Human Papillomaviruses Prevalence and Genital Co-infections in HIV-seropositive Women in Ouagadougou (Burkina Faso)
The vaginal swabs among HIV-positive women in Africa often revealed opportunistic infections such as human Papillomavirus (HPV) and Mycoplasma that induce respectively cervix cancer and diseases such as vaginosis, abortions, infertility in through salpingitis. The purposes of this study were to: (1) seek for, the prevalence of pathogens such as HPV and Mycoplasma; (2) characterize the strains of HPV and estimate their prevalence; (3) identify among these women, those who were co-infected by these pathogens in order to cure them. From February 2009 to January 2010, 156 HIV-positive women attending our medical centers and aged from 19-45 years (mean age 33.65±5.75 years) had voluntarily accepted vaginal specimens tests. PCR, ELISA and molecular hybridization were used for the identification and characterization of these pathogens. The results revealed the presence of Mycoplasma and HPV in 25.64 and 58.33% cases, respectively. The following HPV genotypes and the following prevalence were recorded: HPV-50'S (24.11%), HPV-18 (21.28%), HPV-30'S (18.44%) and HPV-16 (5.67%). The study also enable the identification of co-infections such as HPV-18 strains with HPV-30'S (5.67%) and HPV-30'S with HPV-50'S (3.55%). Other germs infecting the female genital tract including Candida albicans (20.51%), Escherichia coli (12.18%), Treponema pallidum (3.85%), Streptococcus agalactiae (3.21%) and Staphylococcus aureus (1.92%) were isolated. This preliminary research work showed the incidence of several genital pathogens, this could be a springboard for nationwide epidemiological study on HPV strains circulating in Burkina Faso.
to cite this article:
T. Sagna, F. Djigma, M. Zeba, C. Bisseye, S.D. Karou, D. Ouermi, V. Pietra, C. Gnoula, K. Sanogo, J.B. Nikiema and J. Simpore, 2010. Human Papillomaviruses Prevalence and Genital Co-infections in HIV-seropositive Women in Ouagadougou (Burkina Faso). Pakistan Journal of Biological Sciences, 13: 951-955.
Received: June 23, 2010;
Accepted: August 26, 2010;
Published: September 17, 2010
The immunodeficiency caused by HIV infection, raises the problem of opportunistic
infections (OIs). Indeed, women infected with HIV are mainly exposed to infections
with human Papillomavirus (HPV), Mycoplasma, Candida albicans
and Escherichia coli (Moradi and Talat, 2006).
The risk of HPV infection increases along with the level of immunodeficiency
and therefore the risk to develop cervix cancer (Spano et
al., 2005). HPV cervix cancer is the second most common cancer worldwide
and the first in Sub-Saharan Africa. The use of High Active Antiretroviral therapy
(HAART) has reduced significantly the mortality rate among patients infected
with HIV. However, in spite of better control of viral replication and immunity
by HAART, the emergence of co-infection among patients infected with HIV has
become a serious cause of morbidity and mortality (Spano
et al., 2006).
HIV-positive women have in general Mycoplasma infection (Irwin
et al., 2000; Bebear and Bebear, 2007) those
are also isolated in the cases of bacterial vaginosis (Anukam
and Reid, 2007). Mycoplasma pathogens that generally infect the female
genital tract are mainly: Mycoplasma hominis, Ureaplasma urealyticum
and Mycoplasma genitalium (Judlin, 2003).
The human Papillomaviruses (HPV) are viruses that infect skin and mucous. Genital
HPV are sexually transmitted and they are the most common cause of sexually
transmitted infections (STI) (Louie et al., 2008).
The clinical manifestations of HPV depend on viral genotype and include skin
lesions, mucosal benign (verruca vulgaris, plantar warts, flat warts, anogenital
warts, genital warts, epidermodysplasia verruciformis and laryngeal papillomas),
cervical intraepithelial neoplasia and cervix cancers (Heard,
2005). Among the 500,000 new cases of cancer of the cervix diagnosed each
year, 80% are women living in developing countries (Cutts
et al., 2007). Cervix cancer, due to HPV, is the second most common
cancer, after the breast cancer in women; and in terms of mortality, it is the
second leading cause of cancer deaths in women worldwide (Pyeon
et al., 2009).
HPV genotypes are classified according to their nucleotide sequence homology.
The ranking is based on comparisons of specific genomic regions (E6, E7 and
L1) (Spano et al., 2005). Currently, more than
100 genotypes, including those with anogenital tropism (approximately 40), have
been identified. They are classified according to their oncogenic potential
in high-risk genotype (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68) or
low risk (6, 11, 26, 34, 40, 42-44, 53-55, 62, 66) (Santin
et al., 1999). The prevalence of genotypes involved in cervical cancer
varies according to geographic regions (Louie et al.,
2008). However, the human Papillomavirus type 16 (HPV-16) are the most common
genotype in the world. Porting these germs could possibly complicate immunocompromised
Thus this study aimed to: (1) seek for the prevalence of pathogens such as HPV, Mycoplasma hominis, Candida albicans, Escherichia coli, Streptococcus agalactiae, Staphylococcus aureus, Staphylococcus epidermidis, Trichomonas vaginalis, Treponema pallidum, (2) determine HPV genotypes in Burkina Faso and their prevalence (3) identify HIV-positive women, co-infected by these pathogens for appropriated medical care.
MATERIALS AND METHODS
Patients and the study: This study was conducted at the Saint Camille Medical Center (CMSC) and the Center for Biomolecular Research Pietro Annigoni (CERBA/LABIOGENE), University of Ouagadougou, Burkina Faso. From February 2009 to January 2010, 156 HIV-positive women attending the CMSC and CERBA and aged from 19-45 years old (average age of 33.65±5.75 years) freely accepted to participate to the study. Indeed, each woman was asked to sign a consent form certifying her agreement with the form which was edited to explain the design and the importance of the study. Pregnant women and virgins were not included.
Sample collection: From each woman, three endocervical swabs were prepared. The first swab was used for bacterial cultivation and identification. The second swab was used for microscopic observation of fresh and stained sample. The third swab was used for molecular detection of HPV by PCR / hybridization.
Mycoplasma and other bacteria detection
Mycoplasma identification: Mycoplasmas were identified using the kit Mycoplasma system plus of Diagnostic Liofilhem ®). The vaginal swab was plunged into 7 mL of saline solution provide by the manufacturer. The obtained suspension was used to inoculate 24 well microplates (0.2 mL well) and plates were incubated at 37°C for 24 to 48 h prior to Mycoplasma identification. The turn colour (from yellow to red) of the wells during the alkalinization of medium after 24 or 48 h of cultivation at 37°C enables the identification and enumeration of Mycoplasma denominated in units of colour change per milliliter (CCU mL-1) and from 0 to > 105 CCU mL-1.
Other germs identification: The above suspension was used to inoculate muller hinton, Sabouraud and chocolate agar + polyvitex agar plates. These media were incubated at 37°C for 24 h. Positive cultures were characterized by determining their biochemical characteristics according to conventional methods used in the center.
PCR/Hybridization for HPV identification
DNA extraction: Viral DNA was extract from each sample using a kit Instant Virus DNA of bio® analytkjena solutions by following the protocol provided by the manufacturer.
PCR/hybridization: The DNA obtained was used for the detection of HPV genotypes using a kit "HPV Star blotting Diatech® using nitrocellulose strips. This kit can detect HPV genotype following: 16, 18, 30'S (31, 33, 35, 39), 45, 50'S (51, 52, 53, 56, 58, 59), 6, 11 and other HPV genotype high-risk and low risk.
Ethical committee: The Committee of Ethics of the CMSC and CERBA made sure that each person provided an informed consent before sample was taken for this study.
Statistical analysis: Demographic and clinical profiles were recorded on computer files and analyzed by standard software SPSS-10 and EpiInfo-6. Statistical significance was set at p<0.05.
RESULTS AND DISCUSSION
Clinical records Analysis allowed us to show that 95/156 (60.90%) women in
the study did not exceed the level of primary school and rarely used condoms
33/156 (21.15%). Table 1 shows that 39.10% of women had a
higher level of study. 77.27% of employed women were using prophylactic against
67.52% among housewives and 58.82% among traders.
|| Level of study, occupation and condoms use by diagnosed women
|| Carriage of Mycoplasma and HPV according to the age groups
||Other genital infectious microorganisms isolated from diagnosed
||HPV genotypes among the most experienced the women of the
We detected the presence of Mycoplasma into 25.64% [19.15 to 33.36] women of
the study. There was statistically significant difference between the presence
of Mycoplasma and the age groups of women (p<0.001). According to Table
2 women below 30 years old had a low proportion in our sample (50/156 =
The rate of HPV infection in this group compared to the infected population was 31.87% (29/91). The HPV test showed that 58.33% (91/156) [50.17 to 66.08] of women were infected.
Despite Mycoplasma and HPV, women were also diagnosed for the presence of genital infectious microorganisms such as Candida albicans, Escherichia coli, Treponema pallidum, Streptococcus agalactiae, Staphylococcus aureus (Table 3). According to our results there was neither Trichomonas vaginalis, Staphylococcus epidermidis nor Klebsiella oxytoca.
The present study revealed that the following HPV strains HPV-50'S (26.77%); HPV-18 (23.62%); HPV-30'S (20.47%) and HPV-16 (6.30%) were the most common in the diagnosed women. The study also pointed out co-infections such as HPV-30 strains with HPV-50'S (3.55%); HPV-18 with HPV-30S (5.67%) (Table 4).
Among HPV infected-women, 3.30% were co-infected with Mycoplasma and Candida; while, this co infection rate raised to 6.15% among HPV negative women (Table 5).
This research revealed that HIV-positive women suffered from many gynecological
infections. In our study, among the 156 HIV-positive, 117 (75.00%) were infected
with at least one of the following germs: HPV, Mycoplasma and C. albicans.
While, Minkoff et al. (1999) showed in their
investigation that 46.9% of HIV-infected women had at least one gynecological
problem that required medical care.
Thus, candidiasis are an important cause of morbidity in immunocompromised
patients such as HIV infected-patients (Machet et al.,
2006). Other germs such as E. coli, T. pallidum, etc., which
are often found in cases of vaginosis, have been identified in our study with
relatively low prevalence rates. However, we isolated neither Trichomonas
vaginalis, Klebsiella oxytoca nor Staphylococcus epidermidis,
which are often responsible for vaginal infections. Among these women Mycoplasma
prevalence was 25.64%, similarly (26.7%) by Djigma et al. (2008) obtained
26.7% in Ouagadougou and Mamadou et al. (2006)
30.9% in Niamey among sex workers. However, the carrier rate in our sample is
higher than that reported in Ivory Coast (20%) (Faye-Kette
et al., 2000) and in Bangui (92,0%) (Rapelanoro
et al., 1998).
|| Co-infection rate of Mycoplasma with C. albicans
among women HPV positive and negative
The probable reason of the low prevalence of mycoplasmas in the sample is the
fact that our diagnosed women are under consistent follow up; since they are
HIV infected subjects, many attention is paid to prevent opportunistic infections.
Indeed, although no statistically significant difference existed, the HAART
and antibiotics taking seems to have an effect on Mycoplasma carriage among
these HIV-positive women (p>0.050). We observed in our study a high prevalence
of C. albicans (20.51%) (Table 3). A low prevalence
(14.2%) was previously found in Burkina Faso (Meda et
al., 1995; Djigma et al., 2008). Candida albicans is the
main yeast species that occurs in 80% of the population. The infected subjects
often develop no particular symptom, indeed the microorganism behaves as a commensal
saprophyte. However, it may cause fungal infections (candidiasis) mainly mucosal
digestive and gynecological in certain conditions.
The study on human Papillomavirus allowed us to determine the prevalence of
HPV among HIV-positive women (58.33%). This rate is comparable to that reported
by Ouermi (2009) (52.66%) in Ouagadougou. However, our
prevalence is lower compared to other studies carried out in Burkina Faso among
HIV-positive women, in Brazil, San Paolo (Goncalves et
al., 2008), in Rwanda (Singh et al., 2009)
and in South Africa in Johannesburg (Firnhaber et al.,
2009). Our results indicated that 91/156 women were predisposed to develop
cervix cancer. Among the HPV positive 95.51% had a high risk for developing
cervix cancer. According to present results, HPV-50, 18, 30'S and 16 strains
are most experienced in the sample.
An increased prevalence of infection with human Papillomavirus (HPV) and precancerous
lesions and cancer was observed among women infected with HIV. (Larsen,
1995; Monsonego, 2007; Louie et
al., 2008). Indeed, HPV clearly play an important role in the pathogenesis
of many neoplastic processes, some being considered low-risk oncogenic (HPV6,
HPV11) also called LR-HPV (for Low Risk HPV) and others as responsible benign
tumors (warts), and others as being at high risk oncogenic (HPV16, 18, 31, 45)
named HR-HPV (for High Risk HPV) implicated in various cancers (head and neck,
cervix). Although HPV infection have a key role in the occurrence of a malignant
process, other factors seem necessary, as immunity (Heard,
1999; Spano et al., 2005).
Indeed, the natural history of HPV infection is impaired in individuals infected
with HIV and there is an increased risk of persistent HPV infections in this
population. The HIV-positive women in particular those who are severely immunodeficients
are five times more likely to contract HPV than HIV-negative women (Smits
et al., 2005; Dames et al., 2009).
We isolated any viral and bacterial co-infections in our sample. However, we did not found statistically significant difference between the calculated and observed frequencies neither among HPV positive women co-infected with Candida and Mycoplasma (p = 1) or those HPV negative co-infected with Candida and Mycoplasma (p = 0.72) (Table 5).
This preliminary research showed results that have impact on public health and could be a springboard for a testing campaign and for epidemiological surveillance of Mycoplasma and different types of HPV strains circulating in Burkina Faso. The evidence of the high prevalence of papillomaviruses infection in our country, leads us to propose the introduction of specific vaccines against HPV strains for adolescents.
The Authors are grateful to the staff of Saint Camille laboratory and CERBA, Ouagadougou. In particular, the skilful and patient collaboration of Mr Oscar Zoungrana, Hermann Somda and Mrs Fatoumata Nana. They are deeply grateful to the Italian Episcopal Conference (C.E.I) and to the RADIM House, Roma, Italy and Doctor Luigi SPARANO for the financial support.
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