Appendix B: Human Papilloma Virus in Sub-Saharan Africa and the Impact of Condom Use on Its Spread

Human papilloma virus (HPV) is used to describe more than 100 different types of related viruses. HPV can be transmitted through contact with skin surfaces or genital fluids infected with the virus.¹ Genital HPV infection is usually, though not always, sexually transmitted. While many other sexually transmitted infections (STIs) have been associated with increased risk of acquiring or transmitting HIV, this association has not been observed for HPV. However, persons with HIV/AIDS seem to be at increased risk for HPV infection and associated sequelae of HPV infections such as genital warts and dysplasia.²

Cervical and anal/genital cancers, precancerous cervical tissue abnormalities, genital warts and wart-like lesions, and cervical cell dysplasia have been associated with infection with specific HPV types. Cervical cancer is the leading cancer among women in Africa.³ The report of a workshop sponsored by the National Institutes of Health National Institute of Allergy and Infectious Diseases (NIH/NIAID) within the Department of Health and Human Services (HHS) on the evidence of the effectiveness of condoms to prevent sexually transmitted diseases (STDs) concludes that co-infection with HPV and HIV may lead to increased risk of cervical neoplasia and anal cancers among persons infected with HIV, as HIV suppresses the body’s immune system.⁴

There is little known about the prevalence of HPV in sub-Saharan Africa.^5,6,7 Few studies on the prevalence of any STI, let alone HPV, have been conducted in the region. Of the available recent published reports, HPV research often covers specific populations in geographically specific areas of a country. For example, a 2001 study of HPV genotypes among 262 women in a rural area of Mozambique found that 40 percent of women in the study tested positive for at least one type of HPV.⁸ A 2003 study of 429 female family planning clinic attendees in urban Nairobi, Kenya, found an HPV prevalence of 44 percent. In addition, research sample sizes have been small and non-representative, making it difficult to generalize to entire populations, and advanced definitive diagnostic methods for HPV have only recently been made available. There have been no national or sentinel surveillance programs to assess HPV infection in sub-Saharan Africa. Therefore, it is difficult to accurately HPV prevalence in the region.

Additional HPV epidemiological research in developing countries is needed to develop more effective HPV and cervical cancer prevention strategies. The focus of this research should include the prevalence of specific HPV strains associated with cervical cancer, the prevalence of cofactors affecting the progression to cervical cancer, region-specific risk factors for HPV infection and cervical cancer, and the association between HIV infection and HPV epidemiology. Screening and treatment programs for cervical cancer are also recommended to prevent cervical cancer deaths in sub-Saharan Africa.

Condoms have been shown to be effective in preventing the transmission of many STIs, including HIV/AIDS. Because HPV is transmitted via skin-to-skin contact and genital fluids, HPV is not entirely preventable through condom use. Laboratory and field-based research to evaluate the effectiveness of condoms in preventing HPV transmission has been limited, but correct and consistent use of condoms can be expected to decrease (though not eliminate) the risk of transmitting HPV.⁹ The U.S. Centers for Disease Control and Prevention reports that a number of studies show an association between condom use and a reduced risk of HPV-associated diseases, including genital warts, cervical dysplasia and cervical cancer.¹⁰ The previously mentioned 2001 NIAID workshop report recommended that “robust research be pursued to ascertain the true benefits and limitations of an available risk reduction technology – latex male condoms – for preventing the transmission of STDs. At the same time, research on additional prevention technologies and behavioral interventions must also be pursued in order to advance the health of the public in the U.S. and abroad.”¹¹

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     ¹ National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia. 
     ² Ibid. 
     ³ IDe Vuyst, H. et al. 2003. “Distribution of Human Papillomavirus in a Family Planning Population in Nairobi, Kenya.” Sexually Transmitted Diseases 30(2): 137-42. 
     ⁴ National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia. 
     ⁵ Castellsague, S. et al. 2001. “Human Papillomavirus genotypes in Rural Mozambique.” Lancet 358: 1429-30. 
     ⁶ De Vuyst, H. et al. 2003. “Distribution of Human Papillomavirus in a Family Planning Population in Nairobi, Kenya.” Sexually Transmitted Diseases 30(2): 137-42. 
     ⁷ Okobia, M.N. 2003. “Cancer Care in Sub-Saharan Africa – Urgent Need for Population-based Cancer Registries.” Ethiopian Journal of Health and Development 17(2): 89-98. 
     ⁸ Castellsague, S. et al. 2001. “Human Papillomavirus genotypes in Rural Mozambique.” Lancet 358: 1429-30. 
     ⁹ National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia. 
     ¹⁰ CDC. No date. “Male Latex Condoms and Sexually Transmitted Diseases.” Fact Sheet for Public Health Personnel. 
     ¹¹ National Institute of Allergy and Infectious Diseases. 2001. “Workshop Summary: Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention.” June 12-13, 2000. Hyatt Dulles Airport. Herndon, Virginia.

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