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The World Health Organization (WHO) global strategy to eliminate cervical cancer (CxCa) could result ingt;62 million lives saved by 2120 if strategy targets are reached and maintained: 90% of adolescent girls receiving prophylactic human papillomavirus (HPV) vaccine, 70% of women receiving twice-lifetime cervical cancer screening, and 90% of cervical pre-cancer lesions and invasive CxCa treated. However, the cost and complexity of CxCa screening and treatment approaches has hampered scale-up, particularly in low- and middle-income countries (LMICs), and new approaches are needed. Therapeutic HPV vaccines (TxV), which could clear persistent high-risk HPV infection and/or cause regression of pre-cancerous lesions, are in early clinical development and might offer one such approach. During October 2021 to March 2022, WHO, in collaboration with the Bill and Melinda Gates Foundation, convened a series of global expert consultations to lay the groundwork for understanding the potential value of TxV in the context of current CxCa prevention efforts and for defining WHO preferred product characteristics (PPCs) for TxV. WHO PPCs describe preferences for vaccine attributes that would help optimize vaccine value and use in meeting the global public health need. This paper reports on the main discussion points and findings from the expert consultations. Experts identified several ways in which TxV might address challenges in current CxCa prevention programmes, but emphasized that the potential value of TxV will depend on their degree of efficacy and how quickly they can be developed and implemented relative to ongoing scale-up of existing interventions. Consultation participants also discussed potential use-cases for TxV, important PPC considerations (e.g., vaccine indications, target populations, and delivery strategies), and critical modelling needs for predicting TxV impact and cost-effectiveness.

Background Biological and epidemiological evidence suggest that herpes simplex virus type 2 (HSV-2) elevates HIV acquisition and transmission risks. We improved previous estimates of the contribution of HSV-2 to HIV infections by using a dynamic transmission model. Setting World Health Organization regions. Methods We developed a mathematical model of HSV-2/HIV transmission among 15- to 49-year-old heterosexual, non-drug-injecting populations, calibrated using region-specific demographic and HSV-2/HIV epidemiological data. We derived global and regional estimates of the contribution of HSV-2 to HIV infection over 10 years [the transmission population-attributable fraction (tPAF)] under 3 additive scenarios, assuming: (1) HSV-2 increases only HIV acquisition risk (conservative); (2) HSV-2 also increases HIV transmission risk (liberal); and (3) HIV or antiretroviral therapy (ART) also modifies HSV-2 transmission risk, and HSV-2 decreases ART effect on HIV transmission risk (fully liberal). Results Under the conservative scenario, the predicted tPAF was 37.3% (95% uncertainty interval: 33.4%-43.2%), and an estimated 5.6 (4.5-7.0) million incident heterosexual HIV infections were due to HSV-2 globally over 2009-2018. The contribution of HSV-2 to HIV infections was largest for the African region [tPAF = 42.6% (38.0%-51.2%)] and lowest for the European region [tPAF = 11.2% (7.9%-13.8%)]. The tPAF was higher among female sex workers, their clients, and older populations, reflecting their higher HSV-2 prevalence. The tPAF was approximately 50% and 1.3- to 2.4-fold higher for the liberal or fully liberal scenario than the conservative scenario across regions. Conclusion HSV-2 may have contributed to at least 37% of incident HIV infections in the past decade worldwide, and even more in Africa, and may continue to do so despite increased ART access unless future improved HSV-2 control measures, such as vaccines, become available.

Background Numerous vaccines have been evaluated and approved for coronavirus disease 2019 (COVID-19). Since pregnant persons have been excluded from most clinical trials of COVID-19 vaccines, sufficient data regarding safety of these vaccines for the pregnant persons and their fetus have rarely been available at the time of product licensure. However, as COVID-19 vaccines have been deployed, data on the safety, efficacy or effectiveness, reactogenicity, and immunogenicity of COVID-19 vaccines for pregnant persons and neonates are becoming increasingly available. A living systematic review (LSR) of the safety and effectiveness of COVID-19 vaccines for pregnant persons and newborns could provide information necessary to help guide vaccine policy decisions. Methods We aim to conduct a LSR based on biweekly searches of medical databases (e.g., MEDLINE, EMBASE, CENTRAL) and clinical trial registries to systematically identify relevant studies of COVID-19 vaccines for pregnant persons. Pairs of reviewers will independently select, extract data, and conduct risk of bias assessments. We will include randomized clinical trials, quasi-experimental studies, cohort, case-control, cross-sectional studies, and case reports. Primary outcomes will be the safety (i.e., impacts on obstetric and neonatal outcomes), efficacy or effectiveness of COVID-19 vaccines in pregnant persons. Secondary outcomes will be immunogenicity and reactogenicity. We will conduct paired meta-analyses, including pre-specified subgroup and sensitivity analyses, and will use the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to evaluate the certainty of evidence. Conclusion This will be the first living systematic review (LSR) and meta-analysis assessing the safety, reactogenicity, immunogenicity, and effectiveness of COVID-19 vaccines for pregnant persons. An online interactive dashboard for data visualization using Microsoft Power BI will be developed to regularly update and disseminate the latest findings (an in-progress version is available at https://safeinpregnancy.org/lsr/). In addition, the findings will be disseminated through publications and presentations.

Summary Background HIV enhances human papillomavirus (HPV)-induced carcinogenesis. However, the contribution of HIV to cervical cancer burden at a population level has not been quantified. We aimed to investigate cervical cancer risk among women living with HIV and to estimate the global cervical cancer burden associated with HIV. Methods We did a systematic literature search and meta-analysis of five databases (PubMed, Embase, Global Health [ CABI.org ], Web of Science, and Global Index Medicus) to identify studies analysing the association between HIV infection and cervical cancer. We estimated the pooled risk of cervical cancer among women living with HIV across four continents (Africa, Asia, Europe, and North America). The risk ratio (RR) was combined with country-specific UNAIDS estimates of HIV prevalence and GLOBOCAN 2018 estimates of cervical cancer to calculate the proportion of women living with HIV among women with cervical cancer and population attributable fractions and age-standardised incidence rates (ASIRs) of HIV-attributable cervical cancer. Findings 24 studies met our inclusion criteria, which included 236 127 women living with HIV. The pooled risk of cervical cancer was increased in women living with HIV (RR 6·07, 95% CI 4·40–8·37). Globally, 5·8% (95% CI 4·6–7·3) of new cervical cancer cases in 2018 (33 000 new cases, 95% CI 26 000–42 000) were diagnosed in women living with HIV and 4·9% (95% CI 3·6–6·4) were attributable to HIV infection (28 000 new cases, 20 000–36 000). The most affected regions were southern Africa and eastern Africa. In southern Africa, 63·8% (95% CI 58·9–68·1) of women with cervical cancer (9200 new cases, 95% CI 8500–9800) were living with HIV, as were 27·4% (23·7–31·7) of women in eastern Africa (14 000 new cases, 12 000–17 000). ASIRs of HIV-attributable cervical cancer were more than 20 per 100 000 in six countries, all in southern Africa and eastern Africa. Interpretation Women living with HIV have a significantly increased risk of cervical cancer. HPV vaccination and cervical cancer screening for women living with HIV are especially important for countries in southern Africa and eastern Africa, where a substantial HIV-attributable cervical cancer burden has added to the existing cervical cancer burden. Funding WHO, US Agency for International Development, and US President's Emergency Plan for AIDS Relief.

To generate global and regional estimates for the prevalence and incidence of herpes simplex virus (HSV) type 1 and type 2 infection for 2016.To obtain data, we undertook a systematic review to identify studies up to August 2018. Adjustments were made to account for HSV test sensitivity and specificity. For each World Health Organization (WHO) region, we applied a constant incidence model to pooled prevalence by age and sex to estimate the prevalence and incidence of HSV types 1 and 2 infections. For HSV type 1, we apportioned infection by anatomical site using pooled estimates of the proportions that were oral and genital.In 2016, an estimated 491.5 million people (95% uncertainty interval, UI: 430.4 million-610.6 million) were living with HSV type 2 infection, equivalent to 13.2% of the world's population aged 15-49 years. An estimated 3752.0 million people (95% UI: 3555.5 million-3854.6 million) had HSV type 1 infection at any site, equivalent to a global prevalence of 66.6% in 0-49-year-olds. Differing patterns were observed by age, sex and geographical region, with HSV type 2 prevalence being highest among women and in the WHO African Region.An estimated half a billion people had genital infection with HSV type 2 or type 1, and several billion had oral HSV type 1 infection. Millions of people may also be at higher risk of acquiring human immunodeficiency virus (HIV), particularly women in the WHO African Region who have the highest HSV type 2 prevalence and exposure to HIV.Estimer la prévalence et l'incidence, au niveau régional et mondial, des infections au virus Herpes simplex (HSV) de type 1 et de type 2 en 2016.Pour nous procurer les données nécessaires, nous avons entrepris une revue systématique afin d'identifier des études publiées en août 2018 au plus tard. Des ajustements ont été effectués pour tenir compte de la sensibilité et de la spécificité du dépistage HSV. Pour chaque région définie par l'Organisation mondiale de la Santé (OMS), nous avons appliqué un modèle d'incidence constante par groupe de prévalence en fonction de l'âge et du sexe. Notre but était d'estimer la prévalence et l'incidence des infections à HSV de type 1 et 2. Pour le HSV de type 1, nous avons réparti les infections selon le site anatomique, en utilisant des estimations groupées de la proportion d'atteintes orales et génitales.En 2016, environ 491,5 millions de personnes (intervalle d'incertitude de 95%: 430,4 millions–610,6 millions) vivaient avec une infection à HSV de type 2, l'équivalent de 13,2 % de la population mondiale entre 15 et 49 ans. Nous estimons que 3752,0 millions de personnes (intervalle d'incertitude de 95%: 3555,5 millions–3854,6 millions) souffraient d'une infection à HSV de type 1 à un site quelconque, ce qui représente une prévalence globale de 66,6% chez les 0–49 ans. Différentes tendances ont été constatées en fonction de l'âge, du sexe et de la zone géographique, le plus fort taux de prévalence de HSV de type 2 étant observé chez les femmes de la région Afrique de l'OMS.Près d'un demi-milliard de personnes présentaient une infection génitale à HSV de type 2 ou type 1, et plusieurs milliards avaient une infection orale à HSV de type 1. Des millions de personnes pourraient également être plus susceptibles de contracter le virus de l'immunodéficience humaine (VIH), en particulier les femmes de la région Afrique de l'OMS qui possèdent la plus grande prévalence de HSV de type 2 et sont davantage exposées au VIH.Calcular las estimaciones mundiales y regionales de la prevalencia y la incidencia de la infección por el virus del herpes simple (VHS) tipo 1 y tipo 2 para 2016.Se realizó una revisión sistemática para identificar los estudios hasta agosto de 2018 con el fin de obtener datos. Se hicieron ajustes para tener en cuenta la sensibilidad y la especificidad de la prueba de VHS. Se aplicó un modelo de incidencia constante para cada región de la Organización Mundial de la Salud (OMS) con el fin de agrupar la prevalencia por edad y sexo para estimar la prevalencia y la incidencia de las infecciones por VHS de los tipos 1 y 2. Para el VHS tipo 1, se repartió la infección por sitio anatómico utilizando estimaciones agrupadas de los porcentajes que eran orales y genitales.En 2016, se estima que 491,5 millones de personas (95 % de intervalo de incertidumbre, UI: 430,4 millones a 610,6 millones) vivían con la infección por el VHS tipo 2, equivalente al 13,2 % de la población mundial de 15 a 49 años. Se estima que 3752,0 millones de personas (95 % UI: 3555,5 millones a 3854,6 millones) tenían la infección por VHS tipo 1 sin importar el lugar, lo que equivale a una prevalencia mundial del 66,6 % en las personas de 0 a 49 años. Se observaron patrones diferentes según la edad, el sexo y la región geográfica, siendo la mayor prevalencia del VHS tipo 2 entre las mujeres y en la región de África de la OMS.Se estima que 500 millones de personas tienen una infección genital con VHS tipo 2 o tipo 1, y varios miles de millones tienen una infección oral de VHS tipo 1. Millones de personas también pueden correr un mayor riesgo de contraer el virus de la inmunodeficiencia humana (VIH), en particular las mujeres de la Región de África de la OMS que tienen la mayor prevalencia del VHS tipo 2 y la mayor exposición al VIH.الغرض وضع تقديرات للانتشار والإصابة العالمية والإقليمية بعدوى فيروس الهربس البسيط (HSV)، النوعين الأول والثاني في عام 2016. الطريقة للحصول على بيانات، قمنا بإجراء مراجعة لتحديد الدراسات حتى أغسطس/آب 2018. كما تم إجراء تعديلات لتناسب حساسية ومدى خصوصية اختبار فيروس HSV. لكل منطقة من مناطق منظمة الصحة العالمية (WHO)، قمنا بتطبيق نموذج حدوث ثابت على حالات الانتشار المصنفة حسب العمر والجنس، وذلك لتقدير انتشار وحدوث العدوى بفيروس HSV من النوعين الأول والثاني. بالنسبة للنوع الأول من فيروس HSV، قمنا بتقسيم العدوى إلى نسب حسب الموقع التشريحي، باستخدام تقديرات مجمعة للنسب التي كانت عن طريق الفم أو الأعضاء التناسلية. النتائج في علم 2016، كان ما يقدر بـ 491.5 مليون شخص (فاصل عدم الثقة 95%: 430.4 مليون إلى 610.6 مليون) يعيشون وهم مصابون بعدوي فيروس HSV من النوع الثاني، أي ما يعادل 13.2% من سكان العالم الذين تتراوح أعمارهم بين 15 و49 عاماً. وما يقدر بـ 3752 مليون شخص (فاصل عدم ثقة 95%: 3555.5 مليون إلى 610.6 مليون) كان لديهم عدوي فيروس HSV من النوع الأول في أي موقع، أي ما يعادل انتشار عالمي بنسبة 66.6% من الأشخاص الذين تتراوح أعمارهم من سن الولادة إلى 49 عاماً. وتمت ملاحظة أنماط متباينة حسب العمر والجنس والمنطقة الجغرافية، مع وجود أعلى انتشار لفيروس HSV من النوع الثاني بين النساء، وفي المنطقة الأفريقية التابعة لمنظمة الصحة العالمية (WHO). الاستنتاج تم تقدير أن قرابة نصف مليار شخص كانوا مصابين بعدوى فيروس HSV من النوع الثاني أو الأول في المنطقة التناسلية، مع إصابة عدة مليارات من الأشخاص بعدوى فيروس HSV من النوع الأول عن طريق الفم. قد يكون الملايين من الأشخاص أيضاً أكثر عرضة لخطر الإصابة بفيروس نقص المناعة البشرية (HIV)، وخاصة النساء في المنطقة الأفريقية التابعة لمنظمة الصحة العالمية (WHO)، والذين لديهم أعلى معدل لانتشار فيروس HSV من النوع الثاني، والتعرض للإصابة بفيروس HIV.旨在估计 2016 年全球和区域范围内感染单纯疱疹病毒 (HSV) 1 型和 2 型的患病率和发病率。.为了收集数据，我们选取截至 2018 年 8 月的研究进行系统性回顾。对单纯疱疹病毒 (HSV) 检测的敏感性和特异性进行了适当调整。对于世界卫生组织 (WHO) 的每个地区，我们利用恒定发病率模型，按年龄和性别混合患病率，以估计感染单纯疱疹病毒 1 型和 2 型的患病率和发病率。对于单纯疱疹病毒 1 型，我们使用口腔和生殖器比例的混合估计数，按解剖部位来分配感染。.2016 年，估计有 4.915 亿人（95% 不确定区间，UI：4.304 亿-6.106 亿）人感染单纯疱疹病毒 2 型，占世界 15-49 岁人口的 13.2%。估计有 37.52 亿人（95% UI：35.555 亿-38.546 亿）在世界各地感染单纯疱疹病毒 1 型，相当于全球 66.6% 的 0-49 岁人群中的患病率。按年龄、性别和地理区域观察到不同的模式，其中单纯疱疹病毒 2 型患病率在妇女和世卫组织非洲地区最高。.据估计，5 亿人患有单纯疱疹病毒 2 型或 1 型生殖器感染，另外有几十亿人患有单纯疱疹病毒 1 型口腔感染。数百万人还可能有更高风险感染人类免疫缺陷病毒 (HIV)，尤其是世卫组织非洲地区的妇女，她们的单纯疱疹病毒 2 型患病率和接触人类免疫缺陷病毒 (HIV) 的可能性最高。.Оценка глобальных и региональных показателей распространенности и заболеваемости вирусом простого герпеса (HSV) 1-го и 2-го типов по состоянию на 2016 год.Для получения данных был проведен систематический обзор и выявлены соответствующие исследования вплоть до августа 2018 года. Данные были скорректированы с учетом чувствительности и специфики тестов на HSV. Для каждого из регионов по классификации Всемирной организации здравоохранения (ВОЗ) авторы применили модель постоянной заболеваемости в отношении общей распространенности по полу и возрасту для оценки распространенности и заболеваемости HSV 1-го и 2-го типов. Для HSV 1-го типа авторы разделили инфицированных по анатомическому участку с использованием обобщенных оценок пропорций орального и генитального герпеса.По состоянию на 2016 год оценочное количество инфицированных HSV 2-го типа составило 491,5 млн (95%-й интервал неопределенности, ИН: 430,4–610,6 млн), что составляет 13,2% от мировой популяции лиц в возрасте 15–49 лет. Примерно 3752,0 миллиона человек (95%-й ИН: 3555,5–3854,6 млн) были инфицированы HSV 1-го типа в каком-либо из участков организма, что эквивалентно коэффициенту глобальной распространенности, равному 66,6% среди населения в возрасте от 0 до 49 лет. Наблюдались различия в распределении заболеваемости по возрастам, полу и географическим регионам, при этом HSV 2-го типа преобладал среди женщин и в Африканском регионе ВОЗ.Примерно полмиллиарда людей имеет генитальную инфекцию HSV 2-го или 1-го типа, а оральную инфекцию HSV 1-го типа имеет несколько миллиардов человек. Миллионы людей также могут быть подвержены более высокому риску заражения вирусом иммунодефицита человека (ВИЧ), в частности женщины из Африканского региона ВОЗ, среди которых наблюдается самый высокий уровень распространенности HSV 2-го типа и которые сильнее всего подвергаются риску ВИЧ-инфекции.

ObjectivesLittle is known about the economic burden of herpes simplex virus (HSV) across countries. This article aims to summarise existing evidence on estimates of costs and healthcare resource utilisation associated with genital and neonatal HSV infection.DesignSystematic literature review.Data sourcesSeven databases were searched from inception to 31 August 2020. A focused search was performed to supplement the results.Eligibility criteriaStudies which reported either healthcare resource utilisation or costs associated with HSV-related healthcare, including screening, diagnosis and treatment of genital HSV infection and neonatal herpes prevention and treatment.Data extraction and synthesisTwo independent reviewers extracted data and assessed the risk of bias using the Larg and Moss’s checklist. All data were summarised narratively.ResultsOut of 11 443 articles, 38 were included. Most studies (35/38, 94.6%) were conducted in high-income countries, primarily the United States, and were more often related to the prevention or management of neonatal herpes (n=21) than HSV genital ulcer disease (n=17). Most analyses were conducted before 2010. There was substantial heterogeneity in the reporting of HSV-related healthcare resource utilisation, with 74%–93% individuals who sought care for HSV, 11.6%–68.4% individuals who received care, while neonates with herpes required a median of 6–34 hospitalisation days. The costs reported were similarly heterogeneous, with wide variation in methodology, assumptions and outcome measures between studies. Cost for screening ranged from US$7–100, treatment ranged from US$0.53–35 for an episodic therapy, US$240–2580 yearly for suppressive therapy, while hospitalisation for neonatal care ranged from US$5321–32 683.ConclusionsA paucity of evidence exists on healthcare resource utilisation and costs associated with HSV infection, especially among low-income and middle-income countries. Future research is needed on costs and healthcare utilisation patterns to improve overall understanding of the global economic burden of HSV.

IntroductionDespite a growing body of research on the risks of SARS-CoV-2 infection during pregnancy, there is continued controversy given heterogeneity in the quality and design of published studies.MethodsWe screened ongoing studies in our sequential, prospective meta-analysis. We pooled individual participant data to estimate the absolute and relative risk (RR) of adverse outcomes among pregnant women with SARS-CoV-2 infection, compared with confirmed negative pregnancies. We evaluated the risk of bias using a modified Newcastle-Ottawa Scale.ResultsWe screened 137 studies and included 12 studies in 12 countries involving 13 136 pregnant women.Pregnant women with SARS-CoV-2 infection—as compared with uninfected pregnant women—were at significantly increased risk of maternal mortality (10 studies; n=1490; RR 7.68, 95% CI 1.70 to 34.61); admission to intensive care unit (8 studies; n=6660; RR 3.81, 95% CI 2.03 to 7.17); receiving mechanical ventilation (7 studies; n=4887; RR 15.23, 95% CI 4.32 to 53.71); receiving any critical care (7 studies; n=4735; RR 5.48, 95% CI 2.57 to 11.72); and being diagnosed with pneumonia (6 studies; n=4573; RR 23.46, 95% CI 3.03 to 181.39) and thromboembolic disease (8 studies; n=5146; RR 5.50, 95% CI 1.12 to 27.12).Neonates born to women with SARS-CoV-2 infection were more likely to be admitted to a neonatal care unit after birth (7 studies; n=7637; RR 1.86, 95% CI 1.12 to 3.08); be born preterm (7 studies; n=6233; RR 1.71, 95% CI 1.28 to 2.29) or moderately preterm (7 studies; n=6071; RR 2.92, 95% CI 1.88 to 4.54); and to be born low birth weight (12 studies; n=11 930; RR 1.19, 95% CI 1.02 to 1.40). Infection was not linked to stillbirth. Studies were generally at low or moderate risk of bias.ConclusionsThis analysis indicates that SARS-CoV-2 infection at any time during pregnancy increases the risk of maternal death, severe maternal morbidities and neonatal morbidity, but not stillbirth or intrauterine growth restriction. As more data become available, we will update these findings per the published protocol.

Genital infection with Chlamydia trachomatis, a gram-negative obligate intracellular bacterium, is the most common bacterial sexually transmitted infection globally. Ascension of chlamydial infection to the female upper genital tract can cause acute pelvic inflammatory disease, tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. Shortcomings of current chlamydia control strategies, especially for low- and middle-income countries, highlight the need for an effective vaccine. Evidence from animal models, human epidemiological studies, and early trachoma vaccine trials suggest that a C. trachomatis vaccine is feasible. Vaccine development for genital chlamydial infection has been in the preclinical phase of testing for many years, but the first Phase I trials of chlamydial vaccine candidates are underway, and scientific advances hold promise for additional candidates to enter clinical evaluation in the coming years. We describe the clinical and public health need for a C. trachomatis vaccine, provide an overview of Chlamydia vaccine development efforts, and summarize current vaccine candidates in the development pipeline.

Background: There is a significant global burden of herpes simplex virus (HSV) related genital ulcer disease yet little is known about its impact on quality of life. This systematic review aimed to identify studies that quantitatively evaluated the effect of genital herpes on various aspects of health-related quality of life. Methods: Six databases were searched (MEDLINE, EMBASE, NHS Economic Evaluation Database, Health Technology Assessment, Database of Abstracts of Reviews of Effects, Web of Science Core Collection) for primary quality of life and economic evaluations of genital herpes from January 1, 2000 to January 7, 2021. Qualitative studies or those without primary data were excluded. Two authors independently extracted data from the publications. The study’s registration number with PROSPERO was CRD42021239410. Findings: We identified 26 relevant publications: 19 presented primary quality of life data, and seven were economic evaluations. The primary studies presented a range of condition-specific tools for describing the quality of life in individuals with genital herpes, but only one study used a direct valuation that could be used to generate utility weights. All economic evaluations of HSV infection were from high-income country settings. Most (6 of 7) focused on neonatal HSV infection with utilities adopted from studies prior to 2000. Interpretation: The extant literature on genital herpes-related quality of life is limited and requires updating. We recommend future studies be conducted in geographic- and population- diverse settings, and use preference-based condition-specific or generic-instruments to better inform economic modelling. Registration Details: The study’s registration number with PROSPERO was CRD42021239410. Funding Information: This review was funded by the World Health Organization through a grant from the US National Institute of Allergy and Infectious Diseases, National Institutes of Health. Declaration of Interests: We declare no competing interests.

Purpose: We aimed to review available data on the incidence of herpes simplex virus (HSV) keratitis and other HSV ocular disease and to estimate the global burden of HSV ocular disease. Methods: We searched Medline and Embase databases to October 2020 for studies reporting on the incidence of HSV ocular disease. Study quality was evaluated using a four-point checklist. Pooled estimates were applied to 2016 population data to estimate global HSV ocular disease burden. Numbers with uniocular vision impairment (any visual acuity 2 = 97.7%) per 100,000 person-years. The majority had epithelial keratitis (pooled incidence 16.1 per 100,000; 95% CI 11.6–22.3; N = 3; I2 = 92.6%). Available studies were few and limited to the USA and Europe. Data were even more limited for HSV uveitis and retinitis, although these conditions may collectively contribute a further >0.1 million cases. Based on global incidence, some 230,000 people may have newly acquired uniocular vision impairment associated with HSV keratitis in 2016. Conclusion: Over 1.8 million people may have herpetic eye disease annually. Preventing HSV infection could therefore have an important impact on eye health. Herpetic eye disease burden is likely to have been underestimated, as many settings outside of the USA and Europe have higher HSV-1 prevalence and poorer access to treatment.

Renewed interest in developing vaccines against Neisseria gonorrhoeae has been sparked by the increasing threat of gonococcal antimicrobial resistance (AMR) and growing optimism that gonococcal vaccines are biologically feasible. Evidence suggests serogroup B Neisseria meningitidis vaccines might provide some cross-protection against N. gonorrhoeae, and new gonococcal vaccine candidates based on several approaches are currently in preclinical development. To further stimulate investment and accelerate development of gonococcal vaccines, greater understanding is needed regarding the overall value that gonococcal vaccines might have in addressing public health and societal goals in low-, middle-, and high-income country contexts and how future gonococcal vaccines might be accepted and used, if available. In January 2019, the World Health Organization (WHO) convened a multidisciplinary international group of experts to lay the groundwork for understanding the potential health, economic, and societal value of gonococcal vaccines and their likely acceptance and use, and for developing gonococcal vaccine preferred product characteristics (PPCs). WHO PPCs describe preferences for vaccine attributes that would help optimize vaccine value and use in meeting the global public health need. This paper describes the main discussion points and conclusions from the January 2019 meeting of experts. Participants emphasized the need for vaccines to control N. gonorrhoeae infections with the ultimate goals of preventing adverse sexual and reproductive health outcomes (e.g., infertility) and reducing the impact of gonococcal AMR. Meeting participants also discussed important PPC considerations (e.g., vaccine indications, target populations, and potential immunization strategies) and highlighted crucial research and data needs for guiding the value assessment and PPCs for gonococcal vaccines and advancing gonococcal vaccine development.

Background: The contribution of HIV infection to cervical cancer burden at a population-level has not been systematically quantified. We aimed to investigate cervical cancer risk among women living with HIV (WLHIV), and to estimate the global cervical cancer burden associated with HIV. Methods: We conducted a systematic literature search and a meta-analysis to estimate the pooled risk ratio (RR) of cervical cancer among WLHIV. The RR was combined with country-specific UNAIDS estimates of HIV prevalence and GLOBOCAN 2018 estimates of cervical cancer, to calculate the proportion of WLHIV among women with cervical cancer, as well as population attributable fractions and age-standardized incidence rates (ASIR) of HIV-attributable cervical cancer. Findings: In all, 24 studies met our inclusion criteria including a total of 236 127 WLHIV, providing a pooled cervical cancer RR of 6·07 (95% CI, 4·40–8·37). Globally, 5·8% (33 000) of all cervical cancers in 2018 were diagnosed in WLHIV and 4·9% (28 000 cases) were attributable to HIV infection. The most affected regions were eastern and southern Africa, and western and central Africa where 35·5% (24 000) and 10·0% (4 300) of cervical cancers were diagnosed among WLHIV, respectively. ASIRs of HIV-attributable cervical cancer were over 20 per 100 000 in 6 countries, all in eastern and southern Africa. Interpretation: WLHIV have a significantly elevated risk of cervical cancer. HPV vaccination and cervical cancer screening for WLHIV are particularly critical for sub-Saharan African countries where a substantial HIV-attributable cervical cancer burden has added to the existing cervical cancer burden. Funding: Support for this project was provided by the World Health Organization (WHO) through funding made possible by United States Agency for International Development (USAID) under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The contents in this article are the sole responsibility of the authors, and do not necessarily represent the decisions, policy or views of WHO, IARC, USAID, PEPFAR or the United States Government. Conflict of Interest: DS: Nothing to declare LFT: Nothing to declare KKL: Nothing to declare IB: Nothing to declare AIK: Nothing to declare ASVS: Nothing to declare DAM: Nothing to declare SLG: Nothing to declare SJK: Nothing to declare ASW: Nothing to declare RB: Nothing to declare GC: Nothing to declare NB: Nothing to declare SD: Nothing to declare

© 2018 Elsevier Ltd Genital Chlamydia trachomatis infection is the most commonly diagnosed sexually transmitted infection. Trachoma is caused by ocular infection with C trachomatis and is the leading infectious cause of blindness worldwide. New serological assays for C trachomatis could facilitate improved understanding of C trachomatis epidemiology and prevention. C trachomatis serology offers a means of investigating the incidence of chlamydia infection and might be developed as a biomarker of scarring sequelae, such as pelvic inflammatory disease. Therefore, serological assays have potential as epidemiological tools to quantify unmet need, inform service planning, evaluate interventions including screening and treatment, and to assess new vaccine candidates. However, questions about the performance characteristics and interpretation of C trachomatis serological assays remain, which must be addressed to advance development within this field. In this Personal View, we explore the available information about C trachomatis serology and propose several priority actions. These actions involve development of target product profiles to guide assay selection and assessment across multiple applications and populations, establishment of a serum bank to facilitate assay development and evaluation, and development of technical and statistical methods for assay evaluation and analysis of serological findings. The field of C trachomatis serology will benefit from collaboration across the public health community to align technological developments with their potential applications.

In 2014, the World Health Organization, the US National Institutes of Health, and global technical partners published a comprehensive roadmap for development of new vaccines against sexually transmitted infections (STIs). Since its publication, progress has been made in several roadmap activities: obtaining better epidemiologic data to establish the public health rationale for STI vaccines, modeling the theoretical impact of future vaccines, advancing basic science research, defining preferred product characteristics for first-generation vaccines, and encouraging investment in STI vaccine development. This article reviews these overarching roadmap activities, provides updates on research and development of individual vaccines against herpes simplex virus, Chlamydia trachomatis, Neisseria gonorrhoeae, and Treponema pallidum, and discusses important next steps to advance the global roadmap for STI vaccine development.

IntroductionHerpes simplex virus (HSV) infection can cause painful, recurrent genital ulcer disease (GUD), which can have a substantial impact on sexual and reproductive health. HSV-related GUD is most often due to HSV type 2 (HSV-2), but may also be due to genital HSV type 1 (HSV-1), which has less frequent recurrent episodes than HSV-2. The global burden of GUD has never been quantified. Here we present the first global and regional estimates of GUD due to HSV-1 and HSV-2 among women and men aged 15–49 years old.MethodsWe developed a natural history model reflecting the clinical course of GUD following HSV-2 and genital HSV-1 infection, informed by a literature search for data on model parameters. We considered both diagnosed and undiagnosed symptomatic infection. This model was then applied to existing infection estimates and population sizes for 2016. A sensitivity analysis was carried out varying the assumptions made.ResultsWe estimated that 187 million people aged 15–49 years had at least one episode of HSV-related GUD globally in 2016: 5.0% of the world’s population. Of these, 178 million (95% of those with HSV-related GUD) had HSV-2 compared with 9 million (5%) with HSV-1. GUD burden was highest in Africa, and approximately double in women compared with men. Altogether there were an estimated 8 billion person-days spent with HSV-related GUD globally in 2016, with 99% of days due to HSV-2. Taking into account parameter uncertainty, the percentage with at least one episode of HSV-related GUD ranged from 3.2% to 7.9% (120–296 million). However, the estimates were sensitive to the model assumptions.ConclusionOur study represents a first attempt to quantify the global burden of HSV-related GUD, which is large. New interventions such as HSV vaccines, antivirals or microbicides have the potential to improve the quality of life of millions of people worldwide.

Development of a vaccine against herpes simplex virus type 2 (HSV-2), a life-long sexually-transmitted infection (STI), would be a major step forward in improving global sexual and reproductive health. In this review, we identified published literature of dynamic mathematical models assessing the impact of either prophylactic or therapeutic HSV-2 vaccination at the population level. We compared each study's model structure and assumptions as well as predicted vaccination impact. We examined possible causes of heterogeneity across model predictions, key gaps, and the implications of these findings for future modelling efforts. Only eight modelling studies have assessed the potential public health impact of HSV-2 vaccination, with the majority focusing on impact of prophylactic vaccines. The studies showed that even an imperfect prophylactic HSV-2 vaccine could have an important public health impact on HSV-2 incidence, and could also impact HIV indirectly in high HIV prevalence settings. Therapeutic vaccines also may provide public health benefits, though they have been explored less extensively. However, there was substantial variation in predicted population-level impact for both types of vaccine, reflecting differences in assumptions between model scenarios. Importantly, many models did not account for heterogeneity in infection rates such as by age, sex and sexual activity. Future modelling work to inform decisions on HSV vaccine development and implementation should consider cost-effectiveness, account for additional HSV-2 sequelae such as neonatal transmission, and model greater heterogeneity in infection rates between individuals, more realistic vaccine deployment, and more thorough sensitivity and uncertainty analyses.

BACKGROUND: HIV and herpes simplex virus type 2 (HSV-2) infections cause a substantial global disease burden and are epidemiologically correlated. Two previous systematic reviews of the association between HSV-2 and HIV found evidence that HSV-2 infection increases the risk of HIV acquisition, but these reviews are now more than a decade old.METHODS: For this systematic review and meta-analysis, we searched PubMed, MEDLINE, and Embase (from Jan 1, 2003, to May 25, 2017) to identify studies investigating the risk of HIV acquisition after exposure to HSV-2 infection, either at baseline (prevalent HSV-2 infection) or during follow-up (incident HSV-2 infection). Studies were included if they were a cohort study, controlled trial, or case-control study (including case-control studies nested within a cohort study or clinical trial); if they assessed the effect of pre-existing HSV-2 infection on HIV acquisition; and if they determined the HSV-2 infection status of study participants with a type-specific assay. We calculated pooled random-effect estimates of the association between prevalent or incident HSV-2 infection and HIV seroconversion. We also extended previous investigations through detailed meta-regression and subgroup analyses. In particular, we investigated the effect of sex and risk group (general population vs higher-risk populations) on the relative risk (RR) of HIV acquisition after prevalent or incident HSV-2 infection. Higher-risk populations included female sex workers and their clients, men who have sex with men, serodiscordant couples, and attendees of sexually transmitted infection clinics.FINDINGS: We identified 57 longitudinal studies exploring the association between HSV-2 and HIV. HIV acquisition was almost tripled in the presence of prevalent HSV-2 infection among general populations (adjusted RR 2·7, 95% CI 2·2-3·4; number of estimates [Ne]=22) and was roughly doubled among higher-risk populations (1·7, 1·4-2·1; Ne=25). Incident HSV-2 infection in general populations was associated with the highest risk of acquisition of HIV (4·7, 2·2-10·1; Ne=6). Adjustment for confounders at the study level was often incomplete but did not significantly affect the results. We found moderate heterogeneity across study estimates, which was explained by risk group, world region, and HSV-2 exposure type (prevalent vs incident).INTERPRETATION: We found evidence that HSV-2 infection increases the risk of HIV acquisition. This finding has important implications for management of individuals diagnosed with HSV-2 infection, particularly for those who are newly infected. Interventions targeting HSV-2, such as new HSV vaccines, have the potential for additional benefit against HIV, which could be particularly powerful in regions with a high incidence of co-infection.FUNDING: World Health Organization.

Pelvic inflammatory disease can produce acute symptoms and result in infertility, ectopic pregnancy, and chronic pelvic pain. This review summarizes current approaches to diagnosis and treatment and the future prospects for better prevention strategies.

Introduction HIV and herpes simplex virus type 2 (HSV-2) infections cause a large burden of disease globally and are correlated epidemiologically through shared risk factors. There is also evidence for direct, biological interactions, with HSV-2 infection increasing HIV susceptibility (and vice versa). We update and expand on two previous systematic reviews of the association between HSV-2 infection and HIV acquisition published over a decade ago. Methods We conducted a systematic review and random-effects meta-analysis of 56 longitudinal studies of the association between HSV-2 infection and HIV acquisition. We calculated pooled effect sizes using DerSimonian-Laird inverse-variance methods for the association between existing (prevalent) HSV-2 infection and HIV seroconversion and the first-ever pooled effect sizes for new (incident) HSV-2 infection on HIV. We extended previous evaluations through detailed meta-regression and sub-group analyses. Results The risk of acquiring HIV infection was approximately doubled in the presence of prevalent HSV-2 infection, and higher among general populations (aRR=2.7; 95% CI 2.2–3.4, n=24) than higher-risk populations such as commercial sex workers and men who have sex with men (aRR=1.7; 95% CI 1.4–2.1, n=25). Incident HSV-2 infection was associated with the highest risk of acquiring HIV: up to aRR=4.7 (95%CI 2.2–10.1, n=6). Adjustment for confounders was often incomplete, but this did not meaningfully influence results in subgroup analysis. Substantial heterogeneity across study estimates was explained by risk group, timing of HSV-2 infection, and world region. Conclusion There is good evidence for a direct effect of HSV-2 infection on HIV acquisition risk. This has important implications for managing individuals diagnosed with genital herpes, given the greater risk of acquiring HIV, especially for those newly infected. Interventions targeted against HSV-2, such as new HSV vaccines, have the potential for an additional benefit against HIV, which could be substantial particularly in regions where co-infections are abundant.

Development of a safe and effective vaccine against herpes simplex virus type 2 (HSV-2) has the potential to limit the global burden of HSV-2 infection and disease, including genital ulcer disease and neonatal herpes, and is a global sexual and reproductive health priority. Another important potential benefit of an HSV-2 vaccine would be to decrease HIV infections, as HSV-2 increases the risk of HIV-1 acquisition several-fold. Acute and chronic HSV-2 infection creates ulcerations and draws dendritic cells and activated CD4+ T cells into genital mucosa. These cells are targets for HIV entry and replication. Prophylactic HSV-2 vaccines (to prevent infection) and therapeutic vaccines (to modify or treat existing infections) are currently under development. By preventing or modifying infection, an effective HSV-2 vaccine could limit HSV-associated genital mucosal inflammation and thus HIV risk. However, a vaccine might have competing effects on HIV risk depending on its mechanism of action and cell populations generated in the genital mucosa. In this article, we review biologic interactions between HSV-2 and HIV-1, consider HSV-2 vaccine development in the context of HIV risk, and discuss implications and research needs for future HSV vaccine development.

BACKGROUND: Neonatal herpes is a rare but potentially devastating condition with an estimated 60% fatality rate without treatment. Transmission usually occurs during delivery from mothers with herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2) genital infection. However, the global burden has never been quantified to our knowledge. We developed a novel methodology for burden estimation and present first WHO global and regional estimates of the annual number of neonatal herpes cases during 2010-15.METHODS: We applied previous estimates of HSV-1 and HSV-2 prevalence and incidence in women aged 15-49 years to 2010-15 birth rates to estimate infections during pregnancy. We then applied published risks of neonatal HSV transmission according to whether maternal infection was incident or prevalent with HSV-1 or HSV-2 to generate annual numbers of incident neonatal infections. We estimated the number of incident neonatal infections by maternal age, and we generated separate estimates for each WHO region, which were then summed to obtain global estimates of the number of neonatal herpes infections.FINDINGS: Globally the overall rate of neonatal herpes was estimated to be about ten cases per 100 000 livebirths, equivalent to a best-estimate of 14 000 cases annually roughly (4000 for HSV-1; 10 000 for HSV-2). We estimated that the most neonatal herpes cases occurred in Africa, due to high maternal HSV-2 infection and high birth rates. HSV-1 contributed more cases than HSV-2 in the Americas, Europe, and Western Pacific. High rates of genital HSV-1 infection and moderate HSV-2 prevalence meant the Americas had the highest overall rate. However, our estimates are highly sensitive to the core assumptions, and considerable uncertainty exists for many settings given sparse underlying data.INTERPRETATION: These neonatal herpes estimates mark the first attempt to quantify the global burden of this rare but serious condition. Better collection of primary data for neonatal herpes is crucially needed to reduce uncertainty and refine future estimates. These data are particularly important in resource-poor settings where we may have underestimated cases. Nevertheless, these first estimates suggest development of new HSV prevention measures such as vaccines could have additional benefits beyond reducing genital ulcer disease and HSV-associated HIV transmission, through prevention of neonatal herpes.FUNDING: World Health Organization.

1. IntroductionThe World Health Organization (WHO), recognizing the pro-found impact of sexually transmitted infections (STIs) on globalsexual and reproductive health and the need for new preventionstrategies, organized a technical consultation on STI vaccines inApril 2013.InternationalexpertsinSTIbasicscience,epidemiology,clinical care, program implementation and policy from multipleworld regions and countries gathered in Geneva, Switzerland toreview current progress toward the development of new STI vac-cines and discuss strategies for ensuring their future availability.The objectives of the consultation were:◦ Toreviewandevaluatetheneed,developmentstatus,andfutureprospects fornew,effectivevaccinesagainstSTIs,aswellaspolicyand programmatic implications for their introduction;◦ To identify the critical gaps in knowledge and current barriers tothe development of effective vaccines against the selected STIs;◦ Toproposepotentialsolutionsandlaytheframeworkforaglobalroadmap for the development and introduction of these STI vac-cines;◦ To engage researchers, donors and the private sector to continueresearch and development of STI vaccines for global use.Adhering tothegoalsofthe2012GlobalVaccineActionPlan[1],which callsforresearchtodevelopnewvaccinestoextendthelife-saving benefits of vaccination to all people, meeting participantsfocused on development of new, effective vaccines against the fol-lowing fiveSTIs:herpessimplexvirus(HSV),Chlamydiatrachomatis(chlamydia), Neisseria gonorrhoeae (gonorrhea), Trichomonas vagi-nalis (trichomoniasis)andTreponemapallidum(syphilis)infections,and the diseases they cause. As effective vaccines against hepatitis

An estimated 499 million curable sexually transmitted infections (STIs; gonorrhea, chlamydia, syphilis, and trichomoniasis) occurred globally in 2008. In addition, well over 500 million people are estimated to have a viral STI such as herpes simplex virus type 2 (HSV-2) or human papillomavirus (HPV) at any point in time. STIs result in a large global burden of sexual, reproductive, and maternal-child health consequences, including genital symptoms, pregnancy complications, cancer, infertility, and enhanced HIV transmission, as well as important psychosocial consequences and financial costs. STI control strategies based primarily on behavioral primary prevention and STI case management have had clear successes, but gains have not been universal. Current STI control is hampered or threatened by several behavioral, biological, and implementation challenges, including a large proportion of asymptomatic infections, lack of feasible diagnostic tests globally, antimicrobial resistance, repeat infections, and barriers to intervention access, availability, and scale-up. Vaccines against HPV and hepatitis B virus offer a new paradigm for STI control. Challenges to existing STI prevention efforts provide important reasons for working toward additional STI vaccines. We summarize the global epidemiology of STIs and STI-associated complications, examine challenges to existing STI prevention efforts, and discuss the need for new STI vaccines for future prevention efforts.

Purpose of review This review provides an update on the need, development status, and important next steps for advancing development of vaccines against sexually transmitted infections (STIs), including herpes simplex virus (HSV), Neisseria gonorrhoeae (gonorrhea), Chlamydia trachomatis (chlamydia), and Treponema pallidum (syphilis). Recent findings Global estimates suggest that more than a million STIs are acquired every day, and many new and emerging challenges to STI control highlight the critical need for development of new STI vaccines. Several therapeutic HSV-2 vaccine candidates are in Phase I/II clinical trials, and one subunit vaccine has shown sustained reductions in genital lesions and viral shedding, providing hope that an effective HSV vaccine is on the horizon. The first vaccine candidate for genital chlamydia infection has entered Phase I trials, and several more are in the pipeline. Use of novel technological approaches will likely see viable vaccine candidates for gonorrhea and syphilis in the future. The global STI vaccine roadmap outlines key activities to further advance STI vaccine development. Summary Major progress is being made in addressing the large global unmet need for STI vaccines. With continued collaboration and support, these critically important vaccines for global sexual and reproductive health can become a reality.

To generate estimates of the global prevalence and incidence of urogenital infection with chlamydia, gonorrhoea, trichomoniasis and syphilis in women and men, aged 15-49 years, in 2016.For chlamydia, gonorrhoea and trichomoniasis, we systematically searched for studies conducted between 2009 and 2016 reporting prevalence. We also consulted regional experts. To generate estimates, we used Bayesian meta-analysis. For syphilis, we aggregated the national estimates generated by using Spectrum-STI.For chlamydia, gonorrhoea and/or trichomoniasis, 130 studies were eligible. For syphilis, the Spectrum-STI database contained 978 data points for the same period. The 2016 global prevalence estimates in women were: chlamydia 3.8% (95% uncertainty interval, UI: 3.3-4.5); gonorrhoea 0.9% (95% UI: 0.7-1.1); trichomoniasis 5.3% (95% UI:4.0-7.2); and syphilis 0.5% (95% UI: 0.4-0.6). In men prevalence estimates were: chlamydia 2.7% (95% UI: 1.9-3.7); gonorrhoea 0.7% (95% UI: 0.5-1.1); trichomoniasis 0.6% (95% UI: 0.4-0.9); and syphilis 0.5% (95% UI: 0.4-0.6). Total estimated incident cases were 376.4 million: 127.2 million (95% UI: 95.1-165.9 million) chlamydia cases; 86.9 million (95% UI: 58.6-123.4 million) gonorrhoea cases; 156.0 million (95% UI: 103.4-231.2 million) trichomoniasis cases; and 6.3 million (95% UI: 5.5-7.1 million) syphilis cases.Global estimates of prevalence and incidence of these four curable sexually transmitted infections remain high. The study highlights the need to expand data collection efforts at country level and provides an initial baseline for monitoring progress of theProduire des estimations de la prévalence et de l'incidence mondiales des infections urogénitales dues à la chlamydiose, à la gonorrhée, à la trichomonase et à la syphilis chez les femmes et les hommes de 15 à 49 ans, en 2016.Pour la chlamydiose, la gonorrhée et la trichomonase, nous avons systématiquement recherché les études menées entre 2009 et 2016 qui s’intéressaient à la prévalence. Nous avons également consulté des experts régionaux. Pour produire des estimations, nous avons eu recours à une méta-analyse bayésienne. Pour la syphilis, nous avons regroupé les estimations nationales obtenues à l'aide de Spectrum-STI.Pour la chlamydiose, la gonorrhée et/ou la trichomonase, 130 études étaient éligibles. Pour la syphilis, la base de données de Spectrum-STI contenait 978 points de données pour la période considérée. Les estimations de la prévalence mondiale en 2016 chez les femmes étaient les suivantes: chlamydiose 3,8% (intervalle d'incertitude de 95%, II: 3,3–4,5); gonorrhée 0,9% (II 95%: 0,7–1,1); trichomonase 5,3% (II 95%: 4,0–7,2); et syphilis 0,5% (II 95%: 0,4–0,6). Chez les hommes, les estimations de la prévalence étaient les suivantes: chlamydiose 2,7% (II 95%: 1,9-3,7); gonorrhée 0,7% (II 95%: 0,5-1,1); trichomonase 0,6% (II 95%: 0,4-0,9); et syphilis 0,5% (II 95%: 0,4–0,6). L'incidence totale estimée était de 376,4 millions de cas: 127,2 millions (II 95%: 95,1–165,9 millions) de cas de chlamydiose; 86,9 millions (II 95%: 58,6-123,4 millions) de cas de gonorrhée; 156,0 millions (II 95%: 103,4-231,2 millions) de cas de trichomonase; et 6,3 millions (II 95%: 5,5–7,1 millions) de cas de syphilis.Les estimations mondiales de la prévalence et de l'incidence de ces quatre infections sexuellement transmissibles guérissables restent élevées. Cette étude souligne la nécessité d'amplifier les efforts de collecte de données au niveau des pays et offre un point de référence pour suivre la progression de laGenerar estimaciones de la prevalencia y la incidencia mundiales de la infección urogenital por clamidia, gonorrea, tricomoniasis y sífilis en mujeres y hombres de 15 a 49 años de edad en 2016.Para la clamidia, la gonorrea y la tricomoniasis, se realizaron búsquedas sistemáticas de estudios realizados entre 2009 y 2016 que registrasen la prevalencia. También se consultó a expertos regionales. Para generar estimaciones, se utilizó el metanálisis bayesiano. Para la sífilis, se añadieron las estimaciones nacionales generadas por el uso de Spectrum-STI.Para la clamidia, la gonorrea y/o la tricomoniasis, hubo 130 estudios que cumplían los criterios. Para la sífilis, la base de datos Spectrum-STI contenía 978 puntos de datos para el mismo periodo. Las estimaciones de prevalencia mundial en mujeres en 2016 fueron: clamidia 3,8 % (intervalo de incertidumbre, II, del 95 %: 3,3-4,5); gonorrea 0,9 % (II del 95 %: 0,7-1,1); tricomoniasis 5,3 % (II del 95 %: 4,0-7,2); y sífilis 0,5 % (II del 95 %: 0,4-0,6). Las estimaciones de prevalencia en hombres fueron: clamidia 2,7 % (intervalo de incertidumbre, II, del 95 %: 1,9-3,7); gonorrea 0,7 % (II del 95 %: 0,5-1,1); tricomoniasis 0,6 % (II del 95 %: 0,4-0,9); y sífilis 0,5 % (II del 95 %: 0,4-0,6). El total estimado de casos incidentes fue de 376,4 millones: 127,2 millones (II del 95 %: 95,1-165,9 millones) de casos de clamidia; 86,9 millones (II del 95 %: 58,6-123,4 millones) de casos de gonorrea; 156,0 millones (II del 95 %: 103,4-231,2 millones) de casos de tricomoniasis; y 6,3 millones (II del 95 %: 5,5-7,1 millones) de casos de sífilis.Las estimaciones mundiales de la prevalencia y la incidencia de estas cuatro enfermedades de transmisión sexual curables siguen siendo elevadas. El estudio destaca la necesidad de ampliar los esfuerzos de recopilación de datos a nivel nacional y proporciona una base inicial para el seguimiento de los progresos de laوضع تقديرات للانتشار والإصابة العالمية لعدوى الجهاز البولي التناسلي، وأمراض الكلاميديا، والسيلان، وداء المشعرات، والزهري لدى النساء والرجال، الذين تتراوح أعمارهم بين 15 و49 سنة، في عام 2016.بالنسبة للكلاميديا، والسيلان، وداء المشعرات، فقد قمنا بالبحث بشكل منهجي عن الدراسات التي تمت خلال الفترة من 2009 إلى 2016 والتي توضح مدى الانتشار. كما قمنا باستشارة خبراء إقليميين. ولوضع التقديرات، قمنا باستخدام التحليل التلوي Bayesian. بالنسبة لمرض الزهري، قمنا بتجميع التقديرات الوطنية الناتجة عن استخدام Spectrum-STI.بالنسبة لأمراض الكلاميديا، والسيلان، وداء المشعرات، كانت هناك 130 دراسة مؤهلة. وبالنسبة لمرض الزهري، احتوت قادة بيانات Spectrum-STI على 978 نقطة بيانات لنفس الفترة. كانت تقديرات الانتشار العالمي في عام 2016 في النساء: الكلاميديا 3.8% (فاصل عدم الثقة 95%: 3.3 إلى 4.5)، والسيلان 0.9% (فاصل عدم الثقة 95%: 0.7 إلى 1.1)، وداء المشعرات 5.3% (فاصل عدم الثقة 95%: 4.0 إلى 7.2)؛ والزهري 0.5% (فاصل عدم الثقة 95%: 0.4 إلى 0.6). كانت تقديرات الانتشار في عام 2016 في الرجال: الكلاميديا 2.7% (فاصل عدم الثقة 95%: 1.9 إلى 3.7)، والسيلان 0.7% (فاصل عدم الثقة 95%: 0.5 إلى 1.1)، وداء المشعرات 0.6% (فاصل عدم الثقة 95%: 0.4 إلى 0.9)، والزهري 0.5% (فاصل عدم الثقة 95%: 0.4–0.6). بلغ مجموع حالات الإصابة التقديري 376.4 مليون حالة: 127.2 مليون (فاصل عدم الثقة 95%: 95.1 إلى 165.9 مليون) حالات الكلاميديا؛ 86.9 مليون (فاصل عدم الثقة 95%: 58.6 إلى 123.4 مليون) حالات السيلان؛ 156.0 مليون (فاصل عدم الثقة 95%: 103.4 إلى 231.2 مليون) حالات داء المشعرات؛ 6.3 مليون (فاصل عدم الثقة 95%: 5.5 إلى 7.1 مليون) حالات الزهري.لا تزال التقديرات العالمية عالية لانتشار والإصابة بهذه الأمراض الأربعة المنقولة جنسياً والعلاج منها. تسلط الدراسة الضوء على الحاجة إلى توسيع جهود جمع البيانات على مستوى الدول، وتوفر خط أساس أولي لمراقبة التقدم المحرز في إستراتيجية قطاع الصحة العالمية التابع لمنظمة الصحة العالمية بشأن الأمراض المنقولة جنسياً خلال الفترة من 2016 إلى 2021.旨在估计 2016 年 15-49 岁男女泌尿生殖系统感染衣原体病、淋病、滴虫病和梅毒的全球患病率和发病率。.对于衣原体病、淋病和滴虫病,我们系统搜索了 2009 年至 2016 年间的患病率报告研究。我们还咨询了区域专家。为了生成估计值,我们使用了贝叶斯荟萃分析。对于梅毒,我们汇总分析了使用 Spectrum-STI 生成的全国估计值。.对于衣原体病、淋病和/或滴虫病,符合要求的有 130 项研究。对于梅毒, Spectrum-STI 数据库包含了同一时期的 978 个数据点。2016 年,全球女性患病率估计值为:衣原体病 3.8%(95% 不确定区间,UI:3.3-4.5);淋病 0.9%(95% UI:0.7–1.1);滴虫病 5.3%(95% UI:4.0–7.2)和梅毒 0.5%(95% UI:0.4-0.6)。全球男性患病率估计值为:衣原体病 2.7%(95% UI:1.9-3.7);淋病 0.7%(95% UI:0.5-1.1);滴虫病 0.6%(95% UI:0.4-0.9);梅毒 0.5%(95% UI:0.4-0.6)。预计病例总数为 3.764 亿:1.272 亿(95% UI:9510-16590 万)衣原体病病例;8690 万(95% UI:5860-12340 万)淋病病例;15600 万(95% UI:10340-23120 万)滴虫病病例;630 万(95% UI:550-710 万)梅毒病例。.对这四种可治愈的性传播疾病的患病率和发病率的全球估计值仍然很高。该研究强调了扩大国家级数据收集工作的必要性,并为监测 2016 至 2021 年世卫组织全球卫生部门性传播疾病战略的进展提供了初始基线。.Оценить распространенность в мировом масштабе и частоту урогенитальных инфекций, вызываемых хламидией, а также гонореи, трихомониаза и сифилиса у мужчин и женщин в возрасте от 15 до 49 лет по состоянию на 2016 год.Для хламидиоза, гонореи и трихомониаза авторы провели систематический поиск исследований, выполненных в период с 2009 по 2016 год, в которых приводились данные по распространенности заболеваний. Авторы также консультировались с международными специалистами. Для оценки использовался байесовский метаанализ. Для исследования сифилиса нами были объединены национальные оценки, созданные с использованием методики Spectrum-STI.Было обнаружено 130 исследований на тему хламидийной инфекции, гонореи и (или) трихомониаза. Что касается сифилиса, база данных Spectrum-STI за тот же период содержала 978 источников данных. По состоянию на 2016 год распространенность изучаемых заболеваний в мире среди женщин составляла: хламидиоз 3,8% (95%-й интервал неопределенности, ИН: 3,3–4,5), гонорея 0,9% (95%-й ИН: 0,7–1,1), трихомониаз 5,3% (95%-й ИН: 4,0–7,2) и сифилис 0,5% (95%-й ИН: 0,4–0,6). У мужчин распространенность хламидиоза составила 2,7% (95%-й ИН: 1,9–3,7), гонореи 0,7% (95%-й ИН: 0,5–1,1), трихомониаза 0,6% (95%-й ИН: 0,4–0,9) и сифилиса 0,5% (95%-й ИН: 0,4–0,6). Общее приблизительное количество случаев заболевания составило 376,4 млн человек: 127,2 млн (95 %-й ИН: 95,1–165,9 млн) случаев хламидийной инфекции, 86,9 млн (95%-й ИН: 58,6–123,4 млн) случаев гонореи, 156,0 млн (95%-й ИН: 103,4–231,2 млн) случаев трихомониаза и 6,3 млн (95%-й ИН: 5,5–7,1 млн) случаев сифилиса.Оценки мировой распространенности и частоты этих четырех излечимых инфекций, передаваемых половым путем (ИППП), остаются высокими. Исследование показывает необходимость предпринимать дальнейшие усилия по сбору данных на уровне каждой страны и может служить источником базовых значений для мониторинга прогресса в исполнении глобальных стратегий ВОЗ в секторе здравоохранения относительно ИППП на период 2016–2021 гг.

Efforts to develop vaccines against Neisseria gonorrhoeae have become increasingly important, given the rising threat of gonococcal antimicrobial resistance (AMR). Recent data suggest vaccines for gonorrhoea are biologically feasible; in particular, epidemiological evidence shows that vaccines against a closely related pathogen, serogroup B Neisseria meningitidis outer membrane vesicle (OMV) vaccines, may reduce gonorrhoea incidence. Vaccine candidates using several approaches are currently in preclinical development, including meningococcal and gonococcal OMV vaccines, a lipooligosaccharide epitope and purified protein subunit vaccines. The Global STI Vaccine Roadmap provides action steps to build on this technical momentum and advance gonococcal vaccine development. Better quantifying the magnitude of gonorrhoea-associated disease burden, for outcomes like infertility, and modelling the predicted role of gonococcal vaccines in addressing AMR will be essential for building a full public health value proposition, which can justify investment and help with decision making about future vaccine policy and programs. Efforts are underway to gain consensus on gonorrhoea vaccine target populations, implementation strategies and other preferred product characteristics that would make these vaccines suitable for use in low- and middle-income, as well as high-income, contexts. Addressing these epidemiological, programmatic and policy considerations in parallel to advancing research and development, including direct assessment of the ability of meningococcal B OMV vaccines to prevent gonorrhoea, can help bring about the development of viable gonococcal vaccines.

Genital herpes simplex virus type 2 (HSV-2) is one of the most prevalent sexually transmitted infections in the United States. We sought to assess differences in HSV-2 seroprevalence among non-Hispanic blacks and non-Hispanic whites and describe trends over time from 1988 to 2010.Data from National Health and Nutrition Examination Surveys (NHANES) were used to determine national HSV-2 seroprevalence estimates from National Health and Nutrition Examination Surveys 1988 to 1994, 1999 to 2002, 2003 to 2006, and 2007 to 2010. Persons aged 14 to 49 years were included in the analyses. Race/Ethnicity was defined by self-report as non-Hispanic white or non-Hispanic black. Purified glycoprotein specific for HSV-2 was used to detect type-specific antibodies using an immunodot assay. The same assay was used in all surveys. History of diagnosed genital herpes was self-reported.Overall, HSV-2 seroprevalence decreased in the United States between 1988 to 1994 and 2007 to 2010, from 21.2% to 15.5%. Among non-Hispanic white females, HSV-2 seroprevalence decreased from 19.5% (1988-1994) to 15.3% (2007-2010; P0.001); HSV-2 seroprevalence remained stable among non-Hispanic black females, 52.5% (1988-1994) to 49.9% (2007-2010; P = 0.1). The female black/white prevalence ratio was 2.7 (95% confidence interval [CI], 2.4-3.0) in 1988 to 1994 increasing to 3.3 (95% CI, 2.9-3.7) in 2007 to 2010 (P = 0.01). Among males, the black/white prevalence ratio was 2.4 (95% CI, 1.9-2.9) in 1988 to 1994 increasing to 4.4 (95% CI, 3.3-5.8) in 2007 to 2010 (P = 0.001). The overall percentage of HSV-2-seropositive survey participants who reported never being told by a doctor or health care professional that they had genital herpes did not change significantly between 1988 to 1994 and 2007 to 2010 and remained high (90.7% and 87.4%, respectively).Although HSV-2 seroprevalence decreased overall, the decrease was most marked among non-Hispanic whites, and racial disparities significantly increased over time. These persistent disparities demonstrate the need for innovative prevention strategies among this at-risk population.

BACKGROUND: : Although growing evidence suggests that condoms offer moderate protection against herpes simplex virus type 2 (HSV-2) inability to control for unknown or unmeasured confounders associated with sexual activity may reduce the accuracy of the estimates. The case-crossover design offers increased control of individual-level confounders and was thus used with the aim of producing a more accurate estimate of the effect of condom use on HSV-2 acquisition. METHODS: : Data were pooled from 6 prospective studies that measured HSV-2 status at enrollment and over follow-up and included periodic self-reported condom use and sexual activity. Sexual activity contemporaneous with acquisition was assigned to a case period; earlier sexual activity was assigned to a control period. Conditional logistic regression was used to assess differences in behavior during the case and control periods. RESULTS: : One hundred ninety-one eligible participants acquired HSV-2 during follow-up. This approach detected a 3.6% increase in the odds of HSV-2 acquisition with each unprotected act (odds ratio = 1.036; 95% confidence interval: 1.021-1.052) but no increase in the odds of acquisition associated with protected acts (odds ratio = 1.008; 95% confidence interval: 0.987-1.030). CONCLUSIONS: : This analysis suggests that condoms offer significant protection against HSV-2 transmission.

BACKGROUND Few data exist on potential harms of chlamydia screening. We assessed the psychosocial impact of receiving a positive Chlamydia trachomatis test result. METHODS We prospectively studied women ≥16 years of age undergoing chlamydia testing in 2 Midwestern family planning clinics. We surveyed women at baseline and about 1 month after receiving test results, using 9 validated psychosocial scales/subscales and chlamydia-specific questions. Changes in scale scores were calculated for each woman. Mean percent changes in scores for chlamydia-positive and -negative women were compared using a t test. RESULTS We enrolled 1807 women (response rate, 84%). Of the 1688 women with test results, 149 (8.8%) tested positive. At follow-up, chlamydia-positive women (n = 71) had a 75% increase in anxiety about sexual aspects of their life on the Multidimensional Sexual Self-Concept Questionnaire (P < 0.001), significantly greater than the 26% increase among 280 randomly selected chlamydia-negative women (P = 0.02). There were no differences for the other 8 scales/subscales, including general measures of anxiety, depression, and self-esteem. Chlamydia-positive women were more likely than chlamydia-negative women to be "concerned about chlamydia" (80% vs. 40%, P < 0.001) and to report breaking up with a main partner (33% vs. 11%, P < 0.001) at follow-up. Women testing positive reported a range of chlamydia-specific concerns. CONCLUSIONS Chlamydia-positive women had significant increases in anxiety about sex and concern about chlamydia, but did not have marked changes in more general measures of psychosocial well-being about 1 month after diagnosis. Chlamydia diagnoses were associated with some disruption of relationships with main partners. Chlamydia-specific concerns may guide counseling messages to minimize psychosocial impact.

Background We assessed human papillomavirus (HPV) vaccine uptake among adolescent girls, parents’ intentions to vaccinate daughters, and barriers and facilitators of vaccination in a population at elevated risk for cervical cancer. Methods Between October 2007 and June 2008, telephone surveys were conducted with randomly selected parents/guardians of 11–18 year old girls attending public middle and high schools serving economically disadvantaged populations in Los Angeles County. Results We surveyed 509 predominantly Hispanic (81%) and African American (16%) parents; 71% responded in Spanish. Overall, 23% reported their daughter had received ≥1 dose of HPV vaccine. Although 93% of daughters had seen a doctor in the past year, only 30% reported that a provider recommended HPV vaccine. Characteristics positively associated with odds of having initiated HPV vaccine were having heard of the vaccine (adjusted odds ratio [aOR] 2.6), belief in vaccine effectiveness (aOR 2.9), and doctor recommendation (aOR 48.5). Negative attitudes toward HPV vaccine (aOR 0.2) and needing more information about it (aOR 0.1) were negatively associated with vaccine initiation. Of those with unvaccinated daughters ( n = 387), 62% said they “probably/definitely will” vaccinate within the next year and 21% were undecided or didn’t know; only 11% said they definitely won’t. Conclusions About one-quarter of adolescent girls in this at-risk community had initiated HPV vaccine by mid-2008. Provider recommendation was the single most important factor associated with vaccination. Because a substantial proportion of parents remain undecided about HPV vaccine, health care providers can play a key role by providing needed information and offering HPV vaccine to all eligible adolescents.

Background:Human papillomavirus (HPV) vaccine uptake is low among adolescent girls in the United States. We sought to identify longitudinal predictors of HPV vaccine initiation in populations at elevated risk for cervical cancer.Methods:We interviewed a population-based sample of parents of 10- to 1

The public health response to the threat of pandemic influenza A (H1N1) virus during the 2009-2010 influenza season was extensive. To better understand the lower than expected vaccine uptake, we aimed to characterize correlates of 2009 H1N1 vaccination among adolescent females in the U.S. and examine accessibility of the vaccine to parents.We collected data from a national sample of mothers of adolescent females ages 11-14 years (n=944) during December 2009 using an online survey.Overall, 22% (221/944) of mothers indicated their daughters had received 2009 H1N1 vaccine. H1N1 vaccination was higher among daughters who had received 2009 seasonal influenza vaccine (49% vs. 11%, OR=7.00, 95% CI: 4.18-11.73) or whose mothers expressed higher trust in their daughters' healthcare providers (26% vs. 11%, OR=2.28, 95% CI: 1.10-4.73). Among mothers of unvaccinated daughters, 20% (150/723) indicated they wanted to get their daughters 2009 H1N1 vaccine but were unable to. Vaccination among daughters and accessibility of the vaccine to parents did not differ by race, socioeconomic status, or health insurance status.One explanation for the lower than expected uptake of 2009 H1N1 vaccine is that many parents were unable to get their daughters the vaccine despite wanting to do so. Concomitant administration with seasonal influenza vaccine may increase uptake of novel influenza vaccines.

Immunization is a successful and cost-effective method for preventing disease, yet many adolescents do not receive recommended vaccines. We assessed correlates of uptake of three vaccines (tetanus booster, meningococcal, and human papillomavirus [HPV] vaccines) recommended for adolescent females. Methods. We examined cross-sectional data from 647 parents of 11-20 year-old females from North Carolina who completed the Carolina HPV Immunization Measurement and Evaluation (CHIME) Project follow-up survey in late 2008. Analyses used ordinal and binary logistic regression.Only 17% of parents indicated their daughters had received all three vaccines. Eighty-seven percent of parents indicated their daughters had received tetanus booster vaccine, 36% reported vaccination against meningococcal disease, and 36% reported HPV vaccine initiation. Daughters aged 13-15 years (OR = 1.70, 95% CI: 1.09-2.64) or 16-20 years (OR = 2.28, 95% CI: 1.51-3.44) had received a greater number of these vaccines compared to daughters aged 11-12 years. Daughters who had preventive care visits in the last year (OR = 4.81, 95% CI: 3.14-7.34) or whose parents had at least some college education (OR = 1.90, 95% CI: 1.29-2.80) had also received a greater number of these vaccines.Few daughters, particularly 11-12 years olds, had received all three vaccines recommended for adolescent females. Ensuring annual preventive care visits and increasing concomitant administration of adolescent vaccines may help increase vaccine coverage.

Background: Cervical cancer incidence in the United States may be greatly reduced through widespread human papillomavirus (HPV) vaccination. We estimated the statewide level of HPV vaccine initiation among adolescent girls in North Carolina and identified correlates of vaccine initiation. Methods: We used data from 617 parents of adolescent females from North Carolina who completed the population-based 2008 Child Health Assessment and Monitoring Program survey. Analyses used weighted multivariate logistic regression. Results: Overall, 31.3% of parents reported their daughters had received at least 1 dose of HPV vaccine. Vaccine initiation was higher among daughters aged 13 to 15 years (odds ratio [OR] 2.03, 95% CI, 1.12‐3.67) or 16 to 17 years (OR 3.21, 95% CI, 1.76‐5.86) compared with those 10 to 12 years old. Additional correlates of HPV vaccine initiation included the daughter having a preventive check-up in the last 12 months (OR 5.09, 95% CI, 2.43‐10.67), having received meningococcal vaccine (OR 2.50, 95% CI, 1.55‐4.01), or being from an urban area (OR 1.81, 95% CI, 1.02‐3.21). Among parents of unvaccinated daughters, intent to vaccinate in the next year was higher among those with daughters aged 13 to 17 years. Parents of unvaccinated non-Hispanic white daughters reported lower levels of intent to vaccinate within the next year compared with parents of unvaccinated daughters of other races. Conclusions: HPV vaccine initiation in North Carolina is comparable with other US areas. Potential strategies for increasing HPV vaccination levels include reducing missed opportunities for HPV vaccination at preventive check-ups and increasing concomitant administration of HPV vaccine with other adolescent vaccines.

Background. An important question for chlamydia control programs is the extent to which finding and treating prevalent, asymptomatic Chlamydia trachomatis genital infection reduces reproductive sequelae in infected women. Methods. We reviewed the literature to critically evaluate evidence on the effect of chlamydia screening on development of sequelae in infected women. Results. Two randomized controlled trials of 1-time screening for chlamydial infection—in a Seattle-area health maintenance organization and a Danish school district—revealed that screening was associated with an ∼50% reduction in the incidence of pelvic inflammatory disease over the following year. However, both of these trials had methodological issues that may have affected the magnitude of observed screening benefits and might limit generalizability to other populations. A large, nonrandomized cohort of chlamydia screening among US Army recruits, although limited by lack of outpatient data, did not find a benefit of similar magnitude to the randomized trials. Methodological limitations restrict valid conclusions about individual benefits of screening using data from historical cohorts and ecological studies. We identified no trials directly evaluating the effect of chlamydia screening on subclinical tubal inflammation or damage, ectopic pregnancy, or tubal factor infertility and no studies addressing the effects of >1 round of screening, the optimal frequency of screening, or the benefits of screening for repeat infections. Conclusions. Additional studies of the effectiveness of chlamydia screening would be valuable; feasible study designs may depend on the degree to which screening programs are already established. In addition, better natural history data on the timing of tubal inflammation and damage after C. trachomatis infection and development of more accurate, noninvasive tools to assess chlamydial sequelae are essential to informing chlamydia control efforts.

OBJECTIVE: Most young women initiate sexual activity during adolescence; risk for sexually transmitted infections (STIs) accompanies this initiation. In this study we estimated the prevalence of the most common STIs among a representative sample of female adolescents in the United States. METHODS: Data were analyzed from 838 females who were aged 14 to 19 and participating in the nationally representative National Health and Nutrition Examination Survey 2003–2004. After interview and examination, survey participants provided biological specimens for laboratory testing. The main outcome was weighted prevalence of at least 1 of 5 STIs: Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, herpes simplex virus type 2, and human papillomavirus (HPV) (any of 23 high-risk types or type 6 or 11). RESULTS: Prevalence of any of the 5 STIs was 24.1% among all and 37.7% among sexually experienced female adolescents. HPV (23 high-risk types or type 6 or 11) was the most common STI among all female adolescents (prevalence: 18.3%), followed by C trachomatis infection (prevalence: 3.9%). Prevalence of any of the STIs was 25.6% among those whose age was the same or 1 year greater than their age at sexual initiation and 19.7% among those who reported only 1 lifetime sex partner. CONCLUSIONS: The prevalence of STIs among female adolescents is substantial, and STIs begin to be acquired soon after sexual initiation and with few sex partners. These findings support early and comprehensive sex education, routine HPV vaccination at the age of 11 to 12 years, and C trachomatis screening of sexually active female adolescents.

We examined the prevalence of reported pain following human papillomavirus (HPV) vaccination and whether it differed from that for other adolescent vaccines or affected completion of the HPV vaccine regimen. In 2008, we conducted cross-sectional surveys with parents of adolescent girls aged 11-20 living in areas of North Carolina with elevated cervical cancer rates who had received at least one dose of HPV vaccine. Pain from HPV vaccination, while commonly reported by parents, was less frequent compared to other adolescent vaccines and did not appear to affect vaccine regimen completion. These findings may be important to increase HPV vaccination coverage.

Background: Differential access to basic health information may contribute to persistent cervical cancer disparities. We examined whether human papillomavirus (HPV) vaccine awareness, HPV knowledge, and use of information sources about the vaccine differ by sociodemographic characteristics associated with cervical cancer. Methods: Study participants (n = 889) were caregivers of adolescent girls ages 10 to 18 years living in southeastern North Carolina. Analyses simultaneously controlled for caregivers' gender, race, age, education, income, and rural residence. Results: Although most caregivers were aware of HPV (83%) and the HPV vaccine (82%), awareness differed by gender, race, education, and income. The largest differences were for race, with 87% of Whites versus 68% of African Americans having heard of the vaccine (P < 0.001). Caregivers correctly answered an average of 69% of questions on HPV, with differences by race and education. Most respondents heard of the HPV vaccine through drug company advertisements (83%) or broadcast media coverage (69%). African Americans were less likely than Whites to have heard about the vaccine from advertisements but more likely from a broadcast source (P < 0.05). Health care providers (88%) and the internet (65%) were the most favored sources for future information about the vaccine. Vaccine uptake was associated with awareness, knowledge, and media use. Discussion: Whereas drug company advertisements seem to play a central role in high HPV vaccine awareness, doctors and the internet are the preferred future “go to” sources for seeking out information. Communication-based interventions for caregivers from cervical cancer risk groups, especially African Americans, may need to use different communication channels and content. (Cancer Epidemiol Biomarkers Prev 2009;18(2):363–72)

Purpose Potential barriers to widespread vaccination of adolescent girls against human papillomavirus (HPV) infection are poorly understood. We provide an overview of potential barriers to provision of HPV vaccine and empirical data on the concerns of medical practices that may inhibit HPV vaccine provision. Method We conducted phone interviews with medical practices in rural areas in southeastern North Carolina with high rates of cervical cancer to assess 10 potential concerns about HPV vaccine provision. Results Concerns most commonly reported by medical practices (N = 71) were inadequate reimbursement (68%), high cost of the vaccine to patients (66%), and burden of determining insurance coverage (66%). Practices that were not providing the vaccine reported more concerns about HPV vaccine provision on average than practices providing the vaccine (6.0 vs. 4.5 concerns, p Conclusions Medical practices' concerns about the HPV vaccine may be barriers to stocking it and, thus, to providing it to adolescents. Even providers who stock the vaccine reported concerns. Research is needed to address ways to ameliorate these medical practices' concerns and also to understand other potential barriers to vaccine coverage.