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1.  Seroprevalence and Associated Factors of 9-Valent Human Papillomavirus (HPV) Types among Men in the Multinational HIM Study 
PLoS ONE  2016;11(11):e0167173.
Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. Recently a 9-valent HPV (9vHPV) prophylactic vaccine was licensed. Seroprevalence prior to vaccine dissemination is needed for monitoring vaccine effectiveness over time. Few studies have assessed the seroprevalence of 9vHPV types in men.
To investigate the seroprevalence of 9vHPV vaccine types and associated risk factors among men residing in Brazil, Mexico, and the United States.
Six hundred men were randomly selected from the HPV Infection in Men (HIM) Study. Archived serum specimens collected at enrollment were tested for antibodies against nine HPV types (6, 11, 16, 18, 31, 33, 45, 52 and 58) using a glutathione S-transferase (GST) L1-based multiplex serologic assay. Socio-demographic, lifestyle and sexual behavior data at enrollment were collected through a questionnaire. Binomial proportions were used to estimate seroprevalence and logistic regression was used to examine factors associated with seropositivity of type-specific and grouped (i.e. 9vHPV, high-risk 9vHPV, low risk 9vHPV, and five-additional) HPV types.
Overall, 28.3% of men were seropositive for at least one of the 9vHPV vaccine types, 14.0% for at least one of the seven high-risk types (16, 18, 31, 33, 45, 52 and 58) and 11.2% for at least one of the five high-risk types (31, 33, 45, 52 and 58) not included in the quadrivalent HPV vaccine, and 17.4% for at least one of the low-risk types (6/11). In multivariate analyses, odds ratios adjusted (AOR) for country of residence, age, marital status, smoking, number of anal sex lifetime partners, compared to men with no anal sex lifetime partners, men with ≥2 partners were more likely to be seropositive for grouped HPV [(9vHPV: AOR 2.52; 95% confidence interval (CI) 1.40–4.54), (high-risk 9vHPV: AOR 2.18; 95%CI: 1.05–4.50) and (low-risk 9vHPV: AOR 2.12; 95%CI: 1.12–4.03)], and individual HPV types 6, 16, 33 and 58 with AORs ranging from 2.19 to 7.36. Compared to men aged 18–30 years, men older than 30 years were significantly more likely to be seropositive for any high-risk 9vHPV, in addition to individual types 18 and 45; and compared to never smokers, current smokers were more likely to be seropositive to 9vHPV, low-risk 9vHPV and HPV 6. In contrast, married men were less likely to be seropositive to any high-risk 9vHPV and individual HPV types 18 and 31 when compared to single men.
These data indicate that exposure to the nine HPV types included in the 9vHPV vaccine is common in men and that seropositivity to 9vHPV vaccine types is associated with older age and the lifetime number of anal sex partners. Nine valent HPV vaccination of males and females has the potential to prevent HPV related diseases and transmission in both sexes.
PMCID: PMC5130234  PMID: 27902759
2.  Seroprevalence of Cutaneous Human Papillomaviruses and the Risk of External Genital Lesions in Men: A Nested Case-Control Study 
PLoS ONE  2016;11(11):e0167174.
A variety of cutaneous human papillomaviruses (HPV) are detectable in genital epithelial lesions in men and non-melanoma skin cancer patients. It remains unclear whether these viruses are associated causally with skin lesions. To date, no study has prospectively examined the association between cutaneous HPV seropositivity and development of external genital lesions (EGLs) in men.
To examine the association between seropositivity to cutaneous HPV types and the risk of subsequent development of EGLs.
A nested case-control study including 163 incident EGL cases and 352 EGL-free controls in the HPV Infection in Men (HIM) Study cohort was conducted. Cases were ascertained at each of up to 10 biannual clinical visits and verified through biopsy and pathological diagnoses. EGLs were categorized as condyloma, suggestive of condyloma, penile intraepithelial neoplasia (PeIN), and other EGLs. Archived serum specimens collected at baseline were tested for antibodies against 14 cutaneous HPV types (β types (5, 8, 12, 14, 17, 22, 23, 24, 38, and 47), α type 27, γ type 4, μ type 1, and ν type 41) using a GST L1-based multiplex serology assay. Socio-demographic and sexual behavior data were collected through a questionnaire. Using logistic regression, adjusted odds ratios (AOR) and 95% confidence intervals (CI) were estimated.
Overall, seropositivity to ≥1 cutaneous HPV type (any-HPV) and ≥1 β types (any-β) was 58.3% and 37.5% among other EGL cases, 71.6% and 46.8% among condyloma, 66.8% and 50.0% among PeIN, and 71.9% and 38.4% among controls, respectively. Type-specific seropositivity was most common for ɤ-HPV 4, μ-HPV 1, and β-HPV 8. No statistically significant association was observed between any-HPV, any-β, and type-specific HPV seropositivity and subsequent development of EGLs across all pathological diagnoses.
Overall, seropositivity to cutaneous HPV was common among men; however, it appears that cutaneous HPV is not associated with the development of genital lesions in men.
PMCID: PMC5125700  PMID: 27893841
3.  Seroconversion Following Anal and Genital HPV Infection in Men: The HIM Study 
Papillomavirus research  2015;1:109-115.
Protection from naturally acquired human papillomavirus (HPV) antibodies may influence HPV infection across the lifespan. This study describes seroconversion rates following genital, anal, and oral HPV 6/11/16/18 infections in men and examines differences by HPV type and anatomic site.
Men with HPV 6/11/16/18 infections who were seronegative for those genotypes at the time of DNA detection were selected from the HPV Infection in Men (HIM) Study. Sera specimens collected ≤36 months after detection were analyzed for HPV 6/11/16/18 antibodies using a virus-like particle-based ELISA. Time to seroconversion was separately assessed for each anatomic site, stratified by HPV type.
Seroconversion to ≥1 HPV type (6/11/16/18) in this sub-cohort (N=384) varied by anatomic site, with 6.3, 18.9, and 0.0% seroconverting following anal, genital, and oral HPV infection, respectively. Regardless of anatomic site, seroconversion was highest for HPV 6 (19.3%). Overall, seroconversion was highest following anal HPV 6 infection (69.2%). HPV persistence was the only factor found to influence seroconversion.
Low seroconversion rates following HPV infection leave men susceptible to recurrent infections that can progress to HPV-related cancers. This emphasizes the need for HPV vaccination in men to ensure immune protection against new HPV infections and subsequent disease.
PMCID: PMC4680989  PMID: 26688833
HPV; men; seroconversion; HPV antibodies; human papillomavirus
4.  Associations between ALOX, COX, and CRP polymorphisms and breast cancer among Hispanic and non-Hispanic white women: The Breast Cancer Health Disparities Study 
Molecular carcinogenesis  2014;54(12):1541-1553.
Chronic inflammation is suggested to be associated with specific cancer sites, including breast cancer. Recent research has focused on the roles of genes involved in the leukotriene/lipoxygenase and prostaglandin/cyclooxygenase pathways in breast cancer etiology. We hypothesized that genes in ALOX/COX pathways and CRP polymorphisms would be associated with breast cancer risk and mortality in our sample of Hispanic/Native American (NA) (1,430 cases, 1,599 controls) and non-Hispanic white (NHW) (2,093 cases, 2,610 controls) women. A total of 104 Ancestral Informative Markers was used to distinguish European and NA ancestry. The adaptive rank truncated product (ARTP) method was used to determine the significance of associations for each gene and the inflammation pathway with breast cancer risk and by NA ancestry. Overall, the pathway was associated with breast cancer risk (PARTP =0.01). Two-way interactions with NA ancestry (padj< 0.05) were observed for ALOX12 (rs2292350, rs2271316) and PTGS1 (rs10306194). We observed increases in breast cancer risk in stratified analyses by tertiles of polyunsaturated fat intake for ALOX12 polymorphisms; the largest increase in risk was among women in the highest tertile with ALOX12 rs9904779CC (Odds Ratio (OR), 1.49; 95% Confidence Interval (CI) 1.14–1.94, padj=0.01). In a sub-analysis stratified by NSAIDs use, two-way interactions with NSAIDs use were found for ALOX12 rs9904779 (padj= 0.02), rs434473 (padj= 0.02), and rs1126667 (padj= 0.01); ORs for ALOX12 polymorphisms ranged from 1.55–1.64 among regular users. Associations were not observed with breast cancer mortality. These findings could support advances in the discovery of new pathways related to inflammation for breast cancer treatment.
PMCID: PMC4406776  PMID: 25339205
chronic inflammation; ethnicity; genetic variants
5.  An analysis of HPV infection incidence and clearance by genotype and age in men: The HPV Infection in Men (HIM) Study 
Genital HPV infection in men causes benign and cancerous lesions, the incidence of which differs by age. The goal of this work was to comprehensively evaluate incidence and clearance of individual HPV genotypes among men by age group.
HIV-negative men ages 18–70 with no history of anogenital cancer were recruited for the HPV Infection in Men (HIM) Study. Participants completed clinical exams and questionnaires every six months for up to ~4 years. Genital specimens underwent HPV genotyping, with associations between age and HPV assessed using Cox analyses.
4085 men were followed for a median of 48.6 months (range: 0.3–94.0). Significantly lower HPV incidence rates were observed among the oldest age group (55–70 years) for grouped high-risk (incidence rate ratio [IRR]=0.71), HPV16 (IRR=0.54), grouped low-risk (IRR=0.74), and HPV6 (IRR=0.57) infections compared to men ages 18–24. However, incidence of the grouped 9-valent HPV vaccine types remained constant across the lifespan. Likelihood of HPV6 and HPV16 clearance remained constant until age 54, then increased significantly for men ages 55–70 (adjusted hazard ratio [AHR]=1.92 and 1.65, respectively).
Men remain susceptible to HPV infections throughout their lifespan, highlighting the need for prevention efforts with long-lasting duration.
PMCID: PMC4986989  PMID: 27547836
Human papillomavirus; Natural history; Incidence; Clearance; Age-specific; HIM Study
6.  Active and Passive Cigarette Smoking and Mortality among Hispanic and non-Hispanic White Women Diagnosed with Invasive Breast Cancer 
Annals of epidemiology  2015;25(11):824-831.
Women who smoke at breast cancer diagnosis have higher risk of breast cancer-specific and all-cause mortality than non-smokers; however, differences by ethnicity or prognostic factors and risk for non-cancer mortality have not been evaluated.
We examined associations of active and passive smoke exposure with mortality among Hispanic (n=1,020) and non-Hispanic White (n=1,198) women with invasive breast cancer in the Breast Cancer Health Disparities Study (median follow-up of 10.6 years).
Risk of breast cancer-specific (HR=1.55, 95% CI:1.11-2.16) and all-cause (HR=1.68, 95% CI:1.30-2.17) mortality was increased for current smokers, with similar results stratified by ethnicity. Ever smokers had an increased risk of non-cancer mortality (HR=1.68, 95% CI:1.12-2.51). Associations were strongest for current smokers who smoked ≥20 years, were postmenopausal, overweight/obese, or reported moderate/high alcohol consumption; however, interactions were not significant. Breast cancer-specific mortality was increased 2-fold for moderate/high recent passive smoke exposure among never smokers (HR=2.12, 95% CI:1.24-3.63).
Findings support associations of active and passive smoking diagnosis with risk of breast cancer-specific and all-cause mortality, and ever smoking with non-cancer mortality, regardless of ethnicity and other factors. Smoking is a modifiable lifestyle factor and effective smoking cessation and maintenance programs should be routinely recommended for women with breast cancer.
PMCID: PMC4609618  PMID: 26387598
Breast cancer; Ethnicity; Hispanic; Native American Ancestry; Smoking; Mortality; Survival
7.  Interaction between common breast cancer susceptibility variants, genetic ancestry, and non-genetic risk factors in Hispanic women 
Most genetic variants associated with breast cancer risk have been discovered in women of European ancestry, and only a few genome-wide association studies (GWAS) have been conducted in minority groups. This research disparity persists in post-GWAS gene-environment interaction analyses. We tested the interaction between hormonal and lifestyle risk factors for breast cancer, and ten GWAS-identified single nucleotide polymorphisms (SNPs) among 2,107 Hispanic women with breast cancer and 2,587 unaffected controls, to gain insight into a previously reported gene by ancestry interaction in this population.
We estimated genetic ancestry with a set of 104 ancestry-informative markers selected to discriminate between Indigenous American and European ancestry. We used logistic regression models to evaluate main effects and interactions.
We found that the rs13387042-2q35(G/A) SNP was associated with breast cancer risk only among postmenopausal women who never used hormone therapy [per A allele odds ratio (OR): 0.94 (95% confidence interval 0.74–1.20), 1.20 (0.94–1.53) and 1.49 (1.28–1.75) for current, former and never hormone therapy users, respectively, P-interaction 0.002] and premenopausal women who breastfed >12 months [OR: 1.01 (0.72–1.42), 1.19 (0.98–1.45) and 1.69 (1.26–2.26) for never, <12 months, and >12 months breastfeeding, respectively, P-interaction 0.014].
The correlation between genetic ancestry, hormone replacement therapy use, and breastfeeding behavior partially explained a previously reported interaction between a breast cancer risk variant and genetic ancestry in Hispanic women.
These results highlight the importance of understanding the interplay between genetic ancestry, genetics, and non-genetic risk factors and their contribution to breast cancer risk.
PMCID: PMC4633366  PMID: 26364163
Breast cancer; Hispanics; Latinas; Gene-environment interaction; Genetic ancestry
8.  EUROGIN 2014 Roadmap: Differences in HPV infection natural history, transmission, and HPV-related cancer incidence by gender and anatomic site of infection 
Human papillomaviruses (HPVs) cause cancer at multiple anatomic sites in men and women, including cervical, oropharyngeal, anal, vulvar, and vaginal cancers in women and oropharyngeal, anal, and penile cancers in men. In this EUROGIN 2014 roadmap, differences in HPV-related cancer and infection burden by gender and anatomic site are reviewed. The proportion of cancers attributable to HPV varies by anatomic site, with nearly 100% of cervical, 88% of anal, and less than 50% of lower genital tract and oropharyngeal cancers attributable to HPV, depending on world region and prevalence of tobacco use. Often mirroring cancer incidence rates, HPV prevalence and infection natural history varies by gender and anatomic site of infection. Oral HPV infection is rare and significantly differs by gender; yet HPV-related cancer incidence at this site is several-fold higher than at either the anal canal or penile epithelium. HPV seroprevalence is significantly higher among women compared to men, likely explaining the differences in age-specific HPV prevalence and incidence patterns observed by gender. Correspondingly, among heterosexual partners, HPV transmission appears higher from women to men. More research is needed to characterize HPV natural history at each anatomic site where HPV causes cancer in men and women, information that is critical to inform the basic science of HPV natural history and the development of future infection and cancer prevention efforts.
PMCID: PMC4297584  PMID: 25043222
human papillomavirus; epidemiology; gender differences; natural history; cancer
9.  Associations between Male Anogenital Human Papillomavirus Infection and Circumcision by Anatomic Site Sampled and Lifetime Number of Female Sex Partners 
Male circumcision may lower men’s risk of human papillomavirus (HPV) infection and reduce transmission to sex partners. Reported associations between circumcision and HPV infection in men have been inconsistent.
Four hundred sixty-three men in 2 US cities were tested at 6 anogenital sites and in semen for 37 types of HPV. Men were eligible if they reported sex with a woman within the past year, no history of genital warts or penile or anal cancer, and no current diagnosis of a sexually transmitted infection. Participants completed a self-administered questionnaire. Circumcision status was assessed by the study clinician. Logistic regression was used to examine associations between circumcision and HPV detection at each site and in semen, with adjustment for potential confounders.
Seventy-four men (16.0%) were uncircumcised. Adjusted odds ratios (AORs) for any HPV genotype and circumcision were 0.53 (95% confidence interval [CI], 0.28–0.99) for any anatomic site/specimen, 0.17 (95% CI, 0.05–0.56) for the urethra, 0.44 (95% CI, 0.23–0.82) for the glans/corona, and 0.53 (95% CI, 0.28–0.99) for the penile shaft. AORs were <1.0 but not statistically significant for the scrotum, semen, anal canal, and perianal area.
Circumcision may be protective against HPV infection of the urethra, glans/corona, and penile shaft.
PMCID: PMC5068969  PMID: 19086813
10.  Human Papillomavirus Virus (HPV) Genotype- and Age-Specific Analyses of External Genital Lesions Among Men in the HPV Infection in Men (HIM) Study 
The Journal of Infectious Diseases  2014;211(7):1060-1067.
Background. Human papillomavirus (HPV) causes external genital lesions (EGLs) in men, including condyloma and penile intraepithelial neoplasia (PeIN). We sought to determine the incidence of pathologically confirmed EGLs, by lesion type, among men in different age groups and to evaluate the HPV types that were associated with EGL development.
Methods. HPV Infection in Men (HIM) study participants who contributed ≥2 visits from 2009–2013 were included in the biopsy cohort. Genotyping by an HPV line-probe assay was performed on all pathologically confirmed EGLs. Age-specific analyses were conducted for incident EGLs, with Kaplan–Meier estimation of cumulative incidence.
Results. This biopsy cohort included 2754 men (median follow-up duration, 12.4 months [interquartile range, 6.9–19.2 months]). EGLs (n = 377) were pathologically confirmed in 228 men, 198 of whom had incident EGLs. The cumulative incidence of any EGL was highest among men <45 years old and, for condyloma, decreased significantly over time with age. The genotype-specific incidence of EGL varied by pathological diagnoses, with high- and low-risk genotypes found in 15.6% and 73.2% of EGLs, respectively. Condyloma primarily contained HPV 6 or 11. While PeIN lesions primarily contained HPV 16, 1 PeIN III lesion was positive for HPV 6 only.
Conclusion. Low- and high-risk HPV genotypes contribute to the EGL burden. Men remain susceptible to HPV-related EGLs throughout the life span, making it necessary to ensure the longevity of immune protection against the most common causative HPV genotypes.
PMCID: PMC4432433  PMID: 25344518
human papillomavirus (HPV); genotype; age; external genital lesions; penile intraepithelial neoplasia (PeIN); condyloma; HIM Study
11.  Long-term persistence of oral human papillomavirus type 16: The HPV Infection in Men (HIM) Study 
Persistent infection with oral HPV16 is believed to drive the development of most oropharyngeal cancers. However, patterns of oral HPV16 persistence remain understudied, particularly among HIV-negative individuals. Oral HPV16 persistence was evaluated among 1626 participants of the HPV Infection in Men (HIM) Study. Twenty-three oral HPV16-positive men who provided an oral gargle sample on ≥2 study visits were included in the analysis. Archived oral samples from all follow-up visits were tested for HPV16 using Linear Array and INNO-LiPA detection methods. Persistence was evaluated using consecutive HPV16-positive visits held approximately 6 months apart and using the Kaplan-Meier method. Oral HPV16-positive men were aged 18–64 years (median, 36 years; IQR, 25–42) and were followed for a median of 44.4 months (IQR, 29.9–49.5). Of 13 incident infections, 4 (30.8%) persisted ≥12 months, 1 (10.0%) persisted ≥24 months, and none persisted ≥36 months (median infection duration, 7.3 months [95% CI, 6.4–NA]). Of 10 prevalent infections, 9 (90.0%) persisted ≥12 months, 8 (80.0%) persisted ≥24 months, 4 (57.1%) persisted ≥36 months, and 2 (40.0%) persisted ≥48 months (median infection duration, NA). Twelve-month persistence of incident infections increased significantly with age (P trend=0.028). Prevalent oral HPV16 infections in men persisted longer than newly acquired infections, and persistence appeared to increase with age. These findings may explain the high prevalence of oral HPV observed at older ages. Understanding oral HPV16 persistence will aid in the identification of men at high-risk of developing HPV-related oropharyngeal cancer.
PMCID: PMC4355174  PMID: 25575501
oral HPV; HPV16; natural history; persistence; clearance
13.  Quadrivalent Human Papillomavirus (HPV) Vaccine Induces HPV-Specific Antibodies in the Oral Cavity: Results From the Mid-Adult Male Vaccine Trial 
The Journal of Infectious Diseases  2016;214(8):1276-1283.
Background. Human papillomavirus virus type 16 (HPV-16) and HPV-18 cause a large proportion of oropharyngeal cancers, which are increasing in incidence among males, and vaccine efficacy against oral HPV infections in men has not been previously evaluated.
Methods. Sera and saliva collected in mouthwash and Merocel sponges at day 1 and month 7 were obtained from 150 men aged 27–45 years from Tampa, Florida, and Cuernavaca, Mexico, who received Gardasil at day 1 and months 2 and 6. Specimens were tested for anti–HPV-16 and anti–HPV-18 immunoglobulin G (IgG) levels by an L1 virus-like particle–based enzyme-linked immunosorbent assay.
Results. All participants developed detectable serum anti–HPV-16 and anti–HPV-18 antibodies, and most had detectable antibodies in both oral specimen types at month 7 (HPV-16 was detected in 93.2% of mouthwash specimens and 95.7% of sponge specimens; HPV-18 was detected in 72.1% and 65.5%, respectively). Antibody concentrations in saliva were approximately 3 logs lower than in serum. HPV-16– and HPV-18–specific antibody levels, normalized to total IgG levels, in both oral specimen types at month 7 were significantly correlated with serum levels (for HPV-16, ρ was 0.90 for mouthwash specimens and 0.92 for sponge specimens; for HPV-18, ρ was 0.89 and 0.86, respectively).
Conclusions. This is the first study demonstrating that vaccination of males with Gardasil induces HPV antibody levels at the oral cavity that correlate with circulating levels.
PMCID: PMC5034962  PMID: 27511896
HPV vaccine; males; serum; mouthwash; saliva
14.  The Natural History of Genital Human Papillomavirus Among HIV-Negative Men Having Sex With Men and Men Having Sex With Women 
The Journal of Infectious Diseases  2015;212(2):202-212.
Background. Although human immunodeficiency virus (HIV)–negative men having sex with men (MSM) bear a substantial burden of human papillomavirus (HPV)–associated disease, prospective studies of genital HPV infection in this population are scarce.
Methods. HPV genotyping was conducted on genital samples from men (aged 18–70 years) from Brazil, Mexico, or the United States who provided specimens at 6-month intervals for up to 4 years. Eligibility criteria included no history of genital warts or HIV infection. Evaluable specimens were collected from 564 MSM and 3029 men having sex with women (MSW). Incidence and clearance estimates with 95% confidence intervals were calculated.
Results. The 12-month cumulative incidence of genital HPV was high in both MSM (25%; 95% confidence interval, 21%–30%) and MSW (21%; 20%–23%). After stratifying by city, MSM and MSW incidence rates were comparable, with 3 exceptions where MSM had higher incidence in ≥1 city: the group of quadrivalent vaccine types, HPV-45, and HPV-11. Median times to HPV-16 clearance were also comparable, with point estimates of >6 months for both MSM and MSW.
Conclusions. Unlike with many other sexually transmitted infections, genital HPV natural history may be similar in HIV-negative MSM and MSW. Study periods of ≤6 months, however, may not be long enough to accurately measure the persistence of these infections in men.
PMCID: PMC4565999  PMID: 25649172
HPV; men; incidence; clearance; duration; epidemiology; MSM; bisexual men; heterosexual men
15.  Alternative dosage schedules with HPV VLP vaccines 
Expert review of vaccines  2014;13(8):1027-1038.
Human papillomavirus (HPV) vaccines can prevent multiple cancers in women and men. Difficulties in the cost and completion of the three-dose vaccine series have led to considerations of alternative dose schedules. In clinical trials, three doses given within a 12-month period versus the standard six-month period yielded comparable results, and immunogenicity appears comparable with two doses in adolescent females compared to the three-dose series in adult females. While the data are generally supportive of moving to a two-dose vaccine schedule among young female adolescents, the adoption of a two-dose vaccine schedule still poses a potential risk to the strength and longevity of the immune response. Public health authorities implementing a two-dose vaccine schedule should devise risk management strategies to minimize the potential impact on cancer prevention.
PMCID: PMC4147727  PMID: 25001893
HPV vaccination; dosing; virus-like particle; dose schedules; immunogenicity
16.  Natural History of Polyomaviruses in Men: The HPV Infection in Men (HIM) Study 
The Journal of Infectious Diseases  2014;211(9):1437-1446.
Background. Several new polyomaviruses have been discovered in the last decade, including Merkel cell polyomavirus (MCPyV). Little is known about the natural history of the more recently discovered polyomaviruses. We estimated the incidence, prevalence, and persistence of 9 polyomaviruses (MCPyV, BK polyomavirus, KI polyomavirus, JC polyomavirus, WU polyomavirus, Human polyomavirus 6 [HPyV6], HPyV7, HPyV9, and Trichodysplasia spinulosa–associated polyomavirus) and examined factors associated with MCPyV infection in a prospective cohort of 209 men initially enrolled in the HPV Infection in Men (HIM) study.
Methods. Participants enrolled at the US site of the HIM study were recruited into a substudy of cutaneous viral infections and followed for a median of 12.6 months. Eyebrow hair and normal skin swab specimens were obtained at each study visit, and the viral DNA load was measured using multiplex polymerase chain reaction.
Results. MCPyV infection showed the highest prevalence (65.1% of normal skin swab specimens and 30.6% of eyebrow hair specimens), incidence (81.7 cases per 1000 person-months among normal skin swab specimens, and 24.1 cases per 1000 person-months among eyebrow hair specimens), and persistence (85.8% of normal skin swab specimens and 58.9% of eyebrow hair specimens) among all polyomaviruses examined. Age of >44 years (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.03–4.33) and Hispanic race (OR, 2.64; 95% CI, 1.01–6.88) were associated with an increased prevalence of MCPyV infection in eyebrow hair and normal skin swab specimens, respectively.
Conclusion. MCPyV infection is highly prevalent in adults, with age and race being predisposing factors.
PMCID: PMC4462655  PMID: 25387582
polyomavirus; natural history; eyebrow hair; skin swabs
17.  Diversity of human papillomavirus in the anal canal of men: The HIM study 
Human papillomavirus (HPV) infections are associated with development of anogenital lesions in men. There are no reports describing the distribution of non-alpha HPV types in the anal canal of a sexually diverse men group. The HIM (HPV in Men) Study is a multicenter study of the natural history of HPV infection in Brazil, Mexico and USA. At baseline, 12% of anal canal specimens PCR HPV-positive were not typed by the Roche Linear Array and were considered unclassified. Our goal was characterizing HPVs among these unclassified specimens at baseline and assess associations with participant socio-demographic and behavioral characteristics. Unclassified HPVs were typed by sequencing amplified PGMY09/11 products or cloning of PGMY/GP+ nested amplicons followed by sequencing. Further analysis was conducted using FAP primers. Of men with unclassified HPV at the anal canal, most (89.1%) were men who have sex with women (MSW). Readable sequences were produced for 62.8% of unclassified specimens, of which 75.2% were characterized HPV types. A total of 18, 26, and 3 different α-, β- and γ-HPV types were detected, respectively. Compared to older men (45-70 years), α-HPVs were more commonly detected among young men (18-30 years) whereas β-HPVs were more frequent among mid-adult men (31-44 years). β-HPVs were more common among heterosexual men (85.0%) than non-heterosexual men. β2-HPV types composed all β-HPVs detected among non-heterosexual men. The high prevalence of β-HPV in the anal canal of men who do not report receptive anal sex is suggestive of other forms of transmission that do not involve penile-anal intercourse.
PMCID: PMC4538945  PMID: 25698660
human papillomavirus; cutaneous HPV; males; HIM Study; prevalence; anal canal; unclassified types
18.  Phase II studies to select the formulation of a multivalent HPV L1 virus-like particle (VLP) vaccine 
Human Vaccines & Immunotherapeutics  2015;11(6):1313-1322.
Our objective was to develop a multivalent prophylactic HPV vaccine that protects against infection and disease caused by HPV16/18 (oncogenic types in existing prophylactic vaccines) plus additional oncogenic types by conducting 3 Phase II studies comparing the immunogenicity (i.e., anti-HPV6/11/16/18 geometric mean titers [GMT]) and safety of 7 vaccine candidates with the licensed quadrivalent HPV6/11/16/18 vaccine (qHPV vaccine) in young women ages 16–26. In the first study (Study 1), subjects received one of 3 dose formulations of an 8-valent HPV6/11/16/18/31/45/52/58 vaccine or qHPV vaccine (control). In Study 2, subjects received one of 3 dose formulations (termed low-, mid-, and high-dose formulations, respectively) of a 9-valent HPV6/11/16/18/31/33/45/52/58 vaccine (9vHPV vaccine) or qHPV vaccine (control). In Study 3, subjects concomitantly received qHPV vaccine plus 5-valent HPV31/33/45/52/58 or qHPV vaccine plus placebo (control). All vaccines were administered at day 1/month 2/month 6. In studies 1 and 3, anti-HPV6/11/16/18 GMTs at month 7 were non-inferior in the experimental arms compared with the control arm; however, there was a trend for lower antibody responses for all 4 HPV types. In Study 2, this immune interference was overcome with the mid- and high-dose formulations of the 9vHPV vaccine by increasing antigen and adjuvant doses. In all 3 studies, all vaccine candidates were strongly immunogenic with respect to HPV31/33/45/52/58 and were well tolerated. Based on the totality of the results, the middle dose formulation of the 9vHPV vaccine was selected for Phase III evaluation. Each 0.5mL dose contains 30μg/40μg/60μg/40μg/20μg/20μg/20μg/20μg/20μg of HPV6/11/16/18/31/33/45/52/58 virus-like particles, and 500μg of amorphous aluminum hydroxyphosphate sulfate numbers NCT00260039, NCT00543543, and NCT00551187.
PMCID: PMC4514333  PMID: 25912208
dose selection; formulation; HPV; immunogenicity; vaccine
19.  A prospective analysis of smoking and human papillomavirus (HPV) infection among men in The HPV in Men (HIM) Study 
At present it is unknown whether the higher prevalence of human papillomavirus (HPV) infection among smokers in men is attributed to a higher probability of acquiring an infection or because of longer infection persistence. Thus, we investigated the role of smoking on the (acquisition) and clearance (persistence) of genital HPV infections among 4,026 men in The HPV in Men (HIM) Study, a multinational prospective study of the natural history of genital HPV infection in men. Genital HPV infections were grouped any-, oncogenic-, and non-oncogenic HPV infections and smoking status was categorized as current-, former, and never smokers. The incidence of any-, oncogenic-, and non-oncogenic HPV infections was significantly higher among current smokers compared to former- and never smokers (P < 0.01). In multivariable analyses adjusting for sexual behavior and potential confounders, when compared to never smokers, current smokers exhibited significantly higher probability of acquiring any- (Hazard Ratio [HR] = 1.23; 95% confidence interval [CI] 1.02 – 1.50) and non-oncogenic (HR = 1.21; 95% CI 1.00 – 1.45) infections and a borderline significant probability for oncogenic infections (HR = 1.18; 95% CI 0.98 – 1.41). Although the median duration of HPV infection was generally longer among current smokers, we found no statistically significant associations in the multivariable analyses. Overall, these results demonstrated that current smoking exhibited the highest incidence and highest probability of acquiring genital HPV infections.
PMCID: PMC3949156  PMID: 24222514
HPV; epidemiology; incidence; smoking
20.  Epidemiology of Human Papillomavirus Infection in Men, in Cancers other than Cervical and in Benign Conditions 
Vaccine  2008;26(0 10):K17-K28.
Human Papillomavirus (HPV) infection is commonly found in the genital tract of men and women with or without any clinical lesion. The association of HPV DNA with several different ano-genital cancers other than cervical has been reported for the vulva, vagina, anus and penis. HPV DNA has also been identified in head and neck cancers in the oral cavity, the oropharynx and the larynx in both sexes. In men, 80–85% of anal cancers and close to 50% of penile cancers are associated with HPV infection. In women, HPV DNA is prevalent in 36–40 % vulvar cancer cases and close to 90 % of vaginal cancers. There is limited data available on the natural history and HPV-related diseases in the genital tract in men, although studies are ongoing. Efficacy of HPV vaccines in the prevention of HPV infection and disease among men also remains unknown. Among HPV DNA positive ano-genital cancer cases, HPV-16 is the most frequently found followed distantly by HPV-18. In benign HPV-related diseases such as genital warts or recurrent respiratory papillomatosis HPV-6 and 11, the two most frequent non-oncogenic types, are the predominant types detected. Oncogenic types are rarely detected. In this article we summarize and review studies describing the natural history of HPV infections among men and its impact on HPV related disease in women. We summarize the evidence linking HPV in the epidemiology and etiology of cancers of the vulva, vagina, anus and oropharynx and present recent estimates of the burden of and HPV type distribution in genital warts and in cases of HPV infection of the airways.
PMCID: PMC4366004  PMID: 18847554
cancer; HPV; men; women; infection; genital warts; respiratory papillomatosis; anogenital cancer
21.  Role of Histological Findings and Pathologic Diagnosis for Detection of Human Papillomavirus Infection in Men 
Journal of medical virology  2015;87(10):1777-1787.
Early HPV infection in males is difficult to detect clinically and pathologically. This study assessed histopathology in diagnosing male genital HPV. External genital lesions (n = 352) were biopsied, diagnosed by a dermatopathologist, and HPV genotyped. A subset (n = 167) was diagnosed independently by a second dermatopathologist and also re-evaluated in detail, tabulating the presence of a set of histopathologic characteristics related to HPV infection. Cases that received discrepant diagnoses or HPV-related diagnoses were evaluated by a third dermatopathologist (n = 163). Across dermatopathologists, three-way concordance was fair (k = 0.30). Pairwise concordance for condyloma was fair to good (k = 0.30–0.67) and poor to moderate for penile intraepithelial neoplasia (k = −0.05 to 0.42). Diagnoses were 44–47% sensitive and 65–72% specific for HPV 6/ 11-containing lesions, and 20–37% sensitive and 98–99% specific for HPV 16/18. Presence of HPV 6/ 11 was 75–79% sensitive and 35% specific for predicting pathologic diagnosis of condyloma. For diagnosis of penile intraepithelial neoplasia, HPV 16/18 was 95–96% specific but only 40–64% sensitive. Rounded papillomatosis, hypergranulosis, and dilated vessels were significantly (P<0.05) associated with HPV 6/11. Dysplasia was significantly (P= 0.001) associated with HPV 16/18. Dermatopathologists’ diagnoses of early male genital HPV-related lesions appear discordant with low sensitivity, while genotyping may overestimate clinically significant HPV-related disease. Rounded papillomatosis, hypergranulosis, and dilated vessels may help establish diagnosis of early condyloma.
PMCID: PMC4780420  PMID: 25945468
HPV; condyloma; penile intraepithelial neoplasia; PeIN; histopathology; biopsy
22.  Recurrent BRCA1 and BRCA2 mutations in Mexican women with breast cancer 
Germline mutations in the BRCA1 and BRCA2 genes confer an estimated 58–80% lifetime risk of breast cancer. In general, screening is done for cancer patients if a relative has been diagnosed with breast or ovarian cancer. There are few data on the prevalence of mutations in these genes in Mexican women with breast cancer and this hampers efforts to develop screening policies in Mexico.
We screened 810 unselected women with breast cancer from three cities in Mexico (Mexico City, Veracruz and Monterrey) for mutations in BRCA1 and BRCA2, including a panel of 26 previously reported mutations.
Thirty-five mutations were identified in 34 women (4.3% of total) including 20 BRCA1 mutations and 15 BRCA2 mutations. Twenty-two of the 35 mutations were recurrent mutations (62.8%). Only five of the 34 mutation carriers had a first-degree relative with breast cancer (three with BRCA1 and two with BRCA2 mutations).
These results support the rationale for a strategy of screening for recurrent mutations in all women with breast cancer in Mexico, as opposed to restricting screening to those with a sister or mother with breast or ovarian cancer.
These results will impact cancer genetic testing in Mexico and the identification of at-risk individuals who will benefit from increased surveillance.
PMCID: PMC4495576  PMID: 25371446
23.  Physicians’ Human Papillomavirus Vaccine Recommendations, 2009 and 2011 
Physician recommendation is a key predictor of human papillomavirus (HPV) vaccine uptake. Understanding factors associated with recommendation is important for efforts to increase current suboptimal vaccine uptake.
This study aimed to examine physician recommendations to vaccinate female patients aged 11–26 years, in 2009 and 2011, at 3 and 5 years postvaccine licensure, respectively. A second aim was to identify trends in factors associated with vaccine recommendation for ages 11 and 12 years.
Nationally representative samples of physicians practicing family medicine, pediatrics, and obstetrics and gynecology were randomly selected from the American Medical Association Physician Masterfile (n=1538 in 2009, n=1541 in 2011). A mailed survey asked physicians about patient and clinical practice characteristics; immunization support; and frequency of HPV vaccine recommendation (“always” = >75% of the time vs other). Analyses were conducted in 2012.
Completed surveys were received from 1013 eligible physicians (68% response rate) in 2009 and 928 (63%) in 2011. The proportion of physicians who reported “always” recommending HPV vaccine increased significantly from 2009 to 2011 for patients aged 11 or 12 years (35% vs 40%, respectively; p=0.03), but not for patients aged 13–17 years (53% vs 55%; p= 0.28) or 18–26 years (50% vs 52%; p=0.52). Physician specialty, age, and perceived issues/barriers to vaccination were associated with vaccine recommendation for patients aged 11 or 12 in both years.
Results suggest a modest increase in recommendations for HPV vaccination of girls aged 11 or 12 years over a 2-year period; however, recommendations remain suboptimal for all age groups despite national recommendations for universal immunization.
PMCID: PMC3895928  PMID: 24355675
24.  HPV Population Profiling in Healthy Men by Next-Generation Deep Sequencing Coupled with HPV-QUEST 
Viruses  2016;8(2):28.
Multiple-type human papillomaviruses (HPV) infection presents a greater risk for persistence in asymptomatic individuals and may accelerate cancer development. To extend the scope of HPV types defined by probe-based assays, multiplexing deep sequencing of HPV L1, coupled with an HPV-QUEST genotyping server and a bioinformatic pipeline, was established and applied to survey the diversity of HPV genotypes among a subset of healthy men from the HPV in Men (HIM) Multinational Study. Twenty-one HPV genotypes (12 high-risk and 9 low-risk) were detected in the genital area from 18 asymptomatic individuals. A single HPV type, either HPV16, HPV6b or HPV83, was detected in 7 individuals, while coinfection by 2 to 5 high-risk and/or low-risk genotypes was identified in the other 11 participants. In two individuals studied for over one year, HPV16 persisted, while fluctuations of coinfecting genotypes occurred. HPV L1 regions were generally identical between query and reference sequences, although nonsynonymous and synonymous nucleotide polymorphisms of HPV16, 18, 31, 35h, 59, 70, 73, cand85, 6b, 62, 81, 83, cand89 or JEB2 L1 genotypes, mostly unidentified by linear array, were evident. Deep sequencing coupled with HPV-QUEST provides efficient and unambiguous classification of HPV genotypes in multiple-type HPV infection in host ecosystems.
PMCID: PMC4776183  PMID: 26821041
HPV; multiple-type HPV infection; asymptomatic men; deep sequencing; HPV-QUEST; Linear Array; Papillomavirus Episteme
25.  MAPK genes interact with diet and lifestyle factors to alter risk of breast cancer: The Breast Cancer Health Disparities Study 
Nutrition and cancer  2015;67(2):292-304.
Mitogen-activated protein kinases (MAPK) are integration points for multiple biochemical signals. We evaluated 13 MAPK genes with breast cancer risk and determined if diet and lifestyle factors mediated risk. Data from three population-based case-control studies conducted in Southwestern United States, California, and Mexico included 4183 controls and 3592 cases. Percent Indigenous American (IA) ancestry was determined from 104 Ancestry Informative Markers. The adaptive rank truncated product (ARTP) was used to determine the significance of each gene and the pathway with breast cancer risk, by menopausal status, genetic ancestry level, and ER/PR strata.
MAP3K9 was associated with breast cancer overall (PARTP=0.02) with strongest association among women with the highest IA ancestry (PARTP=0.04). Several SNPs in MAP3K9 were associated with ER+/PR+ tumors and interacted with dietary oxidative balance score (DOBS), dietary folate, body mass index (BMI), alcohol consumption, cigarette smoking, and a history of diabetes. DUSP4 and MAPK8 interacted with calories to alter breast cancer risk; MAPK1 interacted with DOBS, dietary fiber, folate and BMI; MAP3K2 interacted with dietary fat; and MAPK14 interacted with dietary folate and BMI. The patterns of association across diet and lifestyle factors with similar biological properties for the same SNPs within genes provide support for associations.
PMCID: PMC4450722  PMID: 25629224
Breast Cancer; Indigenous Ancestry; MAPK; MAP3K9; diet; diabetes; body size; polymorphisms

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