Journal of Clinical Virology 59 (2014) 18–23

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Journal of Clinical Virology

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The relationship between the cervical and anal HPV infection in

women with cervical intraepithelial neoplasia
Borek Sehnal a,∗ , Ladislav Dusek b , David Cibula c , Tomas Zima d , Michael Halaska a ,
Daniel Driak a , Jiri Slama c
a
Hospital Na Bulovce and 1st School of Medicine, Charles University, Department of Gynaecology and Obstetrics, Budinova 2, Prague 8, 180 81,
Czech Republic
b
Institute of Biostatistics and Analyses, Masaryk University, Kamenice 3, Brno, 625 00, Czech Republic
c
General University Hospital and 1st School of Medicine, Gynaecologic Oncology Centre, Charles University, Apolinarska 18, Prague 2, 128 51,
Czech Republic
d
General University Hospital and 1st School of Medicine, Institute of Medical Biochemistry and Laboratory Diagnostics, Charles University, U Nemocnice 2,
Prague 2, 128 08, Czech Republic

a r t i c l e i n f o a b s t r a c t

Article history: Background: More than 90% of cases of anal cancers are caused by high-risk human papillomavirus (HR
Received 13 August 2013 HPV) infection and a history of cervical intraepithelial neoplasia (CIN) is established as possible risk factor.
Received in revised form Objectives: To demonstrate relationship between anal and cervical HPV infection in women with different
11 November 2013
grades of CIN and microinvasive cervical cancer.
Accepted 16 November 2013
Study design: A total of 272 women were enrolled in the study. The study group included 172 women who
underwent conization for high-grade CIN or microinvasive cervical cancer. The control group consisted
Keywords:
of 100 women with non-neoplastic gynecologic diseases or biopsy-confirmed CIN 1. All participants
HPV
CIN
completed a questionnaire detailing their medical history and sexual risk factors and were subjected to
Cervical infection anal and cervical HPV genotyping using Cobas and Lynear array HPV test.
Anal infection Results: Cervical, anal, and concurrent cervical and anal HPV infections were detected in 82.6%, 48.3%
Anal cancer and 42.4% of women in the study group, and in 28.0%, 26.0% and 8.0% of women in the control group,
respectively. The prevalence of the HR HPV genotypes was higher in the study group and significantly
increased with the severity of cervical lesion. Concurrent infections of the cervix and anus occurred 5.3-
fold more often in the study group than in the control group. Any contact with the anus was the only
significant risk factor for development of concurrent HPV infection.
Conclusions: Concurrent anal and cervical HR HPV infection was found in nearly half of women with CIN
2+. The dominant genotype found in both anatomical locations was HPV 16. Any frequency and any type
of contact with the anus were shown as the most important risk factor for concurrent HPV infection.
© 2013 Elsevier B.V. All rights reserved.

1. Background are caused by high-risk human papillomavirus (HR HPV) infec-

Anal cancer is uncommon disease, but its incidence is on the rise
in most of the world’s developed countries. More than 90% of cases
Abbreviations: AIN, anal intraepithelial neoplasia; AIS, adenocarcinoma in situ;
ASC-H, atypical squamous cells, cannot exclude high-grade squamous intraep-
ithelial lesion; CIN, cervical intraepithelial neoplasia; CIN 2+, high-gradeCIN or
microinvasive cervical cancer; COC, combined oral contraception; DNA, deoxyri-
bonucleic acid; HIV, human immunodeficiency virus; HPV, human papillomavirus;
HR, high-risk; HRT, hormone replacement therapy; HSIL, high-grade squamous
intraepithelial lesion; IUD, intrauterine device; LR, low-risk; OR, odd ratio; PCR,
polymerase chain reaction.
∗ Corresponding author at: Hospital Na Bulovce, Budinova 2, Prague 8, 180 81,
Czech Republic. Tel.: +420 266 083 229; fax: +420 283 840 507.
E-mail addresses: boreksehnal@seznam.cz, borek.sehnal@bulovka.cz (B. Sehnal).
tion combined with a predominant genotype HPV 16 [1,2]. Several
studies have shown that persons at risk of developing anal cancer
include HIV-infected subjects, males who have sex with males and
transplant recipients [3–12]. Anal cancers are, however, detected
in appreciable portion of the generally healthy and HIV-negative
population [13–15]. Invasive anal squamous cell carcinoma rates
increased by 1.7% per year among females in the U.S. between 1973
and 2005 [16]. Moreover the incidence of anal cancers is signifi-
cantly higher in women than in men. In the U.S., there were an
estimated 6230 new cases of anal cancer in 2012, with 3980 cases
occurring in women and only 2250 cases in men [17]. This gen-
der difference has not been clearly explained so far, although a
history of cervical intraepithelial neoplasia (CIN) and cervical can-
cer, a history of anal intercourse and multiple sexual partners were
established as possible risk factors [18–20].

1386-6532/$ – see front matter © 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jcv.2013.11.004
 B. Sehnal et al. / Journal of Clinical Virology 59 (2014) 18–23
Based on data from the National Cancer Registry, the incidence
of anal cancer in the Czech Republic has been stable over the last
30 years. Similar to the U.S., however, the prevalence of anal can-
cer is noticeably higher among women than in men. In 2010, there
were 130 new cases of anal cancer, with 85 cases in women and 44
cases in men. Importantly, the proportion of HIV-positive women
was less than 3%. This fact accentuated the need to identify the pop-
ulation of women with an increased risk of cancer, who could be
candidates for more detailed or even screening examinations of the
anus. We hypothesize that such a population would be particularly
represented by women who were treated for CIN. All women with
history of CIN and cervical cancer are at increased risk for develop-
ing anal cancer, presumably because of enhanced exposure to HR
HPV infection.
2. Objectives
The aim of our study was to describe the association between
anal HPV infection and cervical HPV infection in HIV-negative
women suffering from CIN or microinvasive cervical cancer. To our
best knowledge, this is the first study evaluating anal HPV infection
in a strictly selected cohort of women with different grades of CIN
and the very first data on the prevalence of anal HPV infection in
Czech women.
3. Study design
3.1. Patients
Participants were recruited between September 2011 and June
2012 from women over 18 years of age attending two university-
based colposcopy clinics in Prague. The study cohort included 172
“high-risk” patients in whom CIN 2, CIN 3, AIS or microinvasive
cancer was confirmed by conization. The control group consisted of
100 “low-risk” patients with biopsy-confirmed CIN 1 and patients
with diverse non-neoplastic gynecological diagnoses (irregular
bleeding, endometrial polyp, missed abortion, induced abortion).
Inclusion of patients with any STDs was carefully avoided. All
participants completed an anonymous self-administered question-
naire on their medical histories, tobacco use, social status, and
sexual behavior; they were familiarized with the study protocol
and signed an informed consent. The study had been approved by
the Local Ethical Committee.
3.2. HPV detection and genotyping
Trained clinicians obtained exfoliated cervical cell samples for
HPV detection under general anesthesia. A brush was used to smear
the entire ectocervix and endocervix, including the entire transfor-
mation zone and anal transformation zone. Following the cervical
specimen collection, an exfoliated anal cell specimen was obtained
using another brush, inserted ∼1.5–2.0 cm into the anus and rotated
360◦ clockwise (3 times) and counter-clockwise (3 times). Each
sample was dispersed separately in PreservCyt transport medium
with maximal care being exercised to prevent contamination. The
linear array genotyping HPV test used for all samples was as
described by kit manufacturer (Roche Molecular Systems, Inc.,
Branchburg, NJ). The test was used to identify 37 HPV genotypes
that included 13 high-risk (HPV 16, 18, 31, 33, 35, 39, 45, 51, 52,
56, 58, 59 and 68) and 24 low-risk types (HPV 6, 11, 26, 40, 42,
53, 54, 55, 61, 62, 64, 66, 67, 69, 70, 71, 72, 73, 81, 82, 83, 84, IS39
and CP6108). Subsequent hybridization and HPV genotyping were
performed as described by the manufacturer (Roche Molecular Sys-
tems, Inc., Branchburg, NJ). The strips were manually interpreted
19
using the linear array HPV reference guide, by reading the individ-
ual types down the length of the strip.
3.3. Histopathology
All biopsy specimens submitted for histological assessment
were routinely examined in their entirety. Sections from the
formalin-fixed and paraffin-embedded tissue fragments were
stained with hematoxylin–eosin. Histological grading of dysplasia
was based on the standard CIN 1, CIN 2 and CIN 3 criteria.
3.4. Statistical analysis
Standard robust summary statistics were applied to describe
primary data, absolute and relative frequencies for categorical vari-
ables and median supplied with the 5th–95th percentile range
for continuous variables. The statistical significance of differences
between the control group and the group of CIN 2+ patients in cate-
gorical variables was tested using Fisher exact test; an exact Monte
Carlo method with 100 000 samples was applied to estimate the
significance of differences in variables with more than two cate-
gories. Mann–Whitney U test was applied to test the differences in
continuous variables. Age-adjusted logistic regression analysis was
used for the assessment of the association between various risk
factors and defined end-points related to different types of HPV
infection. The results are represented as estimates of odd ratios
(OR, along with 95% confidence interval) with corresponding sta-
tistical significance (Wald’s test). Concordance of HPV genotype
profiles between cervical and anal infections was analyzed using
Jaccard’s coefficient which belongs to a group of asymmetric binary
coefficients of similarity. All analyses were performed using SPSS
20.0.0. (IBM Corporation, 2011).
4. Results
Altogether 272 women were enrolled in the study, 172 “high-
risk” women in the study group and 100 “low-risk” women in the
control group. The characteristics of both groups are summarized in
Table 1. The majority of evaluated social and medical aspects were
similar in both groups. However, the patients in the control group
reported significantly more pregnancies, childbirths, and the use
of hormones (p < 0.001). There were 169 cervical samples for HPV
testing and 163 anal samples available in the study group and 100
and 98 in the control group, respectively.
The prevalence, site and type of HPV infection were significantly
different between the two groups (Table 2). Cervical infection was
detected in 82.6% of women in the study group and 28.0% of controls
(p < 0.001). Anal HPV infection was detected in 48.3% of women in
the study group and 26.0% of controls (p < 0.001). No HPV infection
in either the cervix or the anus was found in only 11.6% of women
in the study group but in more than a half (54.0%) of the controls
(p < 0.001).
Cervical and anal HPV infections were much more frequent in
the study group than in controls (p < 0.001). HPV infection of the
cervix only was diagnosed in 40.1% of the study group patients
and in 20.0% of controls (p < 0.001). HPV infection of the anus only
was detected in 18.0% of the controls and in 5.8% of the study
group patients (p = 0.001). Concurrent cervical and anal infection
was found in 42.4% of study group cases and in 8.0% of the controls
(p < 0.001). The prevalence of concurrent infection significantly
increased with the grade of cervical lesion (Table 3). Concurrent
infection was found in 42.4% of CIN 2+ and in 49.0% of cases with
CIN 3 and microinvasive cancer.
The presence of 13 high-risk (HR) and 18 low-risk (LR) HPV
genotypes was confirmed; 13 HR and 18 LR genotypes were
detected in the cervix and 11 HR and 16 LR genotypes in the
20 B. Sehnal et al. / Journal of Clinical Virology 59 (2014) 18–23

Table 1
Characteristics of patients and risk factors.

Parameters Overall (n; %) Controls (n; %) Study group (n; %) p-value

Number of patients 272 (100.0%) 100 (36.8%) 172 (63.2%)

Cervical finding
No dysplastic changes 81 (29.8%) 81 (81.0%) 0 (0.0%) NA
CIN 1 19 (7.0%) 19 (19.0%) 0 (0.0%)
CIN 2 61 (22.4%) 0 (0.0%) 61 (35.5%)
CIN 3 99 (36.4%) 0 (0.0%) 99 (57.6%)
Adenocarcinoma in situ 3 (1.1%) 0 (0.0%) 3 (1.7%)
Invasive carcinoma 9 (3.3%) 0 (0.0%) 9 (5.2%)

Age 35.5 (23.9; 58.3) 37.6 (26.2; 60.6) 34.2 (23.5; 56.3) 0.123
a
Education
Elementary/apprenticeship 99 (36.4%) 35 (35.0%) 64 (37.2%) 0.639
High school 125 (46.0%) 46 (46.0%) 79 (45.9%)
University/postgraduate 47 (17.3%) 19 (19.0%) 28 (16.3%)

Number of pregnancies 2 (0; 4) 2 (0; 4) 1 (0; 5) <0.001

Number of childbirths 1 (0; 3) 2 (0; 3) 1 (0; 3) <0.001

Contraception and hormonal therapy

Non-user 151 (55.5%) 72 (72.0%) 79 (45.9%) <0.001
COC 107 (39.3%) 22 (22.0%) 85 (49.4%)
IUD 8 (2.9%) 4 (4.0%) 4 (2.3%)
Gestagen contraception 3 (1.1%) 0 (0.0%) 3 (1.7%)
HRT 3 (1.1%) 2 (2.0%) 1 (0.6%)

HPV vaccination
No 269 (98.9%) 99 (99.0%) 170 (98.8%) 0.998
Yes 3 (1.1%) 1 (1.0%) 2 (1.2%)

Smoking
No smoking in last 6 months 156 (57.4%) 69 (69.0%) 87 (50.6%) 0.004
1–2 packs a week 50 (18.4%) 17 (17.0%) 33 (19.2%)
3 or more packs a week 66 (24.3%) 14 (14.0%) 52 (30.2%)

Coitarche (age)
≤17 110 (40.4%) 30 (30.0%) 80 (46.5%) 0.010
>17 162 (59.6%) 70 (70.0%) 92 (53.5%)

Number of sexual partners

1 14 (5.1%) 9 (9.0%) 5 (2.9%) 0.033
2 28 (10.3%) 13 (13.0%) 15 (8.7%)
3–5 94 (34.6%) 33 (33.0%) 61 (35.5%)
6–9 71 (26.1%) 18 (18.0%) 53 (30.8%)
10 or more 65 (23.9%) 27 (27.0%) 38 (22.1%)

Frequency of unprotected vaginal coitus

Never 15 (5.5%) 6 (6.0%) 9 (5.2%) 0.696
Sometimes 180 (66.2%) 63 (63.0%) 117 (68.0%)
Always 77 (28.3%) 31 (31.0%) 46 (26.7%)

Frequency of sexual contact with anusa

Never 96 (35.3%) 33 (33.0%) 63 (36.6%) 0.708
Exceptionally 127 (46.7%) 46 (46.0%) 81 (47.1%)
Often/always 48 (17.7%) 21 (21.0%) 27 (15.7%)

Frequency of anal sex

Never 177 (65.1%) 72 (72.0%) 105 (61.0%) 0.008
Exceptionally 90 (33.1%) 24 (24.0%) 66 (38.4%)
Often/always 5 (1.8%) 4 (4.0%) 1 (0.6%)

Presence of autoimmune diseases

No 228 (83.8%) 84 (84.0%) 144 (83.7%) 0.965
Yes 44 (16.2%) 16 (16.0%) 28 (16.3%)

History of condylomata acuminataa

Never 224 (82.4%) 79 (79.0%) 145 (84.3%) 0.512
Never (partner was treated) 36 (13.2%) 15 (15.0%) 21 (12.2%)
No (in last 6 months) 3 (1.1%) 2 (2.0%) 1 (0.6%)
Once (no complication after treatment) 7 (2.6%) 4 (4.0%) 3 (1.7%)
Twice or more (no complication during 6–12 months after treatment) 1 (0.4%) 0 (0.0%) 1 (0.6%)
Repeatedly (long term complications) 0 (0.0%) 0 (0.0%) 0 (0.0%)

CIN = cervical intraepithelial neoplasia; COC = combined oral contraception; HRT = hormone replacement therapy; IUD = intrauterine device; NA = not applicable.
a
Missing value for one patient.

anus. Infection with a single HPV genotype was more frequent only; and both HR and LR genotypes in 31. Cervical HR HPV infec-
than multiple infections in both groups and in both locations. Cer- tion occurred significantly more often in the study group than in
vical HPV infection was confirmed in 170 women (both groups the control group (76.8% vs. 27.0%, p < 0.001). Anal infection was
combined)-in 128 cases there were HR genotypes only; in 11, LR detected in 109 women (both groups combined); in 55 cases only
 B. Sehnal et al. / Journal of Clinical Virology 59 (2014) 18–23 21

Table 2
Distribution of genotypes in cases with cervical and/or anal HPV infection.

Parameters Overall (n; %) Controls (n; %) Study group (n; %) p-value

Cervical infection
No infection 99 (36.4%) 72 (72.0%) 27 (15.7%) <0.001

Any infection 170 (62.5%) 28 (28.0%) 142 (82.6%) <0.001

Single LR 11 (4.0%) 1 (1.0%) 10 (5.8%) 0.086
Multiple LR 0 (0.0%) 0 (0.0%) 0 (0.0%)
Single HR 99 (36.4%) 23 (23.0%) 76 (44.2%) <0.001
Multiple HR 29 (10.7%) 2 (2.0%) 27 (15.7%) <0.001
Combined LR and HR 31 (11.4%) 2 (2.0%) 29 (16.9%) <0.001

Insufficient for detection 3 (1.1%) 0 (0.0%) 3 (1.7%) 0.311

Anal infection
No infection 152 (55.9%) 72 (72.0%) 80 (46.5%) <0.001

Any infection 109 (40.0%) 26 (26.0%) 83 (48.3%) <0.001

Single LR 19 (7.0%) 8 (8.0%) 11 (6.4%) 0.618
Multiple LR 2 (0.7%) 0 (0.0%) 2 (1.2%) 0.272
Single HR 44 (16.2%) 10 (10.0%) 34 (19.8%) 0.034
Multiple HR 11 (4.0%) 4 (4.0%) 7 (4.1%) 0.968
Combined LR and HR 33 (12.1%) 4 (4.0%) 29 (16.9%) <0.001

Insufficient for detection 11 (4.0%) 2 (2.0%) 9 (5.2%) 0.195

Cervical and/or anal infection

No infection 74 (27.2%) 54 (54.0%) 20 (11.6%) <0.001
Cervical infection only 89 (32.7%) 20 (20.0%) 69 (40.1%) <0.001
Anal infection only 28 (10.3%) 18 (18.0%) 10 (5.8%) 0.001
Concurrent infection 81 (29.8%) 8 (8.0%) 73 (42.4%) <0.001

HR = high-risk HPV genotype; LR = low risk HPV genotype.

Table 3
Prevalence of concurrent HPV infection in different grades of cervical findings.

Histology Overall (n) Concurrent HPV Difference from the ≥1 Identical HPV HPV 16 in both Difference from the
infection (n; %) control group genotype in both sites (n; %) control group
(p-value) sites (n; %) (p-value)

Non-neoplastic 81 5 (6.2%) 2 (40.0%) 1 (20.0%)

– –
CIN 1 19 3 (15.8%) 3 (100%) 0 (0.0%)
CIN 2 61 17 (27.8%) 0.002 13 (76.5%) 7 (41.2%)
CIN 3 99 48 (48.5%) 38 (79.2%) 29 (60.4%)
<0.001
AIS 3 1 (33.3%) <0.001 1 (100%) 0 (0.0%)
Microinvasive cancer 9 5 (55.5%) 5 (100%) 3 (60.0%)

AIS = adenocarcinoma in situ; CIN = cervical intraepithelial neoplasia.

HR genotypes were found; in 21, LR alone; and in 33, both HR
and LR genotypes were found. There was no significant differ-
ence in the prevalence of HR and LR genotypes in anal infection
between both groups.
Multiple HPV infections were less common than infections with
a single HPV genotype. Cervical HPV infection with several geno-
types in patients without concomitant anal HPV infection was
more frequent in the study group than in the controls (9.3% vs.
3%, p = 0.048). Isolated anal HPV infection with several genotypes
but without cervical infection occurred with similar frequency in
both groups (Table 2). Concurrent multiple cervical and anal HPV
infection was found in 81 out of 272 subjects with a variety of HPV
genotypes detected.
The dominant genotype detected in both groups was HPV 16,
which represented 51.2% of all cervical HPV infections (87/170)
and 48.6% of all anal HPV infections (53/109). Its occurrence
in either site was significantly (p < 0.001) higher in the study
patients than in the controls. Isolated cervical infection with HPV
16 only was detected in 12.2% of study group patients and 5.0%
of controls (p = 0.049). Single anal infection with HPV 16 only
was detected in 1.2% of study group patients and 2.0% of con-
trols (p = 0.626). Small differences between the study group and
controls occurred in the other HR HPV genotypes detected in the
cervix and/or anus. The frequency of LR HPV genotypes in the cervix
and in the anus was not significantly different between the study
group and controls.
The distribution of HPV genotypes was similar in cases with cer-
vical HPV infection only and in cases with the infections of both
cervix and anus, whereas the profile of HPV genotypes in women
with only anal infections was different except for HPV 16 which was
observed in all cases. Considering any HR HPV infection, the simi-
larity of HPV genotypes between cervix and anus reaches a Jaccard
coefficient 0.63, while a value of only 0.44 was found for the LR HPV
genotypes.
Differences in evaluated risk factors and sexual behavior charac-
teristics are shown in Table 1. Almost two thirds (65.1%) of subjects
did not report any anal intercourse. The CIN 2+ subgroup with a
combined infection (n = 73) reported any sexual contact with the
anus more often in comparison to the whole study group (OR 2.43;
95% CI: 1.23–4.79, p = 0.010). Any frequency of anal contact was a
statistically significant risk factor in CIN 2+ patients (n = 57) with
concurrent infections and with at least one identical HPV geno-
type (OR 3.27; 95% CI: 1.52–7.05, p = 0.003). By contrast, no other
risk factor (smoking, presence of autoimmune disease or/and a
history of condylomata acuminata, sexual debut at age <17, more
than 10 sexual partners, a high frequency of unprotected vaginal
coitus, practicing of anal coitus) was statistically significant for
concurrent HPV infection.
22 B. Sehnal et al. / Journal of Clinical Virology 59 (2014) 18–23
5. Discussion
We demonstrated the occurrence of concurrent cervical and
anal HPV infection in nearly half (42.4%) of patients with diagnosed
severe CIN or microinvasive cervical cancer. Although we found
anal HPV infection to be highly prevalent among women with any
CIN, we also observed that the prevalence of concurrent infections
significantly increased with the severity of cervical lesion. CIN 1
was associated with concurrent anal HPV infection in 15.8% (3/19)
of cases, CIN 2 in 27.8% (17/61) of cases, CIN 3 in 48.5% (48/99) of
cases, and microinvasive cervical cancers in 55.5% (5/9) of cases.
Such stratification has not previously been described in any study.
Similar results, but only in high risk populations were obtained
in a study that included 58 women with high-grade CIN and 10
women with cervical cancer. The authors detected concurrent anal
and cervical HPV infection in 52% of these patients [21]. By con-
trast, incidence of concurrent HPV infection in a generally healthy
population was reported to be significantly lower. A large study on
the prevalence of anal HPV infection in a generally healthy popu-
lation demonstrated only 13% (178/1363) of cases with concurrent
anal and cervical HPV infection [22]. This percentage was similar to
that in women with a CIN 1 (15.8%) but still twice as high as that in
women with non-pathological cervical findings (6.2%) in our study.
Concurrent HPV infection occurred 5.3-fold more often in the
group of “high-risk” woman with CIN 2+, compared with “low-risk”
women in the control group (42.4% vs. 8.0%, p < 0.001). It should
be noted that this difference corresponds to previously reported
data about the incidence of anal carcinoma, which was found to be
nearly five-fold greater among patients suffering from CIN, com-
pared to the general population [23–28].
In our study, the overall distribution of HPV genotypes in cervi-
cal infections only and in the concurrent cervical and anal infections
was similar. Likewise in the other studies, similar genotypes were
found in both anatomical sites [8,19,29,30]. The same profile of
HPV genotypes in the cervix and anus was detected in 14.5% of
patients with CIN 2+ and at least one of the same HPV genotype in
cervix and anus was observed in 33.1%. As also described by Parka
et al. [21], a large majority of women with concurrent infections
were infected with a HR HPV. The profile of genotypes in women
with anal HPV infections only was much more heterogenous with
a higher proportion of LR HPV genotypes.
The dominant genotype found in the cervix and/or anus in the
whole study cohort was HPV 16. In patients with CIN 2+ and concur-
rent HPV infection in both anatomical sites, HPV 16 was detected
in 53.4% (39/73). In the high-risk subpopulation of women with
CIN 3 and microinvasive cancer and concurrent HPV infection in
both anatomical sites, HPV 16 was detected at an even higher rate
(60.4%; 32/53). Similarly, HPV 16 was the dominant genotype with
prevalence of 33.3% (14/42) in another study of 42 patients with
lower genital tract neoplasia and concurrent anal HPV infection
[21]. Another evaluation of the occurrence of HPV genotypes in
biopsy-confirmed high-grade anal intraepithelial neoplasias (AIN)
and anal carcinomas revealed the presence of HPV 16 in 68% cases
[31]. An even higher prevalence (76.6%) of HPV 16 in high-grade AIN
was found in a recent meta-analysis [2]. This is in sharp contrast to
the rare anal occurrence of HPV 16 in general population. In a large
cohort of healthy women from Hawaii, only 7% of anal infections
was caused by HPV 16 [22]. Likewise in our control group only 1
woman with concurrent infections had HPV 16 simultaneously in
the cervix and anus.
Multiple HPV infections were less common than single infec-
tions in our study and they were found mainly in the cervix only.
Concurrent multiple cervical and anal HPV infections were found
in 26.8% (73/272) of examined subjects with a wide variety of HPV
genotypes detected. Very similar data were presented in other
studies with multiple anal HPV infections observed in 23–36% of
women [8,21]. The clinical significance of infection with multi-
ple HPV genotypes is still not well understood; nevertheless, it
is important to emphasize that we detected HPV 16 in 60.4% of
the cases of multiple infections in both anatomical sites, in those
patients with the most severe cervical lesions (CIN 3 and microin-
vasive cancer).
Some aspects of sexual behavior impact the incidence of concur-
rent anal and cervical HPV infection, but we did not unambiguously
demonstrate high-risk sexual behavior as strong risk factor. As
demonstrated in previous studies, a history of anal intercourse is
not significantly differently associated with the risk of concurrent
anal and cervical HPV infection when compared with a mere anal
skin contact [8,12,22]. In our study, any type of sexual contact with
the anus with any frequency was shown to be the most important
risk factor for anal HPV infection among patients with CIN. More-
over, the patients who cited any contact with the anus included
all cases with most severe lesions-CIN 3 and microinvasive cervi-
cal cancer. These findings are in agreement with a publication by
Palefsky et al. [8], who demonstrated that in 44.5% (81/182) HIV
infected and high-risk HIV-negative women with concurrent HPV
infection, there was no history of anal intercourse.
Summary, we found concurrent anal and cervical infection in
49.0% of patients with the most severe cervical lesions (CIN 3 and
microinvasive cervical cancer). This cohort of patients was charac-
terized by frequent infection with the HPV 16 genotype and by the
presence of identical HPV genotypes in the cervix and anus. Any fre-
quency and any type of sexual contact with the anus were shown
to be the most important risk factor for concurrent HPV infection.
If these correlations are taken into consideration, then all women
with CIN 3 or microinvasive cervical cancer may represent a suit-
able cohort for further evaluation of anal HPV testing, especially if
they report any sexual contact with the anus.
Authors’ contributions
BS and JS conceived, designed and performed the experiments.
BS, JS, DC, MH and LD analyzed the data. BS and JS wrote the paper.
All authors read and approved the final manuscript.
Funding
None.
Competing interests
None declared.
Ethical approval
Hospital Na Bulovce Ethical Committee, Prague (Judgement’s
reference number: 1862012/6233/EK-Z).
Acknowledgments
This study has been supported by the IGA grant no. NT14079-
3/2013 and by grant no. MH CZ-DRO VFN 64165 from the Ministry
of Health of the Czech Republic, by Charles University in Prague
(UNCE 204024) and PRVOUK-P27/LF1/1.
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