Protecting Caribbean patients diagnosed with cancer from compounding disasters.

Caribbean small island developing states are becoming increasingly vulnerable to compounding disasters, prominently featuring climate-related hazards and pandemic diseases, which exacerbate existing barriers to cancer control in the region. We describe the complexities of cancer prevention and control efforts throughout the Caribbean small island developing states, including the unique challenges of people diagnosed with cancer in the region. We highlight potential solutions and strategies that concurrently address disaster adaptation and cancer control. Because Caribbean small island developing states are affected first and worst by the hazards of compounding disasters, the innovative solutions developed in the region are relevant for climate mitigation, disaster adaptation, and cancer control efforts globally. In the age of complex and cascading disaster scenarios, developing strategies to mitigate their effect on the cancer control continuum, and protecting the health and safety of people diagnosed with cancer from extreme events become increasingly urgent. The equitable development of such strategies relies on collaborative efforts among professionals whose diverse expertise from complementary fields infuses the local community perspective while focusing on implementing solutions.

Barriers and facilitators to anal cancer screening among people living with HIV in Puerto Rico.

BACKGROUND: Anal cancer (AC) disproportionally affects people living with HIV (PLWH). Although there are no consensus-based AC screening guidelines, experts recommend anal pap as a primary screening tool in settings where high-resolution anoscopy (HRA) is available. We aimed to assess barriers and facilitators to anal cancer screening in a sample of Hispanic PLWH in Puerto Rico. METHODS: To assess their knowledge and attitudes, we conducted a cross-sectional survey from 2020-2021 among PLWH in Puerto Rico (n = 212). Data was collected through a telephone interview that assessed information on sociodemographics, knowledge, and attitudes about AC, and the history of AC screening. The chi-square test, Fisher exact test, and logistic regression models were used to assess factors associated with screening uptake. RESULTS: Anal Pap and HRA awareness were 60.4% and 30.7%, respectively. Anal Pap and HRA uptake was 51.5% and 19.3%, respectively. The most common barriers for anal Pap and HRA were lack of knowledge about the test and lack of physician recommendation. MSM were more likely to have heard of anal Pap (OR: 2.15, 95% CI:1.30-3.54) than MSW. MSM (OR: 3.04, 95% CI: 1.79-5.19) and women (OR: 3.00, 95% CI: 1.72-5.20) were also more likely to have undergone anal Pap. Similarly, individuals with a history of genital warts were more likely to have heard of anal Pap and HRA and have undergone anal Pap and HRA. Awareness of where to go for concerns about anal health was positively associated with having received anal Pap and HRA. CONCLUSIONS: With emerging evidence on the effectiveness of screening and treatment for anal cancer, several organizations are steering toward generating consensus-based anal cancer screening recommendations. Our study provides foundational data on barriers and facilitators to anal cancer screening in Puerto Rico that will be critical to informing screening implementation in this US territory.

Development of a multivariable prediction model for anal high-grade squamous intraepithelial lesions in persons living with HIV in Puerto Rico: a cross-sectional study.

Background: Persons living with HIV (PLWH) are at high risk of developing anal high-grade squamous intraepithelial lesions (HSIL). We aimed to develop a prediction model for anal HSIL based on individual characteristics of PLWH. Methods: Cross-sectional study of PLWH aged ≥21 years who attended the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center from 2016 to 2022. The primary outcome was biopsy-confirmed anal HSIL. For each sex, relations between potential predictors and HSIL were examined using univariate (ULRM) and multivariable (MLRM) logistic regression models. Risk modelling was performed with MLRM and validated with bootstrapping techniques. The area under the ROC Curves (AUC) was estimated with 95% CI. Findings: HSIL was detected among 45.11% of patients, 68.48% were males, and 59.42% were ≥45 aged. Multivariable analysis showed that, in women, the only significant predictor for HSIL was having a previous abnormal anal cytology (p = 0.01). In men, significant predictors for HSIL were having a previous abnormal anal cytology (p < 0.001) and a history of infection with any gonorrhoea (p = 0.002). Other suggestive predictors for HSIL among women were obesity and smoking. No association between smoking and HSIL among men was observed (p < 0.05). The AUC estimated among women (0.732, 95% CI: 0.651-0.811) was higher than in men (0.689, 95% CI: 0.629-0.748). Interpretation: Our results support that the inclusion of individual characteristics into the prediction model will adequately predict the presence of HSIL in PLWH. Funding: This work was supported by the NCI (Grants #U54CA096297, #R25CA240120), the NIGMS (Grant #U54GM133807), and the NIMHD (Grant #U54MD007587).

Perceptions of preparedness, timing of cancer diagnosis, and objective emergency preparedness among gynecological cancer patients in Puerto Rico before and after Hurricane Maria.

OBJECTIVES: This study investigated the impact of cancer diagnosis status, individual feelings of preparedness, and other covariates on objective emergency preparedness among women diagnosed with gynecological cancers before or after the 2017 Hurricanes Irma and Maria in Puerto Rico. METHODS: This study included 240 women who were interviewed by telephone from 9/2019-11/2020. Objective emergency preparedness was assessed using a list of six items. Subjective emergency preparedness was assessed by asking the women how prepared they felt (well, somewhat, or not at all) to face an emergency. Crude and multivariable logistic regression analyses were conducted to assess the associations (odds ratios [ORs] and 95% confidence intervals [CIs]) between variables of interest and objective preparedness. RESULTS: Before and after the hurricanes, 60% and 66% of women, respectively, were objectively prepared. Before the hurricanes, women reporting feeling well-prepared (vs. not prepared) (OR=9.31, 95%CI:3.96-21.91) and those who were diagnosed before (vs. after) the hurricanes (OR=1.71, 95%CI:0.95-3.09) were more likely to be objectively prepared. After the hurricanes, self-perceived well-preparedness (OR=2.46, 95% CI: 1.10-5.51) was positively associated with emergency preparedness when compared to feeling unprepared. CONCLUSIONS: Perceptions of emergency preparedness and having a cancer diagnosis increased the likelihood of being objectively prepared for an emergency. POLICY SUMMARY: This study demonstrates the need for state, territorial, and federal governments to include emergency preparedness plans for cancer patients in the Comprehensive Cancer Control plans. The study also indicates a need for cancer specific emergency preparedness information to be readily available for patients.

Association of smoking with anal high-risk HPV infection and histologically confirmed anal high-grade squamous intraepithelial lesions among a clinic-based population in Puerto Rico.

INTRODUCTION: Current smoking is a risk factor for anal cancer. Yet, its association with anal human papillomavirus infection (HPV) and anal high-grade squamous intraepithelial lesions (HSIL) remains unclear. We assessed the association of smoking with 1) anal high-risk HPV (HR-HPV) infection and 2) anal HSIL. METHODS: Data from the baseline visit of patients from the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center (May 2015- June 2021) was analyzed. Patients were eligible if they had information on smoking status, complete high-resolution anoscopy (HRA) with biopsy, and HR-HPV testing (n =  427). Logistic regression models estimated the odds ratio (OR) with 95% confidence intervals (CIs) adjusting for covariates. RESULTS: Mean age was 44 ± 13 years, 69% were men, 74% were HIV-infected, and 25% reported being current smokers. 74% had anal HR-HPV infection. HSIL was diagnosed in 40% of patients. Current smokers had significantly higher odds (OR: 1.71, 95% CI: 1.04-2.82) of having HSIL compared to non-smokers after adjusting for age, sexual risk group, lifetime number of sexual partners, HIV status, and HR-HPV infection. Smoking was not associated with HR-HPV infection (OR: 1.56, 95% CI: 0.83-2.95) after adjusting for age, sexual risk group, lifetime number of sexual partners, and HIV status. CONCLUSIONS: Current smoking was associated with histologically confirmed HSIL but not with HR-HPV infection among this high-risk Hispanic population. Results highlight the need to explore targeted smoking cessation campaigns among populations at higher risk of developing HSIL, as an anal cancer prevention strategy.

Elimination of cervical cancer in U.S. Hispanic populations: Puerto Rico as a case study.

Cervical cancer remains a major burden for women around the world. In 2018, the World Health Organization called for the elimination of cervical cancer worldwide (<4 cases per 100,000 women-years), within the 21st century. In the U.S., despite great progress toward this goal, existing disparities among racial/ethnic groups in cervical cancer raise concerns about whether elimination can be achieved for all women. We describe: 1) disparities in cervical cancer among Hispanics in the U.S. and factors that contribute to their increased risk, 2) prevention and control efforts to increase equity in the elimination of cervical cancer in this population, and 3) cervical cancer control efforts in Puerto Rico (PR), a U.S. territory, as a case study for cervical cancer elimination among a minority and underserved Hispanic population. Hispanics have the highest incidence rates of cervical cancer among all racial/ethnic groups in the U.S. Despite being more likely to complete HPV vaccination series, lower cervical cancer screening and access to treatment may lead to a higher cervical cancer mortality in Hispanics compared to non-Hispanic White women. These disparities are influenced by multiple individual-, sociocultural-, and system-level factors. To achieve the goal of cervical cancer elimination in the U.S., systematic elimination plans that consider the needs of Hispanic populations should be included within the Comprehensive Cancer Control Plans of each state. Because PR has implemented coordinated efforts for the prevention and control of cervical cancer, it represents a notable case study for examining strategies that can lead to cervical cancer elimination among Hispanics.

Correction: Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico.

[This corrects the article DOI: 10.1371/journal.pone.0184540.].

Human Papillomavirus Correlates With Histologic Anal High-Grade Squamous Intraepithelial Lesions in Hispanics With HIV.

OBJECTIVE: To estimate the magnitude of association between anal infection with high-risk human papilloma virus (HR-HPV) types and severity of biopsy-confirmed histopathological anal squamous intraepithelial lesions (SILs) among a clinic-based sample of HIV-infected adults in Puerto Rico. METHODS: This cross-sectional study analyzed data from medical records of adult patients who visited a specialized anal neoplasia clinic from June 2015 to December 2017 (n = 239); sociodemographics, behavioral risk factors, medical history, clinical data, and pathology reports were collected. The magnitude of association between anal HR-HPV and severity of anal SIL, adjusted for potential confounders, was assessed using a multinomial logistic model. RESULTS: A 78.7% of patients had anal HR-HPV infection, 43.9% had histopathological low-grade SIL (LSIL), and 37.7% had histopathological high-grade SIL (HSIL). The prevalence of anal HR-HPV infection was 63.6% among patients with no anal SIL, 70.5% for those with LSIL and 95.6% for those with HSIL. After adjusting for different predictors, patients with anal HR-HPV infection were more likely to have HSIL (odds ratio, 11.0; 95% confidence interval, 3.2-37.2) than those without anal HR-HPV infection, whereas no significant excess was observed for LSIL (odds ratio, 1.4; 95% confidence interval, 0.6-3.1). CONCLUSIONS: This study showed a strong association between anal HR-HPV infection and HSIL. Likewise, a high prevalence of anal HR-HPV infection and presence of anal SIL was observed among HIV-infected individuals. Our result highlights the importance of screening for anal HR-HPV infection and anal SIL and optimizing strategies for HPV vaccination in HIV-infected individuals.

Periodontitis and oral human papillomavirus infection among Hispanic adults.

INTRODUCTION: Research on the association between periodontitis and oral human papilloma virus (HPV) infection is inconsistent. The cross-sectional association of severe periodontitis with oral HPV infection was investigated in a sample of Hispanic adults. METHODS: Data from the 2014-2016 San Juan Overweight Adults Longitudinal Study (n = 740) was analyzed. Periodontitis assessment and self-collection of oral HPV samples followed the National Health and Nutrition Examination Survey methodology. Periodontitis was defined using the Centers of Disease Control and Prevention/American Academy of Periodontology definition. HPV typing was performed using polymerase chain reaction. Multivariate logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: 5.7% of participants had oral HPV infection and 20.3% had severe periodontitis. Adults with severe periodontitis had higher odds of oral HPV infection than those with none/mild disease (OR=2.9, 95% CI: 1.0-8.4, p < 0.05) in multivariable analysis. Adults with clinical attachment loss≥ 7 mm and pocket depth PD≥ 6 mm had 2- to 3-fold higher odds of HPV infection. CONCLUSIONS: Severe periodontitis was positively associated to oral HPV infection. Longitudinal evaluation of periodontal inflammation's role in acquisition and persistence of oral HPV infection is needed, as periodontitis screening could identify individuals at increased risk of HPV-related oral malignancies.

Seroprevalence of Human Papillomavirus (HPV) Type 6, 11, 16, 18, by Anatomic Site of HPV Infection, in Women Aged 16-64 Years living in the Metropolitan Area of San Juan, Puerto Rico.

OBJECTIVE: It is unknown if human papillomavirus (HPV) serum antibody responses vary by anatomic site of infection. We aimed to assess the seroprevalence for HPV 6, 11, 16 and 18 in association with HPV DNA detection in different anatomic sites among women. METHODS: This cross sectional population-based study analyzed data from 524 women aged 16-64 years living in the San Juan metropolitan area of Puerto Rico (PR). Questionnaires were used to assess demographic and lifestyle variables, while anogenital and blood samples were collected for HPV analysis. Logistic regression models were used to estimate the adjusted prevalence odds ratio (POR) in order to determine the association between HPV DNA infection status in the cervix and anus and serum antibody status, controlling for different potential confounders. RESULTS: Overall, 46.9% of women had detectable antibodies to one or more types whereas 8.7% had HPV DNA for one or more of these types detected in cervix (4.0%) or anus (6.5%). Women with cervical HPV detection tended to be more HPV seropositive than women without cervical detection (adjusted POR (95%CI): 2.41 (0.90, 6.47), p=0.078); however the type-specific association between cervical DNA and serum antibodies was only significant for HPV 18 (adjusted POR (95% CI): 5.9 (1.03, 33.98)). No significant association was detected between anal HPV and seropositivity (p>0.10). CONCLUSION: Differences in the anatomic site of infection could influence seroconversion, however, longitudinal studies will be required for further evaluation. This information will be instrumental in advancing knowledge of immune mechanisms involved in anatomic site response.

Population-Based Study of Tobacco Use Among People Living With HIV in Puerto Rico.

BACKGROUND: Despite substantial advances in the era of highly active antiretroviral therapy, HIV-positive persons are at high risk of tobacco-related disease and mortality. This study describes the prevalence and sociodemographic factors associated with current tobacco use among HIV-positive men and women 18 years and older receiving HIV care in Puerto Rico. METHODS: Data from the 2009 Medical Monitoring Project (MMP) was used. A three-stage sampling design was conducted to obtain annual cross-sectional probability samples of HIV-infected adults in care. Factors associated with current tobacco use were identified using logistic regression models. All analyses were performed using STATA version 11.0. RESULTS: The estimated prevalence of current cigarette use among the population was 29.0% (95%CI: 23.5%-35.2%), daily smoking was reported in 76.7% of them. Multivariate logistic regression models, showed that male drug users (injected and noninjected) were up to nine times more likely to be current smokers (OR = 9.9; 95%CI = 3.1, 31.5) as compared to nonusers. CONCLUSION: Findings highlight the need for smoking cessation strategies in this population, particularly among male HIV+ drug users.

Modelling the effects of quadrivalent Human Papillomavirus (HPV) vaccination in Puerto Rico.

BACKGROUND: No study has estimated the potential impact of Human Papillomavirus (HPV) vaccination in Puerto Rico, a population with considerable burden of HPV-related morbidities. We evaluated the health and economic impacts of implementing a vaccination strategy for females and males in Puerto Rico, with the quadrivalent HPV (HPV4) vaccine, under different vaccination scenarios. METHODS: We adapted a mathematical model which estimates the direct and indirect health benefits and costs of HPV4 vaccination in a dynamic population. The model compared three vaccination scenarios against screening only (no-vaccination) for three doses of HPV4 vaccine among individuals aged 11-15 years in Puerto Rico: 1) 34% for females and 13% for males (34%F/13%M), 2) 50% for females and 40% for males (50%F/40%M), and 3) 80% for female and 64% for male (80%F/64%M). Data specific to Puerto Rico was used. When not available, values from the United States were used. Input data consisted of demographic, behavioral, epidemiological, screening, and economic parameters. RESULTS: The model predicted decreases in: 1) HPV infection prevalence for females and males, 2) cervical intraepithelial neoplasia and cervical cancer incidence for females, 3) genital warts incidence for females and males, and 4) cervical cancer deaths among females, when various vaccination program scenarios were considered. In addition, when the vaccination percentage was increased in every scenario, the reduction was greater and began earlier. The analysis also evidenced an incremental cost effectiveness ratio (ICER) of $1,964 per quality-adjusted life year gained for the 80%F/64%M uptake scenario. CONCLUSIONS: HPV vaccine can prove its cost effectiveness and substantially reduce the burden and costs associated to various HPV-related conditions when targeted to the adequate population together with an organized HPV vaccination program.

Factors associated with late stage at diagnosis among Puerto Rico's government health plan colorectal cancer patients: a cross-sectional study.

BACKGROUND: Late stage at diagnosis of cancer is considered a key predictor factor for a lower survival rate. Knowing and understanding the barriers to an early diagnosis of colorectal cancer is critical in the fight to reduce the social and economic burden caused by cancer in Puerto Rico. This study evaluates factors associated to colorectal cancer stage at diagnosis among Puerto Rico's Government Health Plan (GHP) patients. METHODS: We conducted a cross-sectional study based on a secondary data analysis using information from the Puerto Rico Central Cancer Registry (PRCCR) and the Puerto Rico Health Insurance Administration (PRHIA). Logistic regression models were used to estimate the unadjusted odds ratio (ORs) and adjusted odds ratio (AORs), and their 95 % confidence intervals (CIs). Colorectal cancer cases diagnosed between January 1, 2012 and December 31, 2012, among persons 50 to 64 years of age, participants of the GHP and with a cancer diagnosis reported to the PRCCR were included in the study. RESULTS: There were 68 (35.79 %) colorectal cancer patients diagnosed at early stage while 122 (64.21 %) where diagnosed at late stage. In the multivariate analysis having a diagnostic delay of more than 59 days (AOR 2.94, 95 % CI: 1.32 to 6.52) and having the first visit through the emergency room (AOR 3.48, 95 % CI: 1.60 to 7.60) were strong predictors of being diagnosed with colorectal cancer at a late stage. CONCLUSIONS: These results are relevant to understand the factors that influence the outcomes of colorectal cancer patients in the GHP. Therefore, it is important to continue developing studies to understand the Government Health Plan patient's pathways to a cancer diagnosis, in order to promote assertive decisions to improve patient outcomes.

Demographic and High-Risk Behaviors associated with HPV and HPV Vaccine Awareness among Persons Aged 15-74 Years in Puerto Rico.

OBJECTIVE: Studies of human papillomavirus (HPV) awareness in Puerto Rico (PR) are limited and are of interest given low HPV vaccine uptake in this population. This cross-sectional study aimed to determine factors associated to HPV and HPV vaccine awareness among persons aged 15-74 years living in Puerto Rico. METHODS: We analysed data from a sub-sample of 1,476 men and women who participated in a 2008 population-based island-wide household survey and who completed an HPV module. Multivariate logistic regression models were used to examine factors associated with HPV and HPV vaccine awareness. RESULTS: Overall, 37.2% of participants had heard about HPV and 33.4% had heard of the vaccine. Multivariate logistic regression showed that women were more likely to have heard of HPV (OR adjusted: 4.54; 95% CI=3.45, 5.98) or of the HPV vaccine (OR adjusted: 6.15; 95% CI=4.50, 8.40) as compared to men. HPV awareness was also lower among older adults, persons with lower income and with lower educational attainment, those without children and smokers (p < 0.05). CONCLUSION: In 2008, two years after the introduction of the first HPV vaccine in PR and the US, public awareness about HPV infection and the HPV vaccine was lower in Hispanics in PR as compared to other populations. Identified high-risk populations should be targeted in preventive care strategies. Future efforts should increase HPV knowledge and vaccine use in this population in order to maximize the impact of vaccination programs.

Methods in HPV Surveillance: Experiences from a Population-Based Study of HPV Infection among Women in the San Juan Metropolitan Area of Puerto Rico.

This article describes the methodology of the first population-based study of human papillomavirus (HPV) infection among women aged 16-64 years residing in the San Juan Metropolitan Area of Puerto Rico (PR). The sample was identified through a complex sampling design of households. The sampling frame was selected in four stages, using census tracts maps from the Census Bureau. Women completed a face-to-face interview and a computer-assisted self-interview using the Audio CASI system, for the collection of demographic, clinical, and lifestyle variables, and sampling acceptability. Anal, cervical, and oral specimens were collected through self-collection methods for HPV DNA testing using a modified pool of MY09/MY11 consensus HPV L1 and human ß-globin amplification primers. Anthropometric measurements were taken using the Third National Health and Nutrition Examination Survey methodology. Blood samples were collected to create a bio-repository for future HPV-related studies. Fifty census tract blocks were randomly selected. We recruited 566 women, with a response rate of 83.4%. Response rates did not vary by age-group (p>0.05); although they varied by socioeconomic (SES) census block stratums (p<0.05), response rates were good (>75%) in all SES strata. All participants agreed to respond to the surveys and provide the requested anogenital and oral samples. Overall, more than 98% understood and more than 50% felt comfortable with the cervical, anal, and oral self-collection methods used. This article documents the feasibility of performing population-based studies for HPV surveillance in women in PR.

Prevalence and Correlates of Penile HPV Infection in a Clinic-Based Sample of Hispanic Males.

OBJECTIVE: The aim of this manuscript is to describe the prevalence, genotypic distribution of penile HPV infection and the behavioral risk factors associated with penile HPV infection (any HPV type, high-oncogenic-risk [HR] types, low-oncogenic-risk [LR] types, and of multiple HPV types) in a group of sexually active males who went to an STI clinic in San Juan, Puerto Rico. METHODS: After providing informed consent, the participants, underwent a detailed behavioral interview and a clinical examination. Frequency distributions and descriptive statistics were used to characterize the study samples. Prevalence estimates and 95% confidence intervals (CI) were calculated for any type of HPV, HR types, LR types, or multiple types. Logistic regression analyses was performed to determine factors associated with each of the HPV types. RESULTS: Two hundred and six participants were enrolled in this study. The mean age of the participants was 37.8±13.1 years. Close to 80% of the sample were infected with at least one HPV type; 73.5% were infected with one or more LR-HPV types; 32.4%, with one or more HR-HPV types; and 46.0%, with multiple HPV types. The most prevalent HR types were HPV-35, -31, and -16; the most prevalent LR types were HPV 6/11, and -84. After adjusting for age, having a high number of lifetime female sexual partners was highly associated with having multiple types of HPV infection (estimated OR=2.86; 95% CI=1.41, 5.80). CONCLUSION: HPV infection is common among sexually active males frequenting this STI clinic. HPV types not covered by the current quadrivalent HPV vaccine were identified. Multiple HPV types in the penis are significantly related to the lifetime number of female sexual partners. The high prevalence of HPV at this particular STI clinic evidences that males need to be targeted in primary care settings if the available vaccine is to be effectively promoted. In addition, opportunities for secondary prevention of HPV in STI settings are recommended, because of the burden of anal and penile cancer documented in the island.

Cervical Cancer Screening and Sexual Risky Behaviors among a Population of Hispanic Origin.

OBJECTIVE: To assess the prevalence of cervical cancer screening through Papanicolaou (Pap) test utilization and its association with sexual behaviors among a population-based sample of Hispanic women in Puerto Rico (PR). METHODS: This study was a secondary data analysis of the database of a cross-sectional study of HPV infection in PR (2010-2013; n = 554 women). Pap test utilization (past 3 years) was self-reported and sexual risky behavior was defined as an index that considered the following sexual behaviors: early age of sexual debut (≤16 years), 11 or more lifetime sexual partners, and 2 or more sexual partners in the last year. Multivariable logistic regression was used to estimate the magnitude of the association between sexual risk behavior and Pap test utilization, after adjusting for socioeconomic and lifestyles characteristics. RESULTS: The overall prevalence of Pap test utilization was 78.0%. Pap test screening varied with sexual behavior, with women with none or one risky sexual behavior having higher odds of Pap test utilization in the past 3 years (odds ratio [OR], 1.74; 95% CI, 1.03-2.93) compared with those with two or three risky sexual behaviors. This difference remained marginally significant (p < .10) after adjusting for age, educational attainment, smoking status and STI history (OR, 1.72; 95% CI, 0.96-3.08). CONCLUSIONS: The prevalence of cervical cancer screening in this population (78%) is still below Healthy People 2020 recommendations (93%). Also, women with risky sexual behaviors are less likely to have been screened. Efforts to promote cervical screening programs should focus on these high-risk women as a method for cervical cancer prevention and control.

High Prevalence of Diabetes and Prediabetes and Their Coexistence with Cardiovascular Risk Factors in a Hispanic Community.

This study examined the prevalence and association of diabetes mellitus (DM) and prediabetes with cardiovascular risk factors among Puerto Ricans adults. Data from a household survey of 857 adults aged 21-79 years who underwent interviews, physical exams, and blood draws were analyzed. Prevalence of total DM and prediabetes was estimated using American Diabetes Association diagnostic criteria of fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c). Poisson regression models were used to estimate the prevalence ratio for each cardiovascular risk factor under study. Age-standardized prevalence of total DM and prediabetes, detected by FPG and/or HbA1c, was 25.5 and 47.4 %, respectively. Compared with participants with normoglycemia, those with previously diagnosed DM, undiagnosed DM, and prediabetes had more adverse cardiovascular risk factor profiles, characterized by a higher prevalence of general and abdominal obesity, hypertension, low HDL cholesterol, elevated LDL cholesterol, elevated triglycerides, and elevated plasminogen activator inhibitor 1 (p < 0.05). The high prevalence of DM and prediabetes calls for public health actions to plan and implement lifestyle interventions to prevent or delay the onset of DM and cardiovascular disease.