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Cancer Research and Treatment > Volume 50(3); 2018 > Article
Ingabire, Lim, Won, and Oh: Human Papillomavirus Genotype-Specific Persistence and Potential Risk Factors among Korean Women: Results from a 2-Year Follow-up Study

Abstract

Purpose

High-risk human papillomavirus (HPV) infection progression should be considered a critical factor for preventing cervical cancer, although most infections are transient and rarely persist. This study aimed to examine the specific types of HPV infections, their change patterns, and the potential risk factors among Korean women.

Materials and Methods

We included 4,588 women who visited hospitals in Busan and Suwon for cervical cancer screening, and 1,224 of thesewomen attended a 2-yearfollow-up. Infection statuswas evaluated using HPV DNA testing (Hybrid Capture 2) and genotyping testing (Linear Array). Data regarding the potential risk factors for HPV infection were collected by trained nurses using structured questionnaires.

Results

Among the 1,224 women (mean age, 47 years), 105 women (8.6%) were HPV-positive at baseline. HPV infections had been cleared among 92 women (87.6%) within 2 years. Only 13 infections (12.4%) were remained, and the 10 cases of them are high-risk HPV types including genotype 33, 45, 16, 35, and 52. Among women who were negative at baseline, the HPV incidence was 4.8%. The HPV incidence was marginally associated with having multiple sexual partners (odds ratio, 2.0; 95% confidence interval, 1.0 to 3.9), although it was not significantly associated with HPV persistence.

Conclusion

Most HPV infections (88%) among Korean women were cleared within 2 years, with only a small number of persistent infections. The persistent HPV genotypes were different in our study, compared to those from previous studies. Having multiple sexual partners was associated with acquiring a HPV infection, but not with persistence.

Introduction

Human papillomavirus (HPV) infection can cause cervical cancer, and the cancer burden attributed to this infection varies according to geographical region and the genotype of people who are infected with HPV. It is most prevalent in Africa, Asia, and some European countries, compared to other regions of the world. Thirteen high-risk HPV (HRHPV) types, which are carcinogenic or presumed to be carcinogenic in humans, are frequently detected in patients who develop cervical cancer. For example, HPV types 16 and 18 account for approximately 70% of all cervical cancer cases [1]. Several epidemiological studies have evaluated the genotype-specific prevalences of HPV, factors that influence HPV acquisition, and the risk of cervical cancer development according to HPV infection status [1-4]. Furthermore, there are various factors that influence cervical cancer development, including viral infection and host factors. Thus, the prevention of cervical cancer relies on our understanding of the progression of HR-HPV infections, which involves persistence, clearance, new infections, and other determinant factors. However, most HPV infections are transient and rarely persist [5,6]. Only a few studies in specific countries and populations have considered the HPV genotype-specific incidence, persistence, clearance, and new infections [7-17]. Furthermore, only a few studies have evaluated the natural history of HPV infections in Asian countries, where the prevalence of HPV is high. Moreover, the association with cervical cancer development has been highlighted as a major health issue among women. In Korea, the prevalence of HPV is approximately 20% among women with normal cytology, based on the Papanicolaou test (Pap test) [18]. In addition, cervical cancer is a leading cancer among Korean women, with an age-standardized incidence of 9.5/100,000 women in 2012 [19]. Despite these data, there is a lack of Korean studies regarding changes in HPV infection status and the factors that contribute to these changes. Therefore, the present study aimed to examine HPV type-specific infections, their change patterns, and the factors that were involved in these changes, based on two HPV tests that were performed 2 years apart for Korean women who visited two centers.

Materials and Methods

1. Study population

This retrospective study evaluated prospectively collected data from a baseline test and a test at the 2-year follow-up. A total of 4,595 women visited government-affiliated hospitals in Busan and Suwon (Korea) for baseline testing between November 2004 and December 2006, as part of the National Cervical Cancer Screening Program. Among these women, 1,224 women subsequently attended the follow-up testing during 2007 and 2008. The details of the baseline testing have been described elsewhere [5], and Fig. 1 shows the inclusion and exclusion criteria for the present study.

2. Data collection

Data regarding the potential risk factors for HPV infection were obtained using questionnaires at the baseline test. A trained research nurse interviewed each participant and completed the structured questionnaire regarding their socio-demographic characteristics (age, marital status, educational level, and age at marriage), lifestyle behaviors (smoking, alcohol drinking, and number of sexual partners), obstetrical and reproductive history (parity, age of women at first childbirth, oral contraceptive use, intrauterine device use, and hormone therapy), and clinical characteristics (sexually transmitted disease histories for the participant and their partner, family and individual cancer history, and cervical screening history).
The outcome variable was based on the results from two HPV tests at the baseline and follow-up testing. The results were categorized according to the HPV infection change status: (1) type-specific persistence (positivity for the same HPV DNA type in both tests), (2) type-specific HPV clearance (a negative result for a specific HPV type after a previously positive result), and (3) incident HPV infection (a change from HPV DNA negativity at baseline to HPV DNA positivity at the follow-up test). The HPV testing was performed using the Hybrid Capture 2 system (HC2; Digene, Gaithersburg, MA), and HPV genotyping was performed on HC2-positive samples using a Linear Array assay (LA; Roche Molecular Systems, Branchburg, NJ) [20].

3. Statistical analysis

The proportions of HPV type-specific persistence and clearance were calculated among the 105 women who were HPV-positive, based on their baseline LA results. The incidences of new HPV type-specific infections were calculated among the 1,119 women who were HPV-negative, based on their baseline LA results. Pearson’s chi-square test and Fischer exact test was used to assess the frequency distributions of potential risk factors for changing HPV infection status. Logistic regression analyses were also used to evaluate the role of potential risk factors in the changes in HPV infection status. Associations were reported as odds ratios (ORs) and 95% confidence intervals (CIs). All tests were two-sided, and a p-value of < 0.05 was considered statistically significant. All analyses were performed using STATA software ver. 13 (StataCorp LP, College Station, TX).

4. Ethical statement

The study protocol was approved by the Institutional Review Board of the National Cancer Center, and all participants provided written informed consent at the baseline test.

Results

Among the 4,588 women who participated in the baseline survey, only 1,224 women were followed-up and included in the present analysis. When we compared the participants from the baseline and follow-up testing, we did not observe any noticeably differences in their socio-demographic, behavioral, and reproductive characteristics, or in their HPV infection rates (S1 Table). The mean patient age at baseline was 47 years (range, 21 to 66 years), most participants were married or cohabitating, 17% of the participants had ≥ 2 sexual partners during their lifetime, and the prevalence of HPV infections was 8.6%. At the 2-year follow-up, the prevalence of HPV infection decreased to 6.0%. All participants and the high-risk group for HPV infection were most likely to live in Busan, have ≥ 2 sexual partners during their lifetime, have a family history of cancer, and have a history of HPV infection at baseline (Table 1).
Among the 105 HPV infections from the baseline, only 13 infections (12.4%) were remained, and the 10 cases of them are HR-HPV types including genotype 33, 45, 16, 35, and 52. Among the 1,119 women who tested negative at the baseline, 54 women (5%) exhibited new HPV infections at the followup. The most frequent HPV genotypes found in new infection cases were genotypes 39, 52, 16, 51, and 58 (Table 2).
Persistent HPV infections were relatively common among unmarried women, women with ≥ 2 more sexual partners during their lifetime, and women with a family history of cancer. Cleared and new infections were relatively common among women with a history of a sexually transmitted disease or Chlamydia infection. Persistent and new infections were more common in Busan, compared to Suwon (Table 3). After adjusting for all potential factors, having ≥ 2 sexual partners exhibited a marginally significant association with new HPV infections (OR, 2.0; 95% CI, 1.0 to 3.9). No factors were significantly associated with HPV persistence and clearance (Table 4).

Discussion

The present study provided information regarding HPV genotype-specific infections and their change patterns among Korean women. These data are important, because relevant data are sparse in this population, despite the prevalence of HPV infection and incidence of cervical cancer. Furthermore, ours is the first report regarding the natural history of HPV infection among Korean women who visited clinics or hospitals for routine health examinations (e.g., cervical cancer screening), rather than for the diagnosis or treatment of gynecological symptoms. Moreover, we performed both HPV LA and HPV genotyping to confirm the HPV type-specific changes that occurred during the course of the patients’ infections.
Most infections (87.6%) were cleared within 2 years, although 5% of women developed new HPV infections during this time. These results are consistent with findings from previous reports, which suggested that up to 90% of incident infections are cleared within 2 years [5], and that the estimated half-life of HR-HPV infections is 8-10 months [6]. However, HPV persistency varies according to country, and our results revealed a lower persistency (12.4%), compared to results from previous studies in Brazil (19.2%) [9], Italy (49.1%) [16], Denmark (31.4% [21] and 26.9% [12]), the United States (39%) [10], and the Netherlands (44.1%) [22]. These differences may be related to differences in the target populations, who may have different potential risks for persistent infection, and/or differences in the baseline and follow-up testing interval. Nevertheless, the result from a meta-analysis on the patterns of HPV persistence worldwide, the persistence rate tends to decrease with time passed after infection [23]. The association between age and HPV persistence remains controversial. A review of the natural history of HPV infection suggests that age indirectly affects HPV persistence [24], while others studies have reported that younger age is associated with an increased risk of persistence [9,21]. Our results were similar to the persistence rate among young Korean women (17-26 years), despite the differences in the study populations’ ages and the higher rate of new HPV infections among young Korean women [8]. The present study also revealed that the most persistent HPV type was HPV 33, which was followed by genotypes 45, 16, 35, and 52. These results are different with the findings from previous studies, which revealed that HPV 16 and 18 were the most prevalent incident and persistent HPV types [9,16,21,23].
After adjusting for potential risk factors, we did not observe any significant associations with HPV persistence. Some studies have revealed similar findings, although other studies have revealed significant positive [11,12,16,25] or inverse [9,21] associations between age and HPV persistence, including a large retrospective study of Korean women. Another study found that smokers were likely to have persistent HPV infections [22]. In the present study, the number of sexual partners was the only factor to exhibit a marginal association with new HPV infections, and this result is similar to the findings from previous studies [26-28]. The current findings including distributions of HPV genotype-specific infections and their change patterns among Korean women may help improve our understanding of the natural history of HPV infection in the same populations, and facilitate the development of prophylactic vaccines for specific populations.
The present study has several limitations that warrant consideration. First, there is the possibility of selection bias, based on the low follow-up participation rate. However, the participants exhibited similar characteristics at the baseline and follow-up testing, although HPV positivity was slightly more common at the follow-up (10.1%), compared to the baseline (7.7%) (S1 Table). These differences are unlikely to have significantly influenced our findings. Second, the small samples of women who were followed-up and women with HPV (n=105) might have influenced the absence of significant associations between HPV persistence and the potential risk factors in the multivariate analyses. Furthermore, the number of sexual partners not during the last two years when participants followed up but during their life time was included as one of important factors involving HPV infection status and their change. It could be linked to insignificant results on the association between sexual behaviors and change of HPV infection status. Nevertheless, our results regarding HPV change patterns evaluated a large number of Korean women at the baseline (n=4,558), and lifetime sexual behavior could represent overall tendency of sexual behaviors even if it is not the specific sexual behaviors change during the time followed up. Third, detailed data regarding the natural history of HPV infection should be obtained using long-term studies with repeated measurements over shorter intervals (e.g., every 6 months or every year), and we only evaluated HPV infection status after a 2-year interval. Also, information on further diagnosis and treatment such as Pap smear, colposcopic biopsy, and laser therapy during the follow up periods, which might be important factors associated with change of HPV infection status, were not available in this study. Fourth, HPV genotyping was only performed for HPV LA-positive cases at the baseline, although there was disagreement between the test results from HPV LA (6.0%) and HPV HC2 (7.0%) (data not shown). However, the correlation of HPV LA with HR HPV positivity is higher than that with HPV HC2, and this level of disagreement is likely acceptable, based on previously reported results [29,30].
In conclusion, the present study provided information regarding changes in HPV status over a 2-year interval among Korean women. Most infections resolved spontaneously, and only small fractions of the women experienced persistent infections or new HPV infections. The predominant persistent HPV genotypes were different in our study, compared to those from previous studies. We also found a marginally significant association between sexual behavior and HPV infection, but not with HPV persistence or clearance. Further large-scale studies are needed to better understand the natural history of HPV infections and the factors that are associated with HPV type-specific change patterns.

Electronic Supplementary Material

Supplementary materials are available at Cancer Research and Treatment website (http://www.e-crt.org).

Conflicts of Interest

Conflict of interest relevant to this article was not reported.

Acknowledgments

This study was supported by research grants from the National Cancer Center (No. 0410130, 0710140, 1610200), Republic of Korea.

Fig. 1.
Participants in baseline and follow-up survey and their classification by the status of human papillomavirus (HPV) infection. LA, linear array.
crt-2017-340f1.tif
Table 1.
General characteristics of 1,224 study participants at the follow up by HPV infection status
Characteristic Total (n=1,224)
Overall HPV infectiona) (n=73)
HR HPV infectiona) (n=52)
No. (%) No. (%) p-value No. (%) p-value
Region
 Busan 579 (47.3) 57 (9.8) 0.0001 41 (7.1) 0.001
 Suwon 645 (52.7) 16 (2.5) 11 (1.7)
Age group (yr)
 < 39 223 (18.2) 15 (6.7) 0.897 11 (5.0) 0.913
 40-49 529 (43.2) 29 (5.5) 23 (4.3)
 50-59 401 (32.8) 25 (6.2) 16 (4.0)
 ≥ 60 71 (5.8) 4 (5.6) 2 (2.8)
Marital status
 Unmarried (single, divorced, and widower) 204 (16.7) 16 (7.8) 0.214 10 (4.9) 0.612
 Married (married and cohabitant) 1,020 (83.3) 57 (5.6) 42 (4.1)
Education level
 None/Elementary/Middle school 496 (40.5) 34 (6.8) 0.277 24 (4.8) 0.398
 High school/University/≥ Master 728 (59.5) 39 (5.4) 28 (3.8)
First marriage age (yr)
 < 25 402 (41.7) 26 (6.5) 0.169 19 (4.7) 0.125
 ≥ 25 561 (58.3) 25 (4.5) 16 (2.8)
Smoking status
 Non smoker 1,150 (94.0) 70 (6.0) 1.000 49 (4.2) 0.474
 Current smoker 73 (6.0) 3 (5.8) 3 (5.8)
Alcohol drinking
 No 856 (69.9) 45 (5.3) 0.111 31 (3.6) 0.097
 Yes 368 (30.1) 28 (7.6) 21 (5.7)
Lifetime sexual partners
 1 1,003 (82.2) 49 (4.9) 0.001 34 (3.4) 0.003
 ≥ 2 217 (17.8) 23 (10.6) 17 (7.8)
Extramarital affair
 No 1,065 (87.2) 59 (5.5) 0.283 42 (3.9) 0.486
 Yes 156 (12.8) 12 (7.7) 8 (5.1)
Parity
 1 150 (12.8) 10 (6.7) 0.331 7 (4.7) 0.873
 2 719 (61.5) 38 (5.3) 29 (4.0)
 ≥ 3 300 (25.7) 23 (7.7) 14 (4.7)
Menopause
 No 506 (41.4) 35 (6.9) 0.24 22 (4.3) 0.889
 Yes 717 (58.6) 38 (5.3) 30 (4.2)
History of STDa)
 No 1,155 (95.7) 67 (5.8) 0.231 47 (4.1) 0.274
 Yes 52 (4.3) 5 (9.6) 4 (7.7)
Family history of cancer
 No 809 (66.1) 38 (4.7) 0.009 24 (3.0) 0.002
 Yes 414 (33.9) 35 (8.4) 28 (6.8)
Cervical screening history
 No 158 (13.0) 5 (3.2) 0.147 4 (7.8) 0.392
 Yes 1,058 (87.0) 67 (6.3) 47 (4.4)
Chlamydia trachomatis at baseline
 Negative 1,151 (96.2) 67 (5.8) 0.336 48 (4.2) 0.712
 Positive 45 (3.8) 4 (8.9) 2 (4.4)
HPV status at baseline by LA
 Negative 1,119 (91.4) 54 (4.8) < 0.001 36 (3.2) < 0.001
 Positive 105 (8.6) 19 (18.1) 16 (15.2)

HPV, human papillomavirus; STD, sexual transmitted disease; LA, linear array.

a) Sample sizes for individual characteristics may not equal total due to missing values.

Table 2.
HPV genotype distribution of 1,224 participants at the baseline and their changes at follow-up
HPV type Total HPV positive at baseline (n=105)
HPV negative at baseline (n=1,119)
Persistence at follow-upa) Clearance at follow-upa) Reinfection at follow-upa) Incidence at follow-upa)
Alla) 105 13 (12.4) 92 (87.6) 12 (11.4) 54 (4.8)
High risk 90 10 (11.1) 80 (88.9) 9 (8.6) 47 (4.2)
 HPV 16 10 2 (20.0) 8 (80.0) 0 6 (0.5)
 HPV 18 5 0 5 (100) 0 3 (0.3)
 HPV 31 1 0 1 (100) 0 3 (0.3)
 HPV 33 3 1 (33.3) 2 (66.7) 0 0
 HPV 35 5 1 (20.0) 4 (80.0) 0 0
 HPV 39 10 1 (10.0) 9 (90.0) 1 (1.0) 7 (0.6)
 HPV 45 4 1 (25.0) 3 (75.0) 1 (1.0) 1 (0.1)
 HPV 51 11 0 11 (100) 1 (1.0) 6 (0.5)
 HPV 52 15 3 (20.0) 12 (80.0) 4 (3.8) 7 (0.6)
 HPV 56 12 1 (8.3) 11 (91.7) 1 (1.0) 4 (0.4)
 HPV 58 6 0 6 (100) 0 6 (0.5)
 HPV 59 1 0 1 (100) 0 2 (0.2)
 HPV 68 7 0 7 (100) 1 (1.0) 2 (0.2)
Low risk 90 7 (7.8) 83 (92.2) 8 (7.6) 48 (4.3)
 HPV 6 3 0 3 (100) 0 0
 HPV 40 2 0 2 (100) 0 0
 HPV 42 1 1 (100) 0 1 (1.0) 2 (0.2)
 HPV 54 5 1 (20.0) 4 (80.0) 1 (1.0) 3 (0.3)
 HPV 53 15 1 (6.7) 14 (94.3) 0 8 (0.7)
 HPV 55 6 1 (16.7) 5 (83.3) 2 (1.9) 2 (0.2)
 HPV 61 3 1 (33.3) 2 (66.7) 1 (1.0) 4 (0.4)
 HPV 62 11 1 (9.1) 10 (98.9) 1 (1.0) 4 (0.4)
 HPV 66 15 0 15 (100) 0 1 (0.1)
 HPV 70 10 0 10 (100) 1 (1.0) 2 (0.2)
 HPV 71 4 0 4 (100) 1 (1.0) 2 (0.2)
 HPV 72 2 0 2 (100) 0 1 (0.1)
 HPV 81 4 0 4 (100) 0 6 (0.5)
 HPV 83 1 0 1 (100) 0 3 (0.3)
 HPV 84 6 1 (16.7) 5 (83.3) 0 6 (0.5)
 CP6108 2 0 2 (100) 0 2 (0.2)

Values are presented as number (%).

a) Same women can be counted more than once because of multiple infections.

Table 3.
Factors associated with type specific HPV persistence, clearance, and incidencea)
Characteristic Persistent HPV (n=13)
Overall HPV (n=92)
Incident HPV (n=54)
No. (%) No. (%) No. (%) p-value
Region
 Busan 10 (76.9) 46 (50.0) 42 (77.8) < 0.001
 Suwon 3 (23.1) 46 (50.0) 12 (22.2)
Age group (yr)
 < 39 2 (15.4) 24 (26.1) 10 (18.5) 0.31
 40-49 2 (15.4) 35 (38.0) 25 (46.3)
 50-59 8 (61.5) 27 (29.4) 16 (29.6)
 ≥ 60 1 (7.7) 6 (6.5) 3 (5.6)
Marital status
 Unmarried 6 (46.2) 19 (20.6) 8 (14.8) 0.036
 Married 7 (53.9) 73 (79.4) 46 (85.2)
Educational level
 None/Elementary/Middle school 9 (69.2) 39 (42.4) 23 (42.6) 0.19
 High school/University/≥ Master 4 (30.7) 53 (57.6) 31 (57.4)
Smoking status
 Nonsmoker 12 (92.3) 86 (95.9) 53 (98.2) 0.352
 Smoker 1 (7.7) 6 (4.1) 1 (1.8)
Alcohol drinking
 No 8 (61.5) 58 (63.1) 34 (62.9) 0.201
 Yes 5 (38.5) 34 (36.9) 20 (37.1)
Lifetime sexual partners
 1 8 (61.5) 64 (70.3) 38 (71.7) < 0.001
 ≥ 2 5 (38.5) 27 (29.7) 15 (28.3)
Parity
 1 2 (16.6) 9 (11.1) 6 (11.3) 0.393
 2 5 (41.7) 47 (58.0) 29 (54.7)
 ≥ 3 5 (41.7) 25 (30.9) 18 (34.0)
Hormone therapy use
 Never user 9 (100) 31 (81.6) 20 (83.3) 0.478
 Ever user 0 7 (18.4) 4 (16.7)
History of STD
 No 12 (100) 85 (92.4) 49 (90.7) 0.078
 Yes 0 7 (7.6) 5 (9.3)
Family history of cancer
 No 5 (38.5) 57 (62.0) 29 (53.7) 0.021
 Yes 8 (61.5) 35 (38.0) 25 (46.3)
Chlamydia trachomatis at baseline
 Negative 13 (100) 82 (90.1) 49 (94.2) 0.019
 Positive 0 9 (9.9) 3 (5.8)

HPV, human papillomavirus; STD, sexual transmitted disease.

a) Sample sizes for individual characteristics may not equal total due to missing values.

Table 4.
ORs and 95% CI of potential factors associated with HPV persistence, and incidence
Characteristic HPV positive at baseline
HPV negative at baseline
Total HPVa) (n=105) Persistent HPV (n=13)
Adjusted OR
Total HPVa) (n=1,119) Incident HPVa) (n= 54)
Adjusted OR
No. (%) OR (95% CI) No. (%) OR (95% CI)
Age group (yr)
 < 39 26 2 (7.7) Ref 197 10 (5.1) Ref
 40-49 37 2 (5.4) 1.0 (0.1-8.8) 492 25 (5.1) 1.2 (0.5-3.9)
 50-59 35 8 (22.7) 4.6 (0.7-29.0) 366 16 (4.4) 1.0 (0.4-2.4)
 ≥ 60 7 1 (14.3) 3.4 (0.3-60.1) 64 3 (4.7) 1.1 (0.3-4.2)
Smoking status
 Non-smoker 98 12 (12.2) Ref 1,074 53 (4.9) Ref
 Current smoker 7 1 (14.3) 1.7 (0.1-21.7) 44 1 (2.3) 0.3 (0.1-2.4)
Lifetime sexual partners
 1 72 8 (11.6) Ref 931 38 (4.1) Ref
 ≥ 2 32 5 (15.6) 1.6 (0.4-7.0) 185 15 (8.1) 2.0 (1.0-3.9)
Family history of cancer
 No 62 5 (8.1) Ref 747 29 (3.9) Ref
 Yes 43 8 (18.6) 4.0 (0.9-17.2) 371 25 (6.7) 1.7 (0.9-3.1)
History of STD
 No 97 12 (13.4) Ref 1,058 49 (4.6) Ref
 Yes 7 0 - 45 5 (11.1) 2.3 (0.8-6.2)
Chlamydia trachomatis at baseline
 Negative 95 13 (13.7) Ref 1,056 49 (4.6) Ref
 Positive 9 0 - 36 3 (8.3) 1.3 (0.3-5.5)

Adjustment was done using all variable presented in this table except region. OR, odds ratio; CI, confidence interval; HPV, human papillomavirus; STD, sexually transmitted diseases.

a) Sample sizes for individual characteristics may not equal to total due to missing values.

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