LETTER TO THE EDITORS

The prevalence of selected high-risk

human papillomavirus infections
among female sex workers in Dhaka,
Bangladesh
Sirs: Human papillomavirus (HPV) infection of the uterine
cervix is one of the most common sexually transmitted infections (STIs) and a major risk factor for cervical cancer.
Among the 84 HPV genotypes, HPV 16, 18 and 33 are most frequently associated with cervical cancer in south east Asia.1,2
Little information exists on prevalence of the most common
high-risk HPV genotypes (HPV 16, 18 and 33) among women
including female sex workers (FSWs) in Bangladesh.3
An exploratory cross-sectional study was conducted among
FSWs attending a STI service delivery facility in Dhaka,
Bangladesh, from January 2003 to January 2006. The study
was approved by the ethical review committee of
International Center for Diarrhoeal Disease Research
Bangladesh (ICDDR, B). All consecutive FSWs (irrespective of
symptoms) attending the clinic were invited to enter the
study. To be eligible for the study, participants had to be sexually active and provide written informed consent. The exclusion
criteria were current menses and pregnancy. Participants were
interviewed by a female social worker, and sociodemographic
and sexual risk behaviour information was collected using a
questionnaire. All patients had a full gynaecological examination including speculum examination and cervical sampling
by a qualied study physician.
Exfoliated endocervical cells were collected with using a cervical cytobrush (DNAPAP Cervical sampler specimen collection kit; Digene, Gaithersburg, MD, USA). Specimens were
transported to the ICDDR, B laboratory at 2 88C and stored
at 2808C until further analysis. Genomic DNA was extracted
according to the Oxford protocol4 and dissolved in water to a
nal concentration of 200 ng/mL for HPV polymerase chain
reaction (PCR). HPV DNA was amplied using primers specic
for the E6 regions of HPV 16, 18 and 33 as described by
Shimada et al. with some modications5 (an initial 1 minute
denaturation at 958C, followed by 30 cycles of denaturation at
948C for one minute, annealing at 558C for two minutes and
extension at 728C for two minutes with a ve minutes nal
elongation at 728C). Amplicons were detected using 1%
agarose gel electrophoresis. Univariate and multivariate data
analyses were performed using the Statistical Package for
Social Science (SPSS) version 11. The association of cervical
infection (dependent variable) with sociodemographic and behavioural characteristics, signs, and symptoms suggestive of
STIs (independent variables) was calculated with odds ratio
and 95% condence intervals.
A total of 1167 FSWs were invited and 809 FSWs agreed to
participate in the study. The main reason for non-participation
was unwillingness to undergo pelvic examination and the discomfort associated with cervical cell collection. Specimens were
analysed by single round PCR using HPVpF/HPVp16R,
HPVpF/HPVp18R and HPVpF/HPVp33R oligoprimers separately. The prevalence of any of HPV 16, 18 and 33 genotypes
was 18.2% (147/809). Single genotype infection was present in
15.9% (129/809) of patients and multiple genotypes were
detectable in 2.2% (18/809) (Table 1). Risk factors for HPV

Table 1 Prevalence of HPV genotype among 809 FSWs in

Dhaka, Bangladesh
Total samples
n 5 809 (%)

HPV genotype

% among positive
samples

Any HPV infection

147 (18.2)
Infection by single genotype
HPV 16
96 (11.8)
HPV 18
25 (3.1)
HPV 33
8 (1.0)

67.1
17.5
5.5

Infection by multiple genotype

HPV 16 18
10 (1.2)
HPV 16 33
6 (0.7)
HPV 18 33
2 (0.2)
HPV 16 18 33
2 (0.2)

6.9
4.0
1.4
1.4

HPV human papillomavirus; FSWfemale sex workers

prevalence among FSWs were calculated using multivariate

regression analysis. Presence of HPV infection were signicantly associated with duration of sex work (P 0.01) (odds
ratio . 1) (Table 2); however, age and pregnancy were not signicantly associated.
The prevalence and determinants of HPV infection in FSWs
provides valuable information about the epidemiology of
HPV. HPV prevalence was high among women between 19
and 30 years, similar observation has been reported in earlier
studies.3 We explored the risk factors for HPV infection
among FSWs and the duration of sex work. Duration as a sex
worker was identied as the main determinant for HPV infection; this is in turn like the number of sexual partners. Similar
observations have been demonstrated in previous studies.6
HPV 16 was the most common genotype identied (76%,
including single and mixed infections) which is higher than
reported in earlier studies.7,8
In our study, the cancer-associated HPV 16 was most
common (76.2%) among the HPV-positive samples followed
by HPV 18 and HPV 33. Data on HPV prevalence among
women in Bangladesh are limited and further epidemiological
studies are necessary to estimate the disease burden and predominant serotype distribution among women in Bangladesh.

ACKNOWLEDGEMENTS

This study was conducted at the ICDDR, B: Centre for Health

and Population Research with the support of cooperative agreement: HRN-A-00-96-90005-00 from USAID. ICDDR, B acknowledges with gratitude the commitment of USAID to the Centres
research efforts. We thank Dr Jeremy Day for his review of the
manuscript.
M Huq*, S Nahar , A Alam *, H Imam* and M Rahman
*ICDDR, B: Centre for Health and Population Research, Dhaka;

Department of Microbiology, Jahangirnagar University, Savar, Bangladesh;

Centre for Tropical Medicine Oxford University Clinical Research Unit,

Hospital for Tropical Diseases, 190 Ben Ham Tu, Quan 5, Ho Chi Minh City,
Vietnam
Correspondence to: M Rahman
Email: mrahman@oucru.org
DOI: 10.1258/ijsa.2011.011240

International Journal of STD & AIDS 2012; 23: 151 152

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152

International Journal of STD & AIDS

Volume 23

February 2012

................................................................................................................................................

Table 2

Risk factors associated with HPV infection among 809 FSWs in Dhaka, Bangladesh

Variables

Total women
n 5 809
n (%)

HPV-positive
n 5 143
n (%)

HPV-negative
n 5 666
n (%)

Age (year)
30
.30

775 (95.8)
34 (4.2)

141 (98.6)
2 (1.4)

Pregnancy
Parity
No parity

454 (56.1)
355 (43.9)

P value

Crude OR (95% CI)

634 (95.2)
32 (4.8)

0.07

3.56 (0.8 15.0)

78 (54.5)
65 (45.5)

376 (56.5)
290 (43.5)

0.67

0.93 (0.6 1.3)

Duration as a sex worker (years)

1
553 (68.4)
.1
256 (31.6)

112 (78.3)
31 (21.7)

441 (66.2)
225 (33.8)

0.01

1.8 (1.2 2.8)

Condom use during last sex

Yes
561 (69.3)
No
248 (30.7)

100 (70)
43 (30.1)

461 (69.2)
205 (30.8)

0.87

1.03 (0.7 1.5)

Presence of ulcer
Yes
No

2 (1.4)
141 (98.6)

10 (1.5)
656 (98.5)

0.93

0.93 (0.2 4.3)

Clinical sign of vaginal discharge (as observed during pelvic examination)

Yes
617 (76.3)
110 (76.9)
No
192 (23.7)
33 (23.1)

507 (76.1)
159 (23.9)

0.83

1.05 (0.7 1.6)

Clinical symptom of vaginal discharge (reported by FSWs during interview)

Yes
339 (41.9)
51 (35.7)
No
470 (58.1)
92 (64.3)

288 (43.2)
378 (56.8)

0.10

0.73 (0.5 1.1)

Clinical symptom of lower abdominal pain

Yes
71 (8.8)
No
738 (91.2)

10 (7)
133 (93.0)

61 (9.2)
605 (90.8)

0.41

0.75 (0.4 1.5)

Clinical sign of lower abdominal pain

Yes
206 (25.5)
No
603 (74.5)

34 (23.8)
109 (76.2)

172 (25.8)
494 (74.2)

0.61

0.90 (0.6 1.4)

Presence of genital warts

Yes
37 (4.6)
No
772 (95.4)

9 (6.3)
134 (93.7)

28 (4.2)
638 (95.8)

0.28

1.52 (0.7 3.3)

12 (1.5)
797 (98.5)

HPV human papillomavirus; FSW female sex workers; OR odds ratio; CI confidence interval

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