HIGH ANAL HUMAN PAPILLOMAVIRUS (HPV) PREVALENCE AND ANAL-CERVICAL HPV CONCORDANCE AMONG WOMEN OF EASTERN CAPE PROVINCE, SOUTH AFRICA

HIGH ANAL HUMAN PAPILLOMAVIRUS (HPV) PREVALENCE AND ANAL-CERVICAL HPV CONCORDANCE AMONG WOMEN OF EASTERN CAPE PROVINCE, SOUTH AFRICA | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 3 June 2025 V1 Latest version Share on HIGH ANAL HUMAN PAPILLOMAVIRUS (HPV) PREVALENCE AND ANAL-CERVICAL HPV CONCORDANCE AMONG WOMEN OF EASTERN CAPE PROVINCE, SOUTH AFRICA Authors : Zizipho Z. A. Mbulawa 0000-0001-9073-4777 [email protected] , Lindiwe M. Faye , and Charles B. Businge Authors Info & Affiliations https://doi.org/10.22541/au.174894677.73772267/v1 253 views 121 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Anal human papillomavirus (HPV) prevalence is increasing; therefore, this study investigated the anal HPV and associated factors; and further, investigated anal-cervical HPV concordance and associated factors among women of Eastern Cape Province, South Africa. A total of 326 women aged 18–60 were recruited from an Eastern Cape community health facility. HPV DNA was detected in cervical and anal specimens using the Seegene Anyplex™ and Allplex™ II HPV28 assay respectively. Anal HPV was detected in 68.1% and a proportion of 38.7% had ≥1 HPV type(s) covered by the Gardasil ® 9 HPV vaccine. Anal HPV infection was significantly associated with cervical HPV infection (RR: 1.46, 95% CI: 1.22–1.80, p<0.0001) and abnormal cervical cytology (RR: 1.45, 95% CI: 1.24-1.62, p<0.0001). The risk of anal HPV infection was decresed among married (RR:0.80, 95% CI: 0.62-0.98, p=0.041) and once pregnant women (RR: 0.78, 95% CI:0.68-0.94, p=0.015). It was also decreased among those wiping in any direction after peeing or bowel movement than those who wipe from vagina-to-anus (RR: 0.68, 95% CI: 0.45-0.94, p=0.018) or from anus-to-vagina (RR: 0.66, 95% CI: 0.44-0.90, p=0.006). Anal-cervical concordance was observed in 33.5% and it was associated with abnormal cervical cytology (RR: 2.81, 95% CI: 2.12-3.60, p<0.0001), drinking alcohol (RR: 2.01, 95% CI: 1.36-2.91, p=0.001) and increased new sexual partners past 12-months (RR: 1.42, 95% CI: 1.02-1.92, p=0.040). High anal HPV prevalence and anal-cervical HPV type concordance was observed among Eastern Cape women. Understanding anal HPV and associated factors can contribute to strategies towards anal HPV and cancer prevention. HIGH ANAL HUMAN PAPILLOMAVIRUS (HPV) PREVALENCE AND ANAL-CERVICAL HPV CONCORDANCE AMONG WOMEN OF EASTERN CAPE PROVINCE, SOUTH AFRICA Zizipho Z. A. Mbulawa 1,2, , Lindiwe M. Faye 1 , Charles B. Businge 3 1 Department of Laboratory Medicine and Pathology, Walter Sisulu University, Mthatha, South Africa 2 National Health Laboratory Service, Nelson Mandela Academic Hospital, Mthatha, South Africa 3 Department of Obstetrics and Gynaecology, Walter Sisulu University, Mthatha, South Africa Email addresses and ORCID ZAM: [email protected] , ORCID: 0000-0001-9073-4777 LMF : [email protected] ORCID : 0000-0002-7308-4239 CBB: [email protected] ORCD: 0000-0002-8393-1198 # Corresponding Author: A/Prof. Zizipho Z.A. Mbulawa , Department of Laboratory Medicine and Pathology, National Health Laboratory Service, and Walter Sisulu University, Nelson Mandela Academic Hospital, Fort Gale, Mthatha, South Africa. Email: [email protected] , Tel: +2747 502 4909 Abstract Anal human papillomavirus (HPV) prevalence is increasing; therefore, this study investigated the anal HPV and associated factors; and further, investigated anal-cervical HPV concordance and associated factors among women of Eastern Cape Province, South Africa. A total of 326 women aged 18–60 were recruited from an Eastern Cape community health facility. HPV DNA was detected in cervical and anal specimens using the Seegene Anyplex™ and Allplex™ II HPV28 assay respectively. Anal HPV was detected in 68.1% and a proportion of 38.7% had ≥1 HPV type(s) covered by the Gardasil ® 9 HPV vaccine. Anal HPV infection was significantly associated with cervical HPV infection (RR: 1.46, 95% CI: 1.22–1.80, p<0.0001) and abnormal cervical cytology (RR: 1.45, 95% CI: 1.24-1.62, p<0.0001). The risk of anal HPV infection was decresed among married (RR:0.80, 95% CI: 0.62-0.98, p=0.041) and once pregnant women (RR: 0.78, 95% CI:0.68-0.94, p=0.015). It was also decreased among those wiping in any direction after peeing or bowel movement than those who wipe from vagina-to-anus (RR: 0.68, 95% CI: 0.45-0.94, p=0.018) or from anus-to-vagina (RR: 0.66, 95% CI: 0.44-0.90, p=0.006). Anal-cervical concordance was observed in 33.5% and it was associated with abnormal cervical cytology (RR: 2.81, 95% CI: 2.12-3.60, p<0.0001), drinking alcohol (RR: 2.01, 95% CI: 1.36-2.91, p=0.001) and increased new sexual partners past 12-months (RR: 1.42, 95% CI: 1.02-1.92, p=0.040). High anal HPV prevalence and anal-cervical HPV type concordance was observed among Eastern Cape women. Understanding anal HPV and associated factors can contribute to strategies towards anal HPV and cancer prevention. Key words: Human papillomavirus; anal HPV, cervical HPV, anal-cervical concordance, women 1 | Introduction The incidence and mortality of anal cancer have increased in the last decades 1-4 . The major cause of anal cancer is persistent anal human papillomavirus (HPV) infection, with HPV-16 and HPV-18 being the dominant HPV types 1,2,5,6 . Anal HPV and cancer in women are more prevalent in individuals with a history of anal condyloma, cervical cancer, vulvovaginal cancer, and immunosuppression, including HIV infection 2,5,7-9 . Anal intercourse is recognized as a risk factor for anal HPV infection; however, anal HPV acquisition has also been reported in women without a history of receptive anal intercourse. This suggests that alternative transmission routes, such as self-inoculation from HPV-infected genital sites, may contribute to anal infection 2 . Concordance of HPV types between the cervicovaginal and anal sites is common in women and may occur via both sexual and non-sexual routes. The high prevalence and viral load of HPV in the cervicovaginal region further increases the likelihood of autoinoculation and subsequent anal infection. Notably, anal HPV infection can occur independently of cervical HPV infection, indicating distinct acquisition dynamics 2,10,11 . Risky sexual behavior and smoking have been consistently identified as significant risk factors for HPV infections, including anal HPV, cervical HPV, and anal-cervical concordance. Engaging in early sexual debut, having multiple sexual partners, and inconsistent condom use significantly increase the likelihood of acquiring HPV and progression to high-grade lesions 9,12,13 . According to the South African National Cancer Registry, which collects statistics for histologically diagnosed cancers in South Africa, among women anal cancer age standardised incidence in 2013 was 0.47 per 100 000 (95% CI: 0.39-0.56), decade latter (2023) it was increased to 0.92 per 100 000 (95% CI: 0.82-1.03) 14,15 . Zuma et al., (2020) reported increasing anal squamous cell carcinoma in KwaZulu Natal Province of South Africa and influence of HIV-infection. The observed increased anal cancer in women suggests that further investigation on anal cancer risk factors, natural history, screening, and treatment are needed; the high burden of HIV infection in South Africa further enhance the need 16,17 . Persistent anal HPV infection is the principal etiological factor in the development of anal cancer. However, data on the prevalence and determinants of anal HPV infection among women in the general population of South Africa remain scarce. Anal HR-HPV prevalence among South African HIV-positive women attending HIV treatment clinic has been reported to be 62.0%, and 18.8% had HPV-16 18 . In South African HIV-positive men, the higher anal HPV infection has been reported to be 79.0% 19 . Therefore, this study aimed to investigate the prevalence and associated risk factors of anal HPV infection, as well as the anal-cervical HPV type concordance and its determinants, among women residing in the Eastern Cape Province of South Africa. 2 | Methods 2.1 | Study design, setting, and population This quantitative study was conducted at a primary healthcare facility located within the King Sabata Dalindyebo (KSD) sub-district of the Department of Health, in the Oliver Reginald (O.R.) Tambo District Municipality, Eastern Cape Province, South Africa. The healthcare facility provides services to a diverse catchment area that encompasses rural communities, informal settlements, peri-urban areas, and urban settings. Women who attended the facility for any health-related reason, including medication collection, between June and July 2023, were invited to participate in the study. Participants were recruited at the health facility reception by using posters and education leaflets on human papillomavirus and associated diseases. Participation in the study was entirely voluntary, with no obligation or pressure placed upon the individuals to take part. Recruitment and informed consent processes were conducted in isiXhosa, a locally spoken language. Written consent, biological specimens and response to questionnaires were obtained from all study participants. 2.2 | Collection of clinical specimens and an HIV test All study procedures were conducted in a private room by the investigator. To maintain participant confidentiality, a unique study number was assigned to each participant, linking all their collected specimens and questionnaires. To confirm the HIV status of study participants, an HIV rapid test was offered to all HIV negative or unknown participants by a qualified nurse or an HIV lay counsellor. Pre- and post-HIV counselling and rapid HIV tests were administered following the South African Department of Health HIV guidelines. Prior to sample collection, the professional nurse conducted a speculum examination. Clinical examinations were performed by an experienced professional nurse, who carefully noted any signs and symptoms of vaginal abnormalities. The cervical specimens were collected for cervical cancer screening and HPV testing. The cervical cancer screening specimen was collected using the ThinPrep Pap Test collection kit (Hologic, United States of America) and sent to the Nelson Mandela Academic Hospital National Health Laboratory Service cytopathology laboratory. The second cervical specimen was collected using a Digene cervical sampler brush (Qiagen Inc., Gaithersburg, MD, USA) and placed into the Digene transport medium (Qiagen Inc., Gaithersburg, MD, USA). The anal specimen was collected using digene swab specimen collection kit (Qiagen Inc., Gaithersburg, MD, USA) and placed into the digene transport medium (Qiagen Inc., Gaithersburg, MD, USA). The cervical and anal HPV specimens were transported to the Nelson Mandela Academic Hospital NHLS/WSU Virology laboratory and stored at -20°C until the time of nucleic acid extraction. 2.3 | Nucleic acid extraction and molecular detection of Human papillomavirus Nucleic acid extraction from the anal and cervical specimens was performed using an automated procedure, Seegene NIMBUS and a universal STARMag extraction system (Seegene Inc., Seoul, South Korea), following the manufacturer’s instructions. A total of 300µl anal and cervical specimens in transport medium were used as the initial volume for extraction and eluted to approximately 100µl nucleic acid. Seegene Anyplex™ II HPV28 and Seegene Allplex™ II HPV28 (Seegene Inc. Seoul, South Korea) were used to detect and genotype HPV in cervical and anal nucleic extracted specimens respectively. Seegene Anyplex™ II HPV28 and Seegene Allplex™ II HPV28 (Seegene Inc. Seoul, South Korea) multiplexed real-time type-specific polymerase chain reaction (PCR) assays detect, differentiate and quantify 28 different HPV genotypes (19 HR-HPV: 16, 18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 69, 73, 82; 9 LR-HPV: 6, 11, 40, 42, 43, 44, 54, 61, 70 and 6 Probable HR-HPV: 26, 53, 66, 68, 73, 82). Amplification on a Bio-Rad CFX96 real-time thermocycler (Bio-Rad, Hercules, CA, USA) was conducted according to the manufacturer’s instructions. Anyplex™ and Allplex™ II HPV28 targets the L1 major capsid gene of the HPV types. The human housekeeping gene (β-globin) was used as an internal control and was co-amplified simultaneously with the L1 gene of the targeted HPV types. Data was automatically generated and interpreted by Seegene Viewer Software (Seegene Inc., Seoul, Korea) according to the manufacturer’s instructions. Samples with negative internal control and a negative HPV result were re-analysed, and if this persisted, they were deemed invalid. If the internal control was negative, but the HPV test result was positive, the test result was considered valid. Negative HPV tests with a positive internal control were deemed negative for 28 HPV types targeted by the Seegene Anyplex™ and Allplex™ II HPV28. 2.4 | Data analysis HPV prevalence was described according to HR-, probable HR- and LR-HPV. Single HPV infection was defined as infection with one HPV type, while multiple HPV infection was described as being infected with two or more HPV types in the same sample. In addition, HPV types were grouped based on the commercially available HPV vaccines. Anal-cervical HPV concordance was defined as the detection of HPV infection in both anus and cervix of one participant. All variables were captured and coded in Microsoft Excel. GraphPad Prism Software v8.0.1.244 statistical software was used to perform all statistical analyses. Fisher’s exact method was used to compare the proportions between variables and the relative risk (RR). The Mann–Whitney U test was used to compare the medians between the two groups. Differences were considered to be statistically significant when p-values were <0.05. 3 | Results 3.1 | Study population characteristics and HPV anal prevalence A comprehensive description of the study population is available in a separate publication (Mbulawa et al., 2024). Briefly, the study included 326 women with a median age of 36 years (interquartile range [IQR]: 28–45 years; age range: 18–60 years). The majority of the study population was HIV-positive (64.5%, 209/324), and the least were HIV-negative (35.5%, 115/324). HIV-positive women (median age 39 years, IQR: 32 – 46 years) were older than the HIV-negative women (31 years median, IQR: 23 – 42 years, p<0.0001). Anal HPV infection was detected in 68.1% (222/326) of participants and it was not significantly different between HIV-positive women (141/209, 67.5%) and HIV-negative women (80/115, 69.6%). Among those with anal HPV infections, multiple (2-16) HPV types were more common than single infections (59.9%,133/222; 49.1%, 89/222 respectively, p<0.0001) in overall women, HIV-positive women (58.9%, 83/141; 41.1%, 58/141, p=0.004) and HIV-negative women (62.5%, 50/80; 37.5%, 30/80 respectively, p=0.003, Table 1). HR-HPV prevalence was detected at a similar proportion among overall participants (50.9%, 166/326), HIV-positive women (51.7%, 108/209), and HIV-negative women (50.4%, 58/115). Anal HPV prevalence was not found to significantly decrease with increasing age among overall participants (p=0.291), HIV-positive women (p=0.930) and HIV-negative women (p=0.058). However, the prevalence of multiple anal HPV infections significantly declined with increasing age among the overall study population (p=0.026) and among HIV-positive women (p=0.001), but this trend was not statistically significant among HIV-negative women (p=0.061). The four most dominant anal HR-HPV types were HPV-58 (13.2%), followed by HPV-68 (11.0%), HPV-52 (9.2%) and HPV-51, -45 and -35 (8.3 each). The four most common LR-HPV types were HPV-61 (12.0%), HPV-6 (8.9%), HPV-54, -44 (8.6% each), and HPV-70 (8.3%). Among the probable HR-HPV, HPV-53 (11.7%) and HPV-66 (8.3%) were the most common types (Figure 1). The detailed distribution of different HPV types according to HIV status is presented in Figure 1. 3.2 | Prevalence of anal HPV Types Targeted by Current Commercial HPV Vaccines A proportion of 11.7% (38/326) overall women were anal infected with one or more HPV types covered by the Cervarix® HPV vaccine types (HPV-16 and/or -18), 4.6% (15/325) at both the anus and cervix; and 7.1% (23/325) at the anal site only. HPV infection with one or more types covered by Gardasil®4 (HPV-6, -11, -16 and/or -18), were detected in anal site of 19.6% (64/326) women, at both the anus and cervix of 8.6% (27/325); and at the anal site only of 11.4% (37/325). While HPV infection with one or more types covered by Gardasil®9 HPV types (HPV-6, -11, -16, -18, -31, -33, -45, -52 and/or -58) were detected in anal site of 38.7% (126/326) women, at both the anus and cervix of 19.4% (63/325); and at the anal site only of 19.4% (63/325). The anal HPV prevalence of types targeted by the current commercial HPV vaccines did not differ according to participants HIV status (Table 2). 3.3 | Factors associated with anal HPV infection Women with cervical HPV infection were significantly more likely to have anal HPV (76.4% vs. 52.2%; RR: 1.46, 95% CI: 1.22–1.80, p<0.0001). Women with abnormal cervical cytology (ASCUS, ASC-H, LSIL or HSIL) had higher risk of anal HPV infection than those with normal cervical cytology (92.9% vs. 64.1%; RR: 1.45, 95% CI: 1.24-1.62, p<0.0001). Cervical abnormal cytology and HPV positive women remain at increased risk of anal HPV infection when compared with cervical normal cytology and HPV positive women (RR: 1.27, 95% CI: 1.09-1.44, p=0.001) or cervical normal cytology and HPV negative women (RR: 1.80, 95% CI: 1.50-2.28, p<0.0001). All the participants with abnormal cervical cytology had cervical HPV infection. Cervical HPV infection remain a risk for anal infection even when ruling out the abnormal cytology effect as demonstrated by high anal HPV among women with normal cervical cytology and HPV positive compared to those with normal cervical cytology and HPV negative (RR: 1.45, 95% CI: 1.19-1.81, p<0.001). Prevalence of anal HPV was decreased among women who were once pregnant than those who were never pregnant (RR: 0.78, 95% CI:0.68-0.94, p=0.015). It is important to note that women who were never pregnant in their life were significantly younger than those who were once pregnant (26 years median age, IQR: 21-33.5 years; 38 years median age, IQR: 31-47 years, p<0.0001 respectively) as the age might have contributed to the observed difference. Women who currently drink alcohol had higher anal HPV prevalence than those who nerver drank alcohol (80.0% vs 64.4%, RR: 1.24, 95% CI: 1.01-1.49, p=0.050). Women who reported using any direction of wiping after peeing or bowel movement had decreased risk of anal HPV infection when compared to those who reported to wipe from vagina to anus (RR: 0.68, 95% CI: 0.45-0.94, p=0.018) or those who wipe from anus to vagina (RR: 0.66, 95% CI: 0.44-0.90, p=0.006). There was no anal HPV prevalence difference between women who wipe from anus to vagina or from vagina to anus (Table 3). There were few participants who reported history of anal sexual intercourse. Even so the women who once participated in anal intercourse had no significant higher anal HPV prevalence than does who never engage in anal sexual intercourse (8/11, 72.7%; 212/311, 68.2%; RR: 1.07, 95% CI: 0.63-1.35, p<0.999). Anal HPV prevalence was not significantly influenced by age, HIV status, place of residence, education level, income, smoking, sexual debut, contraception use, condom use, number of lifetime sexual partners, number of new sexual partners past 12-months, fruequency of sexual intercouse past 1-month (Table 3). 3.4 | Anal-cervical HPV concordance and associated factors among women Half of overall population were anal and cervical HPV positive (49.8%, 162/325) for any HPV type. A proportion of 33.5% (109/325) women had same specific HPV type at both anus and cervix. Women shared up to ten different HPV types at both the anus and cervix. Among overall women, HPV types with high anal-cervical HPV concordance were HPV-58 (7.1%, 23/325), followed by HPV-68 (4.9%, 16/325), HPV-35 (4.6%, 15/325), HPV-6 (4.3%, 14/326), HPV-61 (3.7%, 12/325) and HPV-52 (3.4%, 11/325). Of the isolates detected in anal site; HR-HPV isolates were detected in both the anus and cervix of 41.0% (128/312), LR-HPV in 30.6% (68/222) and probable HR-HPV types in 27.9% (29/104, Table 4). Even though there was high HPV concordance between the anal and cervical site, the proportion of HPV types to be detected at anal site only ranged between 42.3% and 84.2%. Among the HR-HPV types, HPV-56 had higher proportion of being detected at anal site only (82.6%), while HPV-35 had least chances (42.3%). Among the probable HR-HPV types, HPV-53 had higher proportion of being detected at anal site only (84.2%) while HPV-69 had least chances (42.9%). Among the LR-HPV types, HPV-40 had higher proportion of being detected at anal site only (82.4%) while HPV-6 had least chances (51.7%). The proportion of all detected HPV isolates at the anal site, 64.7% were more likely to be detected at anal site only; when grouped according to risk level, probable HR-HPV types had higher chances (72.1%) followed by LR-HPV types (69.4%) and HR-HPV types (59.0%, Table 4). Anal-cervical HPV concordance was significantly associated with having abnormal cervical cytology (RR: 2.81, 95% CI: 2.12-3.60, p<0.0001); drinking alcohol (RR: 2.01, 95% CI: 1.36-2.91; p=0.001) and having new sexual partners past 12-months (RR: 1.42, 95% CI: 1.02-1.92, p=0.040). In contrast, older age (46-60 years) than young age (18-25 years) was associated with decreased risk of anal-cervical HPV concordance (RR: 0.41, 95% CI: 0.24-0.69, p=0.001) and being pregnant at least once in lifetime (RR: 0.62, 9+5% CI: 0.45-0.90, p=0.016, Table 5). 4| Discussion To the best of our knowledge, this is the first study to report on anal HPV prevalence, anal-cervical HPV concordance, and their associated factors among women in the Eastern Cape Province of South Africa. There was high anal HPV among women of Eastern Cape province of South Africa; this concurs with other studies 2,8,9,20 ; however, in the current study population the HIV infection did not significantly impact the anal HPV and anal-cervical concordance prevalence. In South Africa, there is a high burden of HIV and cervical HPV infection, even in the general population 16,17,21,22 , in particular, in the Eastern Cape population, cervical HPV prevalence has been reported to be up to 76% in the general population 23,24 . In addition, in the current study, HIV-positive women were the majority of the study population; all these could have contributed to this difference. HPV-16 is the dominant type in anal cancer 1,2,25 , and in current study, it was detected only in seven percent of the population. HPV-58 was the dominant anal HPV type in the current study and it is has been detected in Central African Republic as the second most dominant anal HR-HPV type 26 . Anal-cervical HPV concordance and genotype-specific concordance have been observed in a high proportion of the population 10,11,27 . High risk behaviors are associated with high incidence of anal HPV and cancer 5,19 . In the current study, having a new sexual partner in the past 12 months and alcohol consumption were associated with anal-cervical HPV concordance, consistent with findings from previous studies 9 . High HPV viral load usually found in women with abnormal cervical cytology could contribute to the observed high anal HPV and anal-cervical concordance among women with abnormal cervical cytology 20 . Even though history of ana intercourse was limited in this study, women who reported such practice had higher anal-cervical HPV concordance, supporting the reported anal intercourse association with anal HPV infection 2,5 . It is not clear why HPV anal prevalence and anal-cervical concordance was low among women who reported not sure which method of wiping after peeing or bowel movement. Post-toilet wiping behaviours have been reported to have an impact on anal HPV natural history and anal cancer, in particular wiping from vagina to anus is been reported to significantly increase anal HPV and anal precancerous risk 28 . Married and women with prior history of pregnancy had a lower risk of anal HPV; however, young age mostly associated with single and never pregnant women could have contributed on these observations 11,29 . Although several studies reported that women have increased risk of anal HPV as the number of parity increases 30-32 . History of anal intercourse is reported not to be a consistent risk factor for anal HPV, in the current, anal intercourse was not a risk factor of anal HPV, but it was for anal-cervical HPV concordance 2 . Mone than one-third of the study population had anal HPV infection of types targeted by the Gardasil ® 9 HPV vaccine. In the same population, cervical HPV prevalence of Gardasil ® 9 was reported in 42% 23 . Detection of Gardasil ® 9 HPV types at anal and cervical site concurrent were reported at 19.4% of the population. The use of Gardasil ® 9 HPV vaccine in South Africa could benefitial for both anal and cervical HPV associated diseases as the current HPV vaccines have been shown to offer protection at multiple sites 33,34 . Introduction of Gardasil ® 9 HPV vaccine in South African national vaccination program would significantly benefit South Africa in protecting against anal and cervical HPV infection. Currently South Africa use Cervarix ® HPV vaccine for the national HPV vaccination program, and this is beneficial also for anal HPV infection, but Cervarix ® HPV vaccine would protect approximately 11.7% HPV16/18 anal HPV infection cases in this population, while Gardasil ® 9 HPV vaccine would offer more protection. Strengths and weakness The use of molecular based HPV testing and genotyping of 28 different HPV genotypes in both anal and cervical site of the same participant strengthened the study. This is important as there is currently no data on anal HPV prevalence in the Eastern Cape, South African women; in addition the distribution of different HPV types is important in advicing on HPV vaccine related matters as well as anal HPV and cancer screening strategies in South Africa. Specimens used were collected by one study nurse; therefore, this would decrease the inconsistency in sampling between participants. Some of the investigated aspects relied on self-reported responses (like condom use, sexual partners, etc), which could act as a limitation in this study. Not performing anal cytology limited the study, due to this the anal HPV data could not be analysed in conjuction with anal cytology. This data is viewed necessary in advising the South African community on anal HPV and its link with anal precancerous and cancer; as well as policymakers on clinical guidelines for anal cancer screening. However, the anal HPV testing data presentedin this study is also important in advising on this aspect as HPV sensitivity and specificity for detection of anal intraepithelial neoplasia grade 2 or worse is reported to be approximately 92% and 42%, respectively; while anal cytology is reported to have Both anal HPV testing and anal cytology are accepted anal cancer screening methods 35,36 . It is acknowledged that the study population may not be fully representative of the broader Eastern Cape Province, and as such, the findings should not be overgeneralized. Nonetheless, the data generated from this study are of substantial significance for the Eastern Cape and South Africa at large—particularly as this represents the first report on anal HPV infection, anal-cervical HPV concordance, and their associated risk factors among women in the region. These findings offer a critical foundation for future research and public health interventions in similar settings. 5| Conclusion This study identified a high prevalence of anal HPV infection and anal-cervical HPV concordance among women in the Eastern Cape Province of South Africa. Notably, HIV infection did not significantly influence the presence of anal HPV or the rate of anal-cervical concordance. However, cervical HPV positivity and abnormal cervical cytology were found to be significant predictors of both anal HPV infection and concordant anal-cervical HPV detection. To our knowledge, this is the first study to report on anal HPV and associated risk factors among women in this region. These findings contribute critical data to the limited body of literature on anal HPV epidemiology in South Africa and have important implications for cervical and anal cancer prevention. They can inform future HPV-related policies, enhance targeted screening approaches, and support the expansion of HPV vaccination programs in underserved settings. Author contributions Conceptualization, Z.Z.A.M., L.M.F. and C.B.B.; methodology, Z.Z.A.M., L.M.F. and C.B.B.; formal analysis, Z.Z.A.M. and C.B.B.; investigation, Z.Z.A.M., L.M.F. and C.B.B.; resources, Z.Z.A.M., L.M.F. and C.B.B.; writing—original draft preparation, Z.Z.A.M.; writing—review and editing, Z.Z.A.M., L.M.F. and C.B.B.; visualization, Z.Z.A.M. and L.M.F; supervision, Z.Z.A.M.; project administration, Z.Z.A.M.; funding acquisition, Z.Z.A.M. All authors have read and agreed to the published version of the manuscript. Acknowledgements We thank all the women who participated in this study and the health facility staff for supporting the study procedures.This work is based on the research supported wholly by the National Research Foundation of South Africa (Development Grant for Y-Rated Researchers, Grant number 137779). The findings, views, conclusions, or recommendations expressed in this article are those of the authors and do not necessarily represent the views of the funders and institutes affiliated with the authors and/or those mentioned in this section. Ethical statement All study procedures were conducted in accordance with relevant laws, institutional guidelines, and the ethical standards outlined in the Declaration of Helsinki. All study aspects were approved by the Human Research Ethics Committee of Walter Sisulu University (HREC: 004/2022), Eastern Cape Province Department of Health (EC_202203_011), and KSD Department of Health sub-district, Mthatha. 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International Anal Neoplasia Society’s consensus guidelines for anal cancer screening. International Journal of Cancer. 2024;154(10):1694-1702. Supplementary Material File (mbulawa_analhpvmanuscriptfigures.docx) Download 20.44 KB File (mbulawa_analhpvmanuscripttable.docx) Download 55.56 KB Information & Authors Information Version history V1 Version 1 03 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords epidemiology human papillomavirus infection sexually transmitted disease virus classification Authors Affiliations Zizipho Z. A. Mbulawa 0000-0001-9073-4777 [email protected] Walter Sisulu University Faculty of Medicine and Health Sciences View all articles by this author Lindiwe M. Faye Walter Sisulu University Faculty of Medicine and Health Sciences View all articles by this author Charles B. Businge Walter Sisulu University Faculty of Medicine and Health Sciences View all articles by this author Metrics & Citations Metrics Article Usage 253 views 121 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Zizipho Z. A. Mbulawa, Lindiwe M. Faye, Charles B. Businge. HIGH ANAL HUMAN PAPILLOMAVIRUS (HPV) PREVALENCE AND ANAL-CERVICAL HPV CONCORDANCE AMONG WOMEN OF EASTERN CAPE PROVINCE, SOUTH AFRICA. Authorea . 03 June 2025. DOI: https://doi.org/10.22541/au.174894677.73772267/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); Cited by Zizipho Z. A. Mbulawa, Laston Gonah, Lindiwe M. Faye, Charles B. Businge, Prevalence and Risk Factors of Anal Human Papillomavirus and Anal–Cervical Concordance Among Women of Eastern Cape Province, South Africa, Microbiology Research, 17 , 3, (62), (2026). https://doi.org/10.3390/microbiolres17030062 Crossref Loading... View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. 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