Prevalence of potential sexual abuse in adolescents and young adults and feasibility of an assessment and management plan used in three research projects.

The aims of this study were to examine the feasibility of a protocol to assess for assessment and response to potential sexual abuse (defined as self-report of sexual initiation before age 13) among adolescent and young adult research participants in human papillomavirus (HPV) vaccination screening; determine the proportion of participants whose survey responses indicated potential sexual abuse and assess whether age, gender, race, and recruitment site were associated with potential abuse. We pooled data from three cross-sectional studies of 13-26 year-old women and men (N = 1541) recruited at a Teen Health Center (THC) and Health Department (HD). Using written and electronic documentation, we demonstrated feasibility by the following outcomes: 100% of participants who indicated early sexual initiation were interviewed by the research staff, 100% of assessments were disclosed to participants' primary care clinicians, and no adverse consequences of the interviews or referrals occurred. Potential sexual abuse was identified in 95 participants (6.2%). In multivariable logistic regression, the following factors were independently associated with potential abuse: race (Black vs. White, odds ratio [OR] = 3.0, 95% confidence interval [CI] = 1.6-5.7; other race vs. White, OR = 2.6, 95%CI = 1.0-6.5); and recruitment site (HD vs. THC, OR = 2.1, 95%CI = 1.4-3.3). The standardized protocol to identify, assess and refer youth who may have been sexually abused was feasible and can enable researchers to ensure the safety of study participants.

Quality of Web-Based Educational Interventions for Clinicians on Human Papillomavirus Vaccine: Content and Usability Assessment.

BACKGROUND: Human papillomavirus (HPV) vaccination rates fall far short of Healthy People 2020 objectives. A leading reason is that clinicians do not recommend the vaccine consistently and strongly to girls and boys in the age group recommended for vaccination. Although Web-based HPV vaccine educational interventions for clinicians have been created to promote vaccination recommendations, rigorous evaluations of these interventions have not been conducted. Such evaluations are important to maximize the efficacy of educational interventions in promoting clinician recommendations for HPV vaccination. OBJECTIVE: The objectives of our study were (1) to expand previous research by systematically identifying HPV vaccine Web-based educational interventions developed for clinicians and (2) to evaluate the quality of these Web-based educational interventions as defined by access, content, design, user evaluation, interactivity, and use of theory or models to create the interventions. METHODS: Current HPV vaccine Web-based educational interventions were identified from general search engines (ie, Google), continuing medical education search engines, health department websites, and professional organization websites. Web-based educational interventions were included if they were created for clinicians (defined as individuals qualified to deliver health care services, such as physicians, clinical nurses, and school nurses, to patients aged 9 to 26 years), delivered information about the HPV vaccine and how to increase vaccination rates, and provided continuing education credits. The interventions' content and usability were analyzed using 6 key indicators: access, content, design, evaluation, interactivity, and use of theory or models. RESULTS: A total of 21 interventions were identified, out of which 7 (33%) were webinars, 7 (33%) were videos or lectures, and 7 (33%) were other (eg, text articles, website modules). Of the 21 interventions, 17 (81%) identified the purpose of the intervention, 12 (57%) provided the date that the information had been updated (7 of these were updated within the last 6 months), 14 (67%) provided the participants with the opportunity to provide feedback on the intervention, and 5 (24%) provided an interactive component. None of the educational interventions explicitly stated that a theory or model was used to develop the intervention. CONCLUSIONS: This analysis demonstrates that a substantial proportion of Web-based HPV vaccine educational interventions has not been developed using established health education and design principles. Interventions designed using these principles may increase strong and consistent HPV vaccination recommendations by clinicians.

HIV Care Providers' Intentions to Prescribe and Actual Prescription of Pre-Exposure Prophylaxis to At-Risk Adolescents and Adults.

Pre-exposure prophylaxis (PrEP) is indicated for use in US adults, and little is known about clinician intentions to prescribe and actual prescription of PrEP to adolescents younger than 18. Fifty-six clinicians who care for HIV-infected and at-risk youth completed an anonymous online survey in 2014. Primary outcomes were (1) intentions to prescribe PrEP to adolescents and adults in four risk categories [men who have sex with men (MSM), transgender women, heterosexuals with multiple partners of unknown HIV status, heterosexuals with HIV-infected partners]; and (2) actual prescription of PrEP to adolescents and adults in these risk groups. Independent variables included clinician characteristics, experience prescribing nonoccupational postexposure prophylaxis, familiarity with and knowledge of PrEP and PrEP guidance, attitudes toward PrEP, and facilitating factors for prescribing PrEP and incorporation of PrEP guidance into practice. Variables associated with intention to prescribe ("very likely to prescribe" vs. other responses) and actual prescription of PrEP stratified by age and risk category were identified in logistic regression models. Mean age was 45.9 years (standard deviation 10.7); 64% were physicians. More clinicians reported high intention to prescribe PrEP to adult versus adolescent MSM (p = 0.02) and transgender women (p = 0.001). Variables associated with intention to prescribe and prescription of PrEP differed by age and risk category. In adolescents, those variables included positive beliefs, higher number of facilitating factors, and fewer barriers to PrEP prescription. Designing strategies based on these findings that address both facilitating factors and barriers to PrEP prescription may improve PrEP uptake by at-risk youth.

Differences between vaccinated and unvaccinated women explain increase in non-vaccine-type human papillomavirus in unvaccinated women after vaccine introduction.

The aim of this study was to determine whether an observed increase in non-vaccine-type human papillomavirus (HPV) in unvaccinated women during the first eight years after vaccine introduction may be explained by differences in demographics or sexual behaviors, instead of type replacement. We analyzed data from three cross-sectional surveillance studies of 13-26 year-old women (total N = 1180). For women recruited from a health department clinic, older age (OR = 1.4, 95% CI: 1.2-1.6) and consistent condom use with main partner in the past 3 months (OR = 11.6, 95% CI: 3.4-40) were associated with being unvaccinated. For women recruited from a teen health center African American race (OR = 0.2, 95% CI: 0.07-0.7) and having Medicaid health insurance (OR = 0.3, 95% CI: 0.1-0.7) were inversely associated with being unvaccinated. The observed increase in non-vaccine-type HPV prevalence in unvaccinated women may be explained by differences between unvaccinated and vaccinated women.

Distribution of Vaccine-Type Human Papillomavirus Does Not Differ by Race or Ethnicity Among Unvaccinated Young Women.

BACKGROUND: Previous studies have demonstrated racial and ethnic differences in the distribution of human papillomavirus (HPV) types among adult women with cervical precancers. The aim of this study was to determine whether the distribution of vaccine-targeted HPV types varies by race/ethnicity among unvaccinated young women. MATERIALS AND METHODS: A secondary analysis was performed using data from four studies of sexually experienced, unvaccinated, 13-26-year-old women. Participants completed surveys and provided a cervicovaginal swab for HPV DNA testing. Multivariable logistic regression analyses were performed to examine whether race, ethnicity, and other factors were associated with type-specific HPV infection among the overall sample and among HPV-infected participants. Models controlled for age, HPV knowledge, sexual behaviors, substance use, and random study effect. RESULTS: The mean age of participants (N = 841) was 19.3 years; 64.4% were black and 8.9% Hispanic. Black women were more likely than white women to be positive for ≥1 HPV type (odds ratio [OR] 1.83, 95% CI 1.30-2.58) and Hispanic women were less likely than non-Hispanic women to be positive for ≥1 HPV type (OR 0.47, 95% CI 0.24-0.92). However, among all young women and HPV-infected women, neither race nor ethnicity was associated with positivity for HPV types targeted by the following vaccines: 2-valent (HPV16 and/or 18), 4-valent (HPV6, 11, 16, and/or 18), or 9-valent (HPV6, 11, 16, 18, 31, 33, 45, 52, and/or 58). CONCLUSION: The prevalence of HPV types targeted by the 2-valent, 4-valent, and 9-valent vaccines did not differ by race or ethnicity among all and among HPV-infected women in this sample.

Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis.

BACKGROUND: Human papillomavirus (HPV) vaccination programmes were first implemented in several countries worldwide in 2007. We did a systematic review and meta-analysis to assess the population-level consequences and herd effects after female HPV vaccination programmes, to verify whether or not the high efficacy reported in randomised controlled clinical trials are materialising in real-world situations. METHODS: We searched the Medline and Embase databases (between Jan 1, 2007 and Feb 28, 2014) and conference abstracts for time-trend studies that analysed changes, between the pre-vaccination and post-vaccination periods, in the incidence or prevalence of at least one HPV-related endpoint: HPV infection, anogenital warts, and high-grade cervical lesions. We used random-effects models to derive pooled relative risk (RR) estimates. We stratified all analyses by age and sex. We did subgroup analyses by comparing studies according to vaccine type, vaccination coverage, and years since implementation of the vaccination programme. We assessed heterogeneity across studies using I(2) and χ(2) statistics and we did trends analysis to examine the dose-response association between HPV vaccination coverage and each study effect measure. FINDINGS: We identified 20 eligible studies, which were all undertaken in nine high-income countries and represent more than 140 million person-years of follow-up. In countries with female vaccination coverage of at least 50%, HPV type 16 and 18 infections decreased significantly between the pre-vaccination and post-vaccination periods by 68% (RR 0·32, 95% CI 0·19-0·52) and anogenital warts decreased significantly by 61% (0·39, 0·22-0·71) in girls 13-19 years of age. Significant reductions were also recorded in HPV types 31, 33, and 45 in this age group of girls (RR 0·72, 95% CI 0·54-0·96), which suggests cross-protection. Additionally, significant reductions in anogenital warts were also reported in boys younger than 20 years of age (0·66 [95% CI 0·47-0·91]) and in women 20-39 years of age (0·68 [95% CI 0·51-0·89]), which suggests herd effects. In countries with female vaccination coverage lower than 50%, significant reductions in HPV types 16 and 18 infection (RR 0·50, 95% CI 0·34-0·74]) and in anogenital warts (0·86 [95% CI 0·79-0·94]) occurred in girls younger than 20 years of age, with no indication of cross-protection or herd effects. INTERPRETATION: Our results are promising for the long-term population-level effects of HPV vaccination programmes. However, continued monitoring is essential to identify any signals of potential waning efficacy or type-replacement. FUNDING: The Canadian Institutes of Health Research.

Influence of hormonal contraceptive use and health beliefs on sexual orientation disparities in Papanicolaou test use.

OBJECTIVES: Reproductive health screenings are a necessary part of quality health care. However, sexual minorities underutilize Papanicolaou (Pap) tests more than heterosexuals do, and the reasons are not known. Our objective was to examine if less hormonal contraceptive use or less positive health beliefs about Pap tests explain sexual orientation disparities in Pap test intention and utilization. METHODS: We used multivariable regression with prospective data gathered from 3821 females aged 18 to 25 years in the Growing Up Today Study (GUTS). RESULTS: Among lesbians, less hormonal contraceptive use explained 8.6% of the disparities in Pap test intention and 36.1% of the disparities in Pap test utilization. Less positive health beliefs associated with Pap testing explained 19.1% of the disparities in Pap test intention. Together, less hormonal contraceptive use and less positive health beliefs explained 29.3% of the disparities in Pap test intention and 42.2% of the disparities in Pap test utilization. CONCLUSIONS: Hormonal contraceptive use and health beliefs, to a lesser extent, help to explain sexual orientation disparities in intention and receipt of a Pap test, especially among lesbians.

Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females.

PURPOSE: To examine sexual orientation group disparities in the Papanicolaou (Pap) and sexually transmitted infection (STI)/human papillomavirus (HPV) tests among adolescents and young adult females. METHODS: Survey data from 4,224 adolescents and young adults aged 17-25 years who responded to the 2005 wave questionnaire of the Growing Up Today Study were cross-sectionally examined with multivariate generalized estimating equations regression. We examined associations between sexual orientation and reproductive healthcare utilization as well as abnormal results with completely heterosexual as the referent group, controlling for age, race/ethnicity, geographic region, and sexual history. RESULTS: After accounting for sociodemographics and sexual history, mostly heterosexual/bisexual females had 30% lower odds of having a Pap test within the last year and almost 40% higher odds of being diagnosed with an STI, as compared with the completely heterosexual group. Additionally, lesbians had very low odds of having a Pap test in their lifetime (odds ratio = .13, p ≤ .0001) and having a Pap test within the last year (odds ratio = .25, p = .0002), as compared with completely heterosexuals. CONCLUSIONS: Our study demonstrates that sexual minority adolescent and young adult women underutilize routine reproductive health screenings, including Pap smears and STI tests. Providers and health educators should be aware of these disparities so that they can provide appropriate care to young women and their families and ensure that all young women receive reproductive health screening. Further research is needed to explore reasons sexual minority females are not accessing care as recommended because this may suggest opportunities to improve reproductive health screenings as well as broader healthcare access issues.

Integrating clinical, community, and policy perspectives on human papillomavirus vaccination.

Infection with genital human papillomavirus (HPV) may cause anogenital cancers, oropharyngeal cancers, anogenital warts, and respiratory papillomas. Two prophylactic vaccines (a bivalent and a quadrivalent vaccine) are now licensed and currently in use in a number of countries. Both vaccines prevent infection with HPV-16 and HPV-18, which together cause approximately 70% of cervical cancers, and clinical trials have demonstrated 90%-100% efficacy in preventing precancerous cervical lesions attributable to HPV-16 and HPV-18. One vaccine also prevents HPV-6 and HPV-11, which cause 90% of genital warts. A growing literature describes psychosocial, interpersonal, organizational, and societal factors that influence HPV vaccination acceptability. This review summarizes the current literature and presents an integrated perspective, taking into account these diverse influences. The resulting integrated framework can be used as a heuristic tool for organizing factors at multiple levels to guide intervention development and future research.

Epidemiology and risk factors for human papillomavirus infection in a diverse sample of low-income young women.

BACKGROUND: Two HPV vaccines prevent infection with HPV-16 and HPV-18, high-risk (cancer-associated) HPV types which together cause approximately 70% of cervical cancers; one vaccine also prevents HPV-6 and HPV-11, which together cause approximately 90% of anogenital warts. Defining type-specific HPV epidemiology in sexually experienced women will help estimate the potential clinical benefits of vaccinating this population. OBJECTIVES: To examine HPV epidemiology in a diverse sample of sexually experienced women, and to determine factors associated with high-risk HPV and vaccine-type HPV (HPV-6, HPV-11, HPV-16 and HPV-18). STUDY DESIGN: Cross-sectional study of 13-26-year-old women (N=409) who completed a questionnaire and provided a cervicovaginal swab. Swabs were genotyped for HPV using PCR amplification. Logistic regression models were used to determine whether participant characteristics, knowledge, and behaviors were associated with high-risk and vaccine-type HPV. RESULTS: Most women (68.4%) were positive for >or=1 HPV type, 59.5% were positive for >or=1 high-risk type, 33.1% were positive for >or=1 vaccine-type HPV, and 3.5% were positive for both HPV-16 and HPV-18: none was positive for all four vaccine types. In adjusted logistic regression models, Black race (OR 2.03, 95% CI 1.21-3.41) and lifetime number of male sexual partners (OR 4.79, 95% CI 2.04-11.23 for >or=10 partner vs.

Appropriate use of cervical cancer vaccine.

Human papillomavirus (HPV) is a necessary, though not sufficient, cause of cervical cancer. Two vaccines have been developed that prevent two HPV types associated with 70% of cervical cancers. One of the vaccines (a quadrivalent vaccine) also prevents two HPV types associated with 90% of genital warts. Both HPV vaccines have shown very good efficacy and safety. This review summarizes the guidelines for use of the quadrivalent vaccine published by the Advisory Committee on Immunization Practices, presents data on vaccine efficacy and safety, and gives an overview of the findings of cost-effectiveness studies. In addition, we summarize the research on the attitudes of parents and health care providers toward HPV vaccine and critically evaluate controversial and challenging issues surrounding HPV vaccination, including concerns about sexual disinhibition and potential obstacles to vaccine distribution and uptake.

Sociodemographic factors associated with high-risk human papillomavirus infection.

OBJECTIVE: To determine the prevalence of high-risk (cancer-associated) human papillomavirus (HPV) infection in U.S. women, identify sociodemographic factors associated with infection, and explore the implications for prevention of HPV-related disease in the vaccination era. METHODS: Women aged 14-59 years (n=1,921) participating in the 2003-2004 National Health and Nutrition Examination Survey provided a vaginal swab which was evaluated for 37 HPV types. We determined which sociodemographic characteristics were associated with high-risk HPV, using logistic regression models. RESULTS: High-risk HPV infection was present in 15.6% (95% confidence interval [CI] 12.6-18.6%) of participants, corresponding to a population prevalence of 12,028,293 U.S. women. Women living below the poverty line, compared with those living three or more times above it, were more likely to be positive for high-risk HPV (23% versus 12%, P = .03). Among participants living below the poverty line, only Mexican-American ethnicity (odds ratio [OR] 0.4, 95% CI 0.2-0.9) and unmarried status (OR 3.3, 95% CI 1.2-8.9) were associated with HPV prevalence. In contrast, several factors were associated with HPV among participants living above the poverty line, including black race (OR 1.4, 95% CI 1.0-2.0), income (OR 0.92, 95% CI 0.84-0.99), unmarried status (OR 2.0, 95% CI 1.3-3.0), and age (OR for 22-25 year olds 2.4, 95% CI 1.4-4.0). CONCLUSION: High-risk HPV infection is common in U.S. women, particularly in poor women. Cervical cancer prevention efforts in the vaccination era must ensure that all low-income women have access to preventive services including education, Pap test screening, and HPV vaccines. Otherwise, existing disparities in cervical cancer could worsen.