prevalence was higher in this study than that reported for Porto Alegre,
in Southern Brazil ; it was similar to that estimated for Africa ;
and it was less than that reported for Recife , Brasilia ,or
estimated for Central and South America . It was highest among
women younger than 34 years, less in the 35 to 44 years age group, and
higher again among women 45 years or older. Most of the women with
HSILs were between 25 and 54 years old, and there was no linear relation
between age group and HPV prevalence. The overall HPV prevalence in
this study for women with HSILs was higher than that reported for Porto
Alegre , but less than that reported for Recife or Brasilia [18,24].
These differences can be explained not only by variations usually
observed between populations of different geographic regions, but also
by differences in age and lesion grades among study populations and the
sensitivity of the HPV DNA assays used in different studies [2,25].
An association between ethnicity and cervical lesion was observed
only for HSILs, suggesting a trend for lesions to progress faster in
nonwhite women. Most of the women in the 3 groups were married or
had only 1 sexual partner. No associations were observed between
HPV prevalence or development of cervical lesions and marital status.
Compared with the participants with normal cytology results, HPV
prevalence was signiﬁcantly higher in participants with either lesion
grade. The overall prevalence of HPV-16 in this study was similar to
that estimated for Africa, but higher than that reported for Recife 
or estimated for South America [19,20]. We found an association
between HPV infection and the presence of LSILs among women
infected with HPV-16 and HPV-58 as single infections as well as
among those infected with both HPV-56 and HPV-58. We also found
an association between HPV-16 infection and presence of HSILs.
We found both LSILs and HSILs to be associated with age and
multiple sexual partners. On the other hand, we found only HSIL to be
associated with early age at ﬁrst sexual intercourse or with smoking,
even when all variables were considered simultaneously in a logistic
regression model. And we found no association between the presence of
premalignant lesions of either grade and oral contraceptive use or family
history of cancer. These results are concordant with those reported in
studies conducted in São Paulo, Porto Alegre, and Buenos Aires [12,22].
In the 3 study groups, the most of the women testing positive for HPV
were infect ed with 1 or 2 high-risk types. Among women with normal
cytology results, the HPV-16 preva lence w as very similar t o that estimated
for South America  , but higher than that estimated for Africa and twice
than that reported for Recife [1 8]. These results show that HPV-16 is
highly preva lent in the female population of Natal, Brazil. And since other
high-risk HPV types also infect the same population, these women in our
region are at high risk for HPV infection and, consequently , for cervica l
cancer. The distribution of the HPV types in this study was similar to that
described for w omen in Africa and in Central and South America.
The results of this study lead us to conclude that high-grade lesions
are associated with age and ethnic ity. Multiple lifetime sexual
partners, single infection with HPV-16 or HPV-58, and double infection
with HPV-56 and HPV-58 increased the risk of having LSILs. Early age at
ﬁrst sexual intercourse and multiple sexual partners, smoking, and
infection with HPV-16 all increased the risk of having HSILs. The most
prevalent virus type was HPV-16 in the 3 groups, followed by HPV-58
in the normal cytology and LSIL groups, and HPV-45 in the HSIL group.
Despite similarities in the order of prevalen ce of some HPV types
found for Natal in this study and other regions of Brazil in different studies,
there w ere importa nt differences in the prev ale nce of HPV types 3 1, 33, 45,
56, 5 7, and 59. By virtue of the existence of multiple HPV types and
variat ions in their distributions, even within the same geographic region,
more local studies should be conducted to ev alua te the cost-beneﬁtand
expect ed efﬁcacy of a HPV v accination campaign, if found justiﬁed.
This study was supported by funds from the Conselho Nacional
de Desenvolvimento Cientíﬁco e Tecnológico (National Council of
Scientiﬁc and Technological Development [CNPq]) and the Coorde-
nação de Aperfeiçoamento de Pessoal de Nível Superior (Coordination
of Improvement of Higher Education [CAPES]).
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