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Method: Thirty-four adult heterosexual couples attending an HIV testing center in Soweto, South Africa were enrolled.
Human papillomavirus (HPV) is a sexually transmitted infection that causes squamous cervical cancer and some vaginal and anal cancers (1, 2). Cervical HPV infection has been well studied in South Africa, where cervical cancer is one of the leading causes of cancer mortality in women (10). We therefore evaluated oral and genital HPV prevalence, risk factors and concordance among couples attending the Perinatal HIV Research Unit at Chris Baragwanath Hospital in Johannesburg, South Africa. In 2011 we recruited 38 couples attending the Zazi Center at the Perinatal HIV Research Unit, Chris Baragwanath Hospital in Soweto, South Africa for HIV testing.
A couple was defined as two individuals (regardless of gender) who self-identified as current sexual partners. Each study subject provided an oral rinse and gargle sample, a genital swab and completed a risk behavior survey. All study participants were asked to complete a self-administered risk factor questionnaire.
All study participants were tested for HIV as part of their clinical care and if HIV-positive CD4 cell count by the Zazi clinic as part of their clinical visit. Characteristics of participants were compared by gender and by HIV status using chi-squared for categorical and test of medians for continuous variables. This pilot study included 13 individuals who tested positive for HIV infection, as well as 55 people testing HIV-negative, called HIV-uninfected (Table 1). At least one type-specific concordant vaginal-penile HPV infection was observed in 35% of couples (Figure 1).
Our study demonstrated oral HPV prevalence of 15%, consistent with previous studies from South Africa, which showed an oral HPV prevalence of 20–25% (22, 23).
Vaginal HPV was detected in >90% of females in our study and the majority of these individuals were found to have oncogenic HPV subtypes. While this study was cross sectional, the agreement in oral-genital HPV infection between couples is consistent with transmission by oral sex. This research demonstrates high prevalence of genital HPV infection and moderate prevalence of oral HPV infection in a South African population with a modest number of sexual partners. The authors thank the staff at Zazi Center at the Perinatal HIV Research Center in Soweto, South Africa who helped with the implementation of this study, especially Thandekile Essien, the HIV testing counselors and the participants of the study. We can fix you up with a tongue, lip, labret, monroe, or any of a variety of different oral piercings.
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However, little is known about oral human papillomavirus (HPV) infection in high human immunodeficiency virus (HIV) seroprevalence settings. Each participant provided an oral rinse sample and genital swab, which were tested for 37 types of HPV DNA, and completed a risk behavior survey.
This data is consistent with possible transmission of vaginal HPV infection to the oral cavity of sexual partners performing oral sex. More recent data shows that HPV also causes a subset of head and neck cancers including 50–75% of oropharyngeal cancers (3).
Since the advent of effective antiretroviral therapy (ART) and its roll-out in Sub-Saharan Africa, HIV-infected patients are living longer.

The prevalence of cervical HPV infection approaches 80% among HIV-infected women (11) in whom high rates of cervical premalignant lesions have been reported (12), an effect apparently mitigated by ART (13).
The Zazi Center provides free, walk-in, voluntary HIV counseling and testing for individuals and couples. Exclusion criteria included an inability to provide consent, or an unwillingness to provide an oral rinse sample and survey data. Oral rinse and gargle specimens were obtained by having a participant gargle 10 ml of Scope mouthwash for a total of 30 s (10 s rinse, 5 s gargle, 10 s rinse, 5 s gargle). Individuals from the same couple were asked to fill out the survey in separate rooms to ensure privacy of responses. HIV concordance was seen in 2 couples, 9 couples were HIV discordant, and 23 couples were HIV-uninfected. Characteristics of 34 couples attending Zazi Clinic for HIV counseling and testing, stratified by gender.
HIV-uninfected individuals, HIV-infected individuals displayed a statistically significantly higher prevalence of both genital oncogenic HPV subtypes (76.9 vs. In 3 (75%) of these four couples the partner with oral HPV reported ever performing oral sex. Oral-genital concordance couple characteristics among nine couples with at least one oral HPV infection.
We found that 12% of couples displayed oral-genital concordance and among these couples the majority had male oral HPV infection concordant with female vaginal HPV infection. Risk factors for oral HPV infection were similar to those reported in other studies, including performing oral sex, male gender, and HIV-infection (4, 24). The prevalence of high-risk HPV subtypes amongst males in South Africa has been previously reported as 15% for circumcised males and 22% for uncircumcised males (30). Additionally, in three out of the four couples with concordant oral-genital HPV infection, the partner with oral HPV reported having performed oral sex, a finding consistent with previous reports of an association between oral HPV prevalence and reported oral sex (32). The HPV vaccine has recently been shown to be effective in preventing oral, as well as cervical and anal HPV infection (35), and this data underscores the importance of preventative HPV vaccination in South Africa. The other co-authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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While initial cross-sectional studies from the United States suggest that oral HPV prevalence is elevated among human immunodeficiency virus (HIV)-infected individuals and further increased with immunosuppression (4, 5), there is currently limited information about oral HPV infections in Africa. With this increase in survival comes an increased opportunity for progression of oncogenic viral infections into malignancies, including increased incidence of HPV-associated oral, genital, and anal cancers (8, 9). Owing to limited data on oral HPV, the concordance of oral-cervical HPV infection has not been well studied. Clients who test positive for HIV receive CD4 count testing to assist in appropriate referral to care. Specimens were collected in a sterile cup and stored at 4°C while awaiting transport to the laboratory. The questionnaire included questions about risk factors for oral HPV infection including demographics, recent, and lifetime sexual behavior including performing oral sex, alcohol, tobacco, and drug use. This is consistent with higher likelihood of vaginal-to-oral transmission as compared to penile-to-oral transmission, and may help explain previously reported findings of a lack of significant association between oral-penile contact and incident oral HPV infections amongst women (21).
Additionally, HPV prevalence amongst HIV-positive women in South Africa approaches 80% (11). In our study, we did not categorize men by circumcision status, and our reported prevalence is moderately higher than these previous studies.
The remaining couple displayed both oral–oral and oral-genital HPV concordance, but reported no oral sex.

The concordant oral-genital HPV infection detected in these couples supports the transmission of HPV infection to the mouth by oral sex. Risk factors for oral HPV infection among a high prevalence population of HIV-positive and at-risk HIV-negative adults.
Invasive cervical cancer risk among HIV-infected women: a North American multi-cohort collaboration prospective study. To be included in this study, participants were required to be 18 years or older and be able to read English. The study was approved by the Johns Hopkins Bloomberg School of Public Health institutional review board and the University of Witwatersrand human research ethics committee.
Women were asked to provide a self-collected vaginal sample, obtained using a Dacron applicator (Qiagen female swab specimen collection kit) and stored at room temperature while awaiting transport to the laboratory. McNemar’s test was used to compare oral and genital HPV prevalence among the paired male and female couples. Oral–oral HPV concordance was rare in our study, even among HIV-infected individuals, consistent with no or low salivary transmission. Our overall reported vaginal HPV prevalence exceeds these previously reported estimates, although our sample size was small. There was a strong correlation between HIV status and both genital HPV prevalence and genital–genital HPV concordance between couples, which is consistent with previous studies (31).
Possible modes of transmission in this couple could include deep kissing or auto-inoculation, as both of these modes of transmission have previously been suggested, although not clearly demonstrated (33, 34).
Additionally, our study provides cross-sectional data only so could not demonstrate transmission over time from one partner to another.
Given higher HPV prevalence, persistence, and HPV-associated cancer risk among HIV-infected individuals (8), the prevalence of oncogenic oral HPV infection in this population is of note.
A convenience sample that included all couples coming to the Zazi HIV testing clinic during the enrollment period were asked by their HIV testing counselor if they were interested in participating in the study. The penile swab was collected from participating men by a clinical study team member and penile cells were collected using two Dacron HC (Qiagen) swabs. For oral HPV there was a trend toward higher prevalence amongst HIV-positive individuals, but this finding was not statistically significant. However, oral–oral HPV concordance was low suggesting HPV may not be transmitted by deep kissing, or may be rare.
However this study provides some of the first estimates of oral–oral and oral-genital HPV concordance in couples in Africa. Roughly 33% of the individuals who came to the HIV clinic during this time period came without a partner and were therefore not eligible for this study.
One swab sampled the coronal sulcus and glans penis, while the other sampled the penile shaft. All statistical analyses were performed using STATA version 11.0 (College Station, TX, USA). Sexually active couples who reported being together for at least 1 month were eligible for enrollment as long as both partners were willing to participate and provide informed consent. Given the high HIV prevalence in South Africa and other countries in the region, as individuals with HIV live longer due to effective ART, it is not known whether a similar increase in HPV-associated oropharyngeal cancer will be observed in this region. Oncogenic HPV subtypes were detected in 4% of oral, 26% of penile, and 74% of vaginal samples, including HPV16 in 1, 12, and 21% of these samples respectively. Oncogenic HPV subtypes were detected in 4% of oral, 29% of penile, and 74% of cervical samples, including HPV 16 in 1, 12, and 21% of these samples respectively.

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