Review
The epidemiology of human papillomavirus infections

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Abstract

Infection with oncogenic human papillomavirus (HPV) types is a necessary cause of cervical cancer, the second most frequently occurring cancer in women worldwide. Rates of acquisition of HPV are high, particularly among sexually active young adults. Reported estimates of incident HPV infection among initially negative women have reached as high as 60% over a 5-year follow-up period. In this article, we review the epidemiology of HPV infection. In addition to estimates of disease frequency, we highlight risk factors for HPV infection, including the number of lifetime sex partners, which is the most salient risk factor. We discuss significant issues surrounding the natural history of HPV infection, including viral persistence versus clearance, immune response, development of lesions and development of cancer. Finally, we discuss strategies for preventing HPV infection.

Introduction

Human papillomaviruses (HPV) cause warts and have been well-established as the sexually transmitted agents that cause most invasive cervical cancers and their associated precancerous lesions (IARC, 1995). HPV is a very common infection, though most infected individuals eliminate evidence of the virus without ever developing clinically recognized manifestations. Thus, very few HPV-infected individuals progress to invasive cervical cancer. A well-established factor that partially explains differential cervical cancer risk is HPV type. Over 40 HPV types infect the human anogenital tract (zur Hausen, 1996). Based on pooled data from 11 case-control studies of the association between cervical cancer and HPV infection from multiple countries (Munoz et al., 2003), 15 HPV types have been classified as high-risk for development of cervical cancer, 3 have been classified as probable high-risk, 12 have been classified as low risk and 3 are considered to have undetermined risk (Table 1).

Section snippets

Prevalence

Estimates of the population prevalence of HPV infection among women around the world range from 2% to 44% (Bosch and de Sanjose, 2003). The wide variation in estimates is largely explained by differences in the age range of the populations studied and the sensitivity of the DNA assay used for detection of HPV infection. Overall, these DNA-based studies, combined with measurements of type-specific antibodies against HPV capsid antigens, have shown that most (>50%) sexually active women have been

Incidence

Acquisition of HPV is very common, particularly among sexually active young adults, and incidence of infection with oncogenic HPV types appears to be higher than the incidence of infection with non-oncogenic types (Franco et al., 1999, Giuliano et al., 2002, Ho et al., 1998, Richardson et al., 2003). The cumulative incidence of HPV infection among women aged 15–19 in England was found to be 44% over a 3-year period and increased to 60% at 5 years (Woodman et al., 2001). Similar results have

Number of sex partners

The most consistent risk factor for HPV infection is increased number of sex partners. Several studies of women have demonstrated strong associations between lifetime number of sex partners and genital HPV acquisition (Burk et al., 1996, Tarkowski et al., 2004, Wang et al., 2003, Wheeler et al., 1993) and in men (Franceschi et al., 2002, Hippelainen et al., 1993, Svare et al., 2002). Furthermore, it has been shown that a woman's reported estimate of her male partner's lifetime number of sex

Clearance/persistence

Most women infected with a specific HPV type will not show evidence of that same type 6–12 months later (Cuschieri et al., 2004b, Franco et al., 1999, Hildesheim et al., 1994, Hinchliffe et al., 1995, Ho et al., 1998). In a prospective study of female college students, approximately 70% of women no longer had detectable levels of HPV DNA within 12 months of follow-up after incident HPV infection. After 18 months, over 80% appeared to have cleared their infections (Ho et al., 1998). Other cohort

Abstain, be faithful, use condoms

Because HPV infections associated with anogenital cancers are sexually transmitted, efforts focusing on prevention of HPV infection can and should mirror those of other STDs. One approach to HIV prevention that was found to be successful in Uganda in the late 1980s and 1990s is the ‘ABC’ approach, an acronym that stands for Abstain, Be faithful, use Condoms (Cohen, 2003). Some aspects of the epidemiology of HPV suggest that the ABC approach might have some success in preventing HPV infection.

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