. gonorrheae1.3 (0.6-3.9) T. vaginalis1.5 (0.5-5.0) Bacterial vaginosis1.3 (0.6-2.7) >1 HPV type2.6 (1.5-4.9)

15. Results: Multivariate Logistic Regression Associations with high-risk HPV persistence Coinfection at index visit Adjusted OR (95% C. I.) C. trachomatis5.1 (1.8-14.5) >1 HPV type3.6 (1.2-10.3)

16. Results Factors not associated with persistence of high-risk HPV types Frequency of sex act (vaginal, anal, or oral) in the previous 90 days Number of sex partners in the previous 90 days Number of lifetime sex partners before HPV detection Douching in previous 90 days Oral contraceptive use in previous 90 days Smoking was associated in univariate but not multivariate analysis

17. Conclusions Co-infection with C. trachomatis is associated with persistence of high-risk HPV types Infection with >1 HPV type is associated with persistence of high-risk HPV types.

18. Acknowledgements Study participants Study interviewers Study Coordinators Sakinah Carter Antonya Pierce Jamia Holland April Cameron CDC/DSTDP Emily Koumans Lauri Markowitz Eileen Dunne Deblina Datta Maya Sternberg Elizabeth R. Unger