Human Papillomavirus is the most common sexually familial infection worldwide Trottier and Franco, 2006, with a estimated planetary prevalence among adult females of 10.4 % ( de Sanjose et al. , 2007 ) . HPV prevalence among African adult females is disproportionately high, runing from 22.1 % to 46.0 % ( Clifford et al. , 2005a ; de Sanjose et al. , 2007 ; Smith et al. , 2008 ) . In a survey of venereal HPV prevalence among heterosexual work forces on 5 continents, Vardas and co-workers found the prevalence of any HPV type at 21.0 % ( 18.7 % phallus, 13.1 % scrotum, 7.9 % perineal / perianal part ) ( Vardas et al. , 2011 ) . In surplus of 100 HPV genotypes have been identified, with about 40 infecting the mucosal epithelial tissue. These HPV genotypes are divided into bad and low-risk genotypes, harmonizing to their association with cervical lesions. The high hazard HPV ( hrHPV ) types are more often found in premalignant or malignant lesions and are associated with malignant neoplastic diseases of the neck, vulva, vagina, anus, and phallus ( Baldwin et al. , 2004 ; Castellsague, 2008 ; Castellsague et al. , 2002 ; Cogliano et al. , 2005 ; Gravitt et al. , 2000 ; Gustavsson et al. , 2009 ; WHO-IARC, 2007 ; WHO, 2007b ) .
An underlying association between cervical malignant neoplastic disease and hrHPV has been good established ( Bosch et al. , 1995 ; Castellsague et al. , 2002 ; Koutsky et al. , 1992 ; Lehtinen et al. , 2001 ; Morris, 2007 ; Rozendaal et al. , 2000 ) , as demonstrated by the estimated worldwide prevalence of hrHPV in cervical carcinomas of 99.7 % ( Walboomers et al. , 1999 ) . Cervical malignant neoplastic disease is the most widespread malignant neoplastic disease impacting adult females in developing states and more than 70 % of instances of cervical malignant neoplastic disease happening in this part have been attributed to hrHPV genotypes 16 and 18 ( de Sanjose et al. , 2007 ; Munoz et al. , 2004 ; Schiffman et al. , 2007 ) . Therefore, any intercession cut downing the acquisition or transmittal of HPV will besides significantly cut down the load of disease, particularly in developing states ( Castellsague et al. , 2002 ) .
Ninety per centum of venereal warts ( GWs ) , besides called condylomata acuminate is caused by low-risk HPV ( lrHPV ) genotypes 6 and 11 ( Garland et al. , 2009 ) . LrHPV prevalence in adult females has been estimated at 13.6 % in Sub-Saharan Africa ( Clifford et al. , 2005a ) , Relatively small is known about the epidemiology and natural history of lrHPV infection and GWs in sub-Saharan Africa. LrHPV prevalence shows considerable regional fluctuation, such as 11 % in the Gambia, 28 % in Tanzania and can run from 1.2 % to 30.0 % depending on geographical part, mark population, and sexual behavior ( Smith et al. , 2008 ) . Although intervention helps to extinguish the virus, GWs by and large non painful, but they do rub and with frequent new lesions or returns doing in patient hurt ( Garland et al. , 2009 ; Lacey, 2005 ) . GWs can do a diminution in health-related quality of life ( Woodhall et al. , 2008 ) . The psychological load of GWs have the largest impact on quality of life compared with other clinical signifiers of HPV, chiefly due to impact on gender, self-image, and spouse transmittal ( Pirotta et al. , 2009 ) .
Multiple hrHPV and lrHPV infections may hold of import clinical and epidemiological deductions. Infection with multiple HPV genotypes has been associated with anogenital warts ( Brown et al. , 1999 ; Chan et al. , 2009 ; Nielson et al. , 2009 ) , the acquisition of new HPV type and HPV infection continuity ( Kjaer et al. , 2005 ) , dysplasia ( Fife et al. , 2001 ) , cervical intraepithelial neoplasia badness ( Bello et al. , 2009 ; Spinillo et al. , 2009 ) , cytological abnormalcies in anal epithelial tissue ( Damay et al. , 2010b ) , and HIV co-infection ( Banura et al. , 2008 ; Muller, Chirwa, and Lewis, 2009 ; Vajdic et al. , 2009 ) . Therefore, the probe of lrHPV infection and the figure of lrHPV genotypes detected in urethral swabs is cardinal since being infected with one or multiple genotypes may ensue in a different clinical result.
Incidence and HPV type distribution in work forces with GWs was 2.35 instances per 1000 person-years, the highest incidence among work forces aged 18-30 old ages ( 3.43 instances per 1000 person-years ) , with HPV 6 ( 43.8 % ) , HPV 11 ( 10.7 % ) , and HPV 16 ( 9.8 % ) the genotypes most normally detected in GWs ( Anic et al. , 2011 ) . In a survey of work forces who have sex with work forces ( MSM ) infected with HIV, 74.6 % had anal HPV infection, 68.7 % had hr HPV infection, and 56.7 % had multiple infections. Most frequent HPV types identified were HPV 44/55 ( 19.4 % ) , HPV 53 ( 19.4 % ) , HPV 16 ( 16.4 % ) , HPV 39 ( 16.4 % ) , and HPV 42 ( 14.9 % ) ( Damay et al. , 2010a ) . In a South African cohort of heterosexual work forces, the prevalence of anogenital HPV among survey participants was 78 % . In 81 % , HPV 6, 11, 16 and 18 were prevailing as either individual or combined infections. HPV types 6 and/or 11 were significantly higher among GW patients ( p & lt ; 0.001 ) . HIV seropositivity was significantly associated with multiple HPV infections ( OR=3.98, 95 % CI 1.58 to 10.03 ) ( Muller, Chirwa, and Lewis, 2009 ) .
Since work forces are bearers of HPV and the chief path of transmittal to adult females is through sexual contact with septic work forces, it would be of benefit to cut down the HPV prevalence, non merely in adult females, but in work forces every bit good. Recent experimental surveies have suggested that HPV prevalence was reduced among circumcised work forces compared to uncircumcised work forces ( Baldwin et al. , 2004 ; Castellsague et al. , 2007 ; Castellsague et al. , 2002 ; Giuliano et al. , 2009 ; Hernandez et al. , 2008b ; Vaccarella et al. , 2006 ) whereas other surveies failed to happen an association ( Nielson et al. , 2007b ; Shin et al. , 2004 ) . However, two recent male Circumcision ( MC ) tests have demonstrated a lower hrHPV prevalence and incidence among circumcised work forces by 32 % to 35 % . The writers argue that while male Circumcision is chiefly a male concern, one test besides reported benefits derived by female spouses of circumcised work forces ( Wawer et al. , 2011 ) . This protective consequence of MC against acquisition could be explained by the function of the prepuce on HPV transmittal. Viral entree to the basal keratinocytes in the cornified epithelial tissue of the circumcised phallus is limited. There is no a difference between the keratinization of the glans phallus of circumcised work forces and uncircumcised work forces, but the mucosal epithelial tissue of the interior foreskin is non keratinised which makes it more susceptible to microtrauma hurt during intercourse ( vaginal, anal and unwritten sex ) . It is postulated that hapless venereal hygiene, inflammatory consequence of accrued smegma, can besides help in the harbouring of HPV infection ( Gray et al. , 2009 ) . Consequently, the same protective consequence of MC can be expected on lrHPV prevalence, but to day of the month, really small is known about this association.
The aim of this survey was to analyse the consequence of medical male Circumcision ( MMC ) on the prevalence of hrHPV and lrHPV infection by sing both hrHPV and lrHPV prevalence and the figure of hrHPV and lrHPV genotypes detected among immature work forces. The secondary aim was to place other hazard factors for hour HPV or lrHPV infection.
Datas used were collected during the MMC randomized controlled test ( RCT ) conducted in Orange Farm ( South Africa ) , which demonstrated a partly protective consequence of male Circumcision on the acquisition of HIV ( Auvert et al. , 2005 ) .
An independent and partial protective consequence of MC was demonstrated on the prevalence of hrHPV and lrHPV. This consequence on hrHPV was shown on the prevalence and non incidence because of the available biological samples in this MC test. When the analysis was adjusted for possible confounding factors, such as sexual behavior and rubber usage, the result remained unchanged. Given the consequences of the leaning analysis, the randomisation and the absence of obvious differences between groups in N. gonorrhoea prevalence or sexual behavioral features, the difference in hrHPV prevalence between the 2 groups is likely attributable to MC. Therefore, the difference observed is likely the effect of unsimilarity in hrHPV incidence between circumcised and uncircumcised work forces. In this survey hrHPV prevalence is likely a placeholder for hrHPV incidence, as HPV prevalence rises as a map of age among immature work forces ( Okesola and Fawole, 2000 ) .
HPV-type co-infections can hold an impact of HPV inoculation and disease in work forces due to possible HPV type competition followed by type replacing. It is of import to carry on surveies on multiple HPV infections, HPV distribution, associations between HPV types in multiple infections among work forces and type competition in work forces. Type competition may ensue from unknown biological dynamicss, whereby infection with one HPV type inhibits the acquisition or facilitates continuity of other HPV types ( Rositch et al. , 2012 ) .
No consequence of MC on some hrHPV genotypes, such as 16 and 33 could be established. The evident disparity in the consequence of MC for different genotypes can be the consequence of true fluctuation or random fluctuation. This should be farther investigated, for illustration, by comparing the consequences of the present survey with those of other MMC tests conducted in other African states ( Bailey et al. , 2007 ; Gray et al. , 2007 ) .
The protective consequence of MC demonstrated in this survey, corresponds in magnitude to what could hold been expected from experimental surveies. Castellsague and co-workers ( Castellsague et al. , 2007 ) found in their meta-analysis an odds ratio of 0.56 ( 95 % CI, 0.39-0.82 ) , whereas Baldwin ( Baldwin et al. , 2004 ) reported an adjusted comparative hazard of 0.44 ( 95 % CI, 0.23-0.81 ) . Hernandez ( Hernandez et al. , 2008b ) determined that uncircumcised work forces had an increased hazard of about a 2-fold of oncogenic HPV infections ( comparative hazard, 1.96 [ 95 % CI, 1.02-3.75 ] ) . This survey presents clear grounds that MC lowers the hazard of heterosexual hrHPV acquisition among work forces.
HrHPV remains a major public wellness concern because of its contributory association with malignances, particularly cervical malignant neoplastic disease in adult females. These findings show why MC has long been thought to be protective against cervical malignant neoplastic disease ( Morris, 2007 ) . MC reduces the hazard of hrHPV infection among work forces and as a consequence reduces the exposure of adult females to hrHPV. Consequently, the hazard of cervical malignant neoplastic disease is lowered because of the causal nexus between hrHPV and cervical malignant neoplastic disease among adult females ( Bosch et al. , 1995 ; Castellsague et al. , 2002 ; Koutsky et al. , 1992 ; Lehtinen et al. , 2001 ; Morris, 2007 ; Rozendaal et al. , 2000 ; Wawer et al. , 2011 ) .
Three randomized controlled tests have shown that MC has a partial protective consequence on the acquisition of HIV by males in Africa ( Auvert et al. , 2005 ; Bailey et al. , 2007 ; Gray et al. , 2007 ) . In each instance, the test was terminated as the consequences were conclusive and it was considered unethical non to offer MC to the control groups in progress of the planned test terminal day of the month. The consequence of MC on HPV reinforces the recommendation of the World Health Organization and the Joint United Nations Programme on HIV/AIDS for the execution of MC plans in states with a high prevalence of HIV infection, a low prevalence of MC, and a high credence of MC ( UN, 2007 ) . While the cost of HPV vaccinum remains a job in Africa, the protective consequence of MC may be an alternate to HPV vaccinums in footings of genotype coverage and target-group age scope.
There was a strong independent association found between lrHPV urethral infection and MC. lrHPV infection was analyzed as a prevalence rate and in footings of figure of lrHPV detected in urethral swabs, because it was assumed that being infected with one genotype was different from being infected with two or more genotypes ( Chan et al. , 2009 ; Muller, Chirwa, and Lewis, 2009 ; Nielson et al. , 2009 ) . Results showed that the hazard of being infected with one lrHPV genotype ( PMR ) and with at least one genotype ( PRR ) systematically decreased among work forces from the intercession group. They did non differ significantly from control group participants in footings of sexual behavior, apart from describing more often at the 21-month visit holding had at least one sexual partnership in the previous12 months.
Few experimental surveies have observed this association but consequences remained inconsistent ( Baldwin et al. , 2004 ; Giuliano et al. , 2009 ; Muller, Chirwa, and Lewis, 2009 ; Nielson et al. , 2007b ; Svare et al. , 2002 ) . Merely one of these surveies found statistically important association of Circumcision position with the prevalence of lrHPV infection ( Giuliano et al. , 2009 ) . However, Tobian and co-workers ( Tobian et al. , 2009 ) have published similar consequences, analysing informations collected in another African population and utilizing a different HPV mopping site. A 34 % decrease in lrHPV prevalence among circumcised work forces was reported. For this ground, it can be concluded that the protective consequence of MC on hrHPV infection can be generalized to lrHPV genotypes as good.
In conformity with experimental surveies, this work highlighted some other hazard factors of lrHPV, such as the figure of lifetime sexual spouses ( Giuliano et al. , 2009 ; Hernandez et al. , 2008a ; Nielson et al. , 2007b ; Shin et al. , 2004 ; Vaccarella et al. , 2006 ) and being older than 21 old ages old ( Kjaer et al. , 2005 ) , although the function of age may change ( Giuliano et al. , 2009 ; Nielson et al. , 2007b ; Vaccarella et al. , 2006 ) . The information besides presented grounds that supports the protective function of rubber usage on hrHPV and lrHPV infections ( Baldwin et al. , 2004 ; Kjaer et al. , 2005 ; Nielson et al. , 2007b ; Vaccarella et al. , 2006 ) .
Possible mechanisms by which circumcised work forces are less likely to be infected with HPV could be explained by a decreased acquisition of new infection or an increased clearance of preexistent infection, because the absence of prepuce may cut down the hazard of auto-reinfection at the urethral site ( Gray et al. , 2009 ) .
This survey has some restrictions. First, biological samples were non collected throughout the follow-up period, so the hrHPV and lrHPV position at inclusion are non known. The decreased consequence of MC on HPV infection could be non strictly demonstrated due to the deficiency of informations on HPV position at baseline. This information would hold allowed a comparing of HPV incidence as a map of MC position and HPV prevalence between intercession groups at inclusion. As some participants were already infected by HPV at inclusion, the consequence on prevalence measured undervalued the true consequence of MC. However, MC was indiscriminately assigned, and commanding for the leaning mark did non impact the consequences. Second, participants were non blinded to the intercession and this may hold led to sexual behavior alteration and prejudice. Finally, hrHPV and lrHPV were detected in urethral swab samples, a method that is likely to lose infections ( Giuliano et al. , 2007 ) . The prevalence of HPV infections in this cohort is likely underestimated, because the rate of sensing in the urethra is significantly lower than that in the glans, aureole sulcus, or phallus shaft ( Aguilar et al. , 2006 ; Giuliano et al. , 2007 ) . This underestimate would be every bit distributed among the two groups of randomisation. However, there is no hazard of non-differential misclassification, as there were no difference when the urethral HPV prevalences before and after Circumcision in a subsample of participants were compared. This underestimate would hold no consequence on PRRs and PMRs. Despite this loss of power, this survey demonstrated a important protective consequence of MC against HPV infection. A review of the research lab methodological analysis is that due to the initial showing for 13 hrHPV types merely, followed by automatic genotype proving on the positives, some HPV ( particularly lrHPV ) genotypes might hold been missed.
Human papillomavirus genotypes that infect the venereal path in worlds are divided on the footing of their oncogenic potency into “ bad ” ( hrHPV ) and “ low-risk ” ( lrHPV ) genotypes ( Castellsague, 2008 ) . lrHPVs are most normally associated with lesions such as venereal warts that are non-malignant ( Monk and Tewari, 2007 ) , whereas hrHPV are found in the bulk of premalignant or malignant lesions of the genitalias and are associated with malignant neoplastic diseases of the neck, vulva, vagina, anus, phallus, caput and cervix ( Baldwin et al. , 2004 ; Castellsague, 2008 ; Monk and Tewari, 2007 ; Morris, 2007 ; WHO, 2007b ) .
The prevalence of venereal HPV among both sub-Saharan African males and females is high. Cervical malignant neoplastic disease is 99 % attributable to hrHPV ( Walboomers et al. , 1999 ) . Cervical is the taking cause of malignant neoplastic disease mortality among adult females in Southern African adult females ( Castellsague, 2008 ) . Cervical malignant neoplastic disease is a recognized AIDS-defining unwellness and there is a strong correlativity between HIV and invasive cervical malignant neoplastic disease ( Castro, 1992 ) . In Africa, both infections contribute significantly to the load of morbidity and mortality ; therefore it is of great public wellness importance to carry on research to foreground the epidemiologic and etiological association of HIV and HPV. Recent published epidemiological informations show that the chance of HIV transmittal in African states is amplified by HPV ( Auvert et al. , 2011 ; Mbulawa et al. , 2009 ; Veldhuijzen et al. , 2012 ) . There are several mechanistic accounts why HPV and other STIs can help HIV consumption: 1 ) it can increase the viral load in the venereal piece of land ; 2 ) it can increase the concentration of HIV in venereal secernments and increase viral diverseness ; 3 ) it may play a function in mucosal break and redness to ease HIV acquisition ( Cohen, 2006 )
The focal point of most surveies researching the nexus between HIV and venereal HPV was on the effects that HIV infection has on the prevalence, incidence, and the distribution of HPV genotypes. HIV-positive position is found to be strongly associated with higher HPV prevalence in both sexes ( Castellsague, 2008 ; Giuliano et al. , 2008c ; Ng’andwe et al. , 2007 ; Ng’ayo et al. , 2008 ; Partridge and Koutsky, 2006 ; Safaeian et al. , 2008b ) , higher hrHPV prevalence ( Aynaud et al. , 1998 ; Giuliano et al. , 2008c ; Mayaud et al. , 2001 ; Ng’andwe et al. , 2007 ; Partridge and Koutsky, 2006 ; Safaeian et al. , 2008b ) , higher HPV incidence ( Safaeian et al. , 2008a ) , higher prevalence of infections with multiple HPV genotypes ( Aynaud et al. , 1998 ; Giuliano et al. , 2008c ; Ng’andwe et al. , 2007 ; Ng’ayo et al. , 2008 ; Partridge and Koutsky, 2006 ; Safaeian et al. , 2008a ) , and higher frequence of HPV lesions in multiple locations ( Aynaud et al. , 1998 ) .
The incompatibility in both the clinical patterned advance and transmittal of HIV infection has driven a hunt for cofactors act uponing reproduction of the virus. Host immune and familial factors and reproduction dynamicss influence the patterned advance of HIV disease. Co-infections between diverse exogenously and sexually acquired infective agents and HIV have emerged to act upon the rate of HIV reproduction and transmittal ( Cohen, 2006 ) . Genital herpes simplex virus type 2 ( HSV-2 ) is extremely prevailing worldwide and an progressively of import cause of venereal ulcer disease ( Klug et al. , 2009 ) . Increased HSV-2 prevalence in developing states contributes to an addition in the proportion of GUD and attributes to HIV and HSV-2 symptomless sloughing within the venereal piece of land ( Mahiane et al. , 2009 ; Paz-Bailey et al. , 2007 ) . This observed interactive association between HIV and HSV-2 can be used as a theoretical account for look intoing the co-pathogenic being between HIV and HPV. HPV and HSV-2 portion similarities as for both, quiescence or continuity are cardinal factors in direction and diagnosing, both cause lesions that can help consumption of HIV and prevalence for both viruses can be reduced by MC ( Mahiane et al. , 2009 ; Tobian et al. , 2009 )
The aims of this survey were: 1 ) to research the association of hrHPV and lrHPV with HIV incidence in work forces, and 2 ) to measure HPV as a hazard factor or confounder for HIV acquisition in a immature male cohort from South Africa, a group which is presumptively at high hazard for STIs such as HPV and HIV.
Longitudinal informations were used and collected in Orange Farm ( South Africa ) , an country of high HIV prevalence ( DOH, 2008 ) during a male Circumcision randomized controlled test, which demonstrated a cut downing consequence of male Circumcision on the acquisition of HIV ( Auvert et al. , 2005 ) .
Datas from this test demonstrated an of import association of oncogenic HPV with HIV incidence among immature African work forces. However, the informations did non demo any association of nononcogenic HPV with HIV incidence.
This survey has chief 5 restrictions. First, as with any experimental survey, no causal relationship between HPV and HIV could be concluded from the findings. Second, although urethral sampling has been shown to be unaffected by Circumcision position ( Auvert et al. , 2009 ; Weaver et al. , 2004 ) , it has the defect of undervaluing the presence of venereal HPV ( Aguilar et al. , 2006 ; Giuliano et al. , 2007 ) . This underestimate is non expected to alter the positive association with HIV incidence, but it could be argued that the strength of this association may change with swobing sites. hrHPV was the most prevailing sexually familial infections in this cohort despite this underestimate. Third, the aggregation of venereal swabs for HPV testing was done at the last follow-up visit, which is on mean several months after HIV infection. It is therefore possible that, among the subsets of participants who contracted hrHPV during followup, some got infected with HPV after HIV acquisition. This will be given to thin the strength of the association between HPV and HIV. Fourth, the Roche Linear Array genotyping check used for testing in this survey, detects chiefly. This needs to be considered in the comparing hrHPV and lrHPV prevalence. Last, HPV lesion sensing was non performed in this survey.
Several nonexclusive and plausible accounts could account for these findings. First, both sexually transmitted viruses, HIV and HPV portion the same transmittal path and behavioral hazard factors. However, after commanding for these sexual behavioural variables, this association remains strong. Second, the consequences could be partially due to HIV infection easing HPV acquisition or HPV reactivation from the basal cell bed in the epithelial tissue due to a compromised immune system. This account is improbable as the participants in this survey were late infected with HIV and in all chance still had healthy immune systems. Third, it could be argued that female spouses co-infected with HIV and HPV- may hold shed hrHPV more easy than HIV-negative adult females. HPV lesions are more likely to be dysplasic when the immune system is depressed ( Steben and Duarte-Franco, 2007 ) and latent HPV infection can reactivated in immune compromised persons ( Aubin et al. , 2007 ; Aynaud et al. , 1998 ; Strickler et al. , 2005 ) . The mean age of the female spouses of the survey participants was 3 old ages older than the average age of sexual introduction reported in the same community, which is about 17 ( Pettifor et al. , 2005 ) . This makes this last account unlikely: female spouses who had their sexual introduction on mean 3 old ages earlier, doing it improbable that they already had a compromised immune system due to HIV infection. Fourth, the findings could bespeak that hrHPV, but non lrHPV, facilitates HIV acquisition.
There are several points in favor of the latter account: 1 ) there is strong grounds of a association between HIV and HPV acquisition, as shown in assorted cross-sectional surveies ( Ng’andwe et al. , 2007 ; Ng’ayo et al. , 2008 ; Safaeian et al. , 2008b ) ; 2 ) two other longitudinal surveies have shown that HPV facilitates HIV acquisition among MSM in the United States ( Chin-Hong et al. , 2009 ) and among Zimbabwian adult females ( Smith-McCune, 2009 ) , with the latter showing a differential consequence between hrHPV and lrHPV on HIV acquisition ; 3 ) hrHPVs easing HIV acquisition is biologically plausible. The likeliness of hrHPV increasing the susceptibleness to HIV infection was foremost suggested in 2002 ( Clarke and Chetty, 2002 ) . The statements are that ( a ) hrHPV infection of basal cell epithelial tissues could trip cell-mediated immune responses through the enlisting of macrophages and T lymph cells ( Coleman et al. , 1994 ; Nicol et al. , 2005 ; Stanley, 2009 ) , these are HIV mark cells and may ease HIV consumption ; ( B ) cytokines could be stimulated by venereal HPV ( Gage et al. , 2000 ; Nicol et al. , 2005 ) , which can ease HIV written text and reproduction ; and ( degree Celsius ) HPV infection can take to prevailing redness and immune system activation ( Behbahani et al. , 2007 ) . hrHPV is more likely to ensue in a relentless infection ( versus lrHPV ) ( Brown et al. , 2005 ; Franco et al. , 1999 ; Rowhani-Rahbar et al. , 2007 ) , intensifying the chance of HIV acquisition if there is truly HPV-induced immune activation.
This survey provides extra grounds of the strong interaction between HPV and HIV ; nevertheless it does non give a definite account of the association of HPV and HIV incidence. There is a demand for farther surveies to look into this association, utilizing, for illustration, informations from other longitudinal male Circumcision tests ( Bailey et al. , 2007 ; Gray et al. , 2007 ) or the informations collected during the COL-1492 test ( Marais et al. , 2008 ) , conducted on South African female sex workers. Testing the hypothesis that hrHPV facilitates HIV acquisition is complex as it entails the presentation of a causal association. The proof of this hypothesis could necessitate proving the possible protective consequence of available HPV vaccinums on HIV acquisition.