Epidemiologic and clinical profile of human Papilloma virus infection in the department of Dermatology-Venerology of the Donka National Hospital in Conakry, Guinea

Objective: The objective of this study was to determine the prevalence and factors associated with human Papilloma virus infection in the department of Dermatology-Venerology of the Donka National Hospital in Conakry, Guinea. Methods: This was a descriptive and analytical cross-sectional study over a 6-month period (from 1 November 2016 to 30 April 2017). We included patients visiting the department of Dermatology-Venereology of the Donka National Hospital of Conakry. Results: Of the 3,000 patients visiting the facility during the study period, 327 had clinical symptoms of HPV infection (10.90%) with a female and younger-aged predominance. 60.24%were respectively single. Clinical symptoms were mainly common warts (30.58%), flat warts (18.65%), and plantar warts (13.15%)and the most frequent locations were the upper limbs (42.20%), the vulvovaginal region (24.46%) and the forehead (19.57%). Factors associated with mucosal infection were HIV infection, history of sexually transmitted infection, multiple sexual partnership while the tropism location were associated withmicro trauma and erosions. Conclusion: Human papilloma virus infections are common in our context with various clinical presentations and locations. The risk factors vary according to the type of infection’s tropism (mucosal or cutaneous tropism).


Introduction
Infection with human papillomavirus (HPV) is a real public health problem with an overall incidence of more than 30 million new cases per year, and probably the most common viral sexually transmitted infection in the world [1]. HPVs infect the skin (warts) and mucous membranes (condylomas), particularly squamous epithelia, and are classified according to their cutaneous or mucosal tropism [2]. More than 120 HPV genotypes are known to cause pathologies of varying severity, ranging from warts to neoplasia. These viruses are transmitted more particularly, but not exclusively, through sex, and are associated with cervical cancer [3][4][5][6]. High-risk oncogenic HPV infections account for 5.2% of all cancers worldwide, 2.2% of cancers in developed countries and 7.7% in developing countries [7]. In several studies, 75% of women have been exposed to HPV in their lifetime [2,8,9] and those aged 15 to 25 are the most affected [4,9]. The highest prevalence (>20%) is observed in Africa and Central America [2].
Prevalence rates of anogenital warts in sub-Saharan Africa among female sex workers and women with STIs range from 2.9% to 10.7%. In men, prevalence rates range from 4.1% to 4.8% in West and Central Africa [10]. The main factors associated with HPV infection are gender, age, race, socio-demographic characteristics, sexual behavior, history of sexually transmitted infections, parity, contraceptive methods, and smoking [11]. Few authors have studied the association between HPV infec-Epidemiologic and clinical profile of human Papilloma virus infection in the department of Dermatology-Venerology of the Donka National Hospital in Conakry, Guinea doi: 10.7243/2052-5958-6-1 tion and sex since most of these studies are conducted only in women [11]. About 12% of women with normal cervical smears show cervical HPV carriage detected by molecular biology, with women in sub-Saharan Africa showing the highest prevalence (24%) compared to women from Eastern Europe (21%) or Latin America (16%) [12]. It is important to note that sub-Saharan Africa has the highest prevalence of cervical HPV infection in the world, with some prevalence reported particularly high, such as in Guinea (48%) and Mozambique (41%) [13,14].
In 2009, Keita et al. [15] reported an overall prevalence of 50.8% HPV in a population of 996 women with or without cervical cancer in Conakry (Guinea). However, there is still a lack of knowledge about the prevalence of this infection in the Guinean hospital context.
The objective of this study was to determine the prevalence and factors associated with human Papilloma virus infection in the department of Dermatology-Venereology of the Donka National Hospital.

Methods
Our study was conductedin the Dermatology and Venereology Department of the Donka National Hospital of Conakry. This department is the only one of its kind in the Conakry TeachingHospital of and the country. It receives an average of 500 patients per month.
This was a descriptive and analytical cross-sectional study over a 6-month period (from 1 November 2016 to 30 April 2017). We included patients admitted and treated in the department who voluntarily accepted to participate in the study. The diagnosis of HPV infection was made based on the clinical features of the lesions examined by a dermato-venerologist. Patients were randomly recruited. The minimum sample size was estimated at N=3000 to allow the recruitment of a representative number of cases of HPV infection. The probing step was six (3000/500) and the first individual was randomly assigned the number three. Consecutively, each sixth patient admitted to the departmentwasselected and asked for his participation in the study (e.g. Patients 3, 9, 15, 21, ...).
Data was collected using a standardized questionary focused on socio-demographic variables (age, sex, marital status, occupation and educational level) and clinical variables (type of clinical symptoms and location of lesions). The analysis of factors associated with HPV infection was performed differently depending on whether the viral tropism was mucosal (age of first sexual intercourse, use of a protective device during sexual intercourse, serological status in the HIV test, history of sexually transmitted infection (STI) and number of sexual partners) or cutaneous (micro trauma or erosion).Data was analysed using Epi info version 7.2 software (CDC Atlanta, USA). The qualitative variables were compared by the chi2 test. Factors associated with HPV infection were identified using bivariate analysis and simple logistic regression with a significance level set at 5%.

Results
Of the 3,000 patients visiting the facility during the study period, 327 (10.9%) had clinical symptoms of HPV infection ( Table 1). Female gender was predominant with a sex ratio of 0.61. The mean age was 26.52 ± 15.74 years ranging 5 to 74 years. Most of our study participant weresingle (60.24%) and had at least a primary level of education (72.17%). In our context, the most common clinical symptoms were common warts (Figure 3) (N=100,30.58%), verruciform epidermodysplasia ofLutz-Lewandowski with acuminate condyloma (Figure  1) (N=68; 20.80%) and flat warts (N = 61.65%) ( Table 2

Discussion
This study is one of the first to evaluate the prevalence of HPV infection in Guinean hospital setting, thus filling a local gap of knowledge on the subject and adding to the existing body of literature in sub-Saharan Africa.
In the literature, the prevalence of HPV infection varies according to the country and population. A 26% proportion has been reported in Africa while Asia seems less affected conservative (8%) [8,11]. HPV infections with a high risk of cancer (such as serotypes 16 and 18) are more prevalent (66.7% of serotypes) than those with low risk (27.7%), regardless of the region of the world [8,16]. In general, HPV type 16 is the most prevalent in the world with an estimated prevalence of 26.3% [16].
We have recorded a female predominance as already reported in several studies [2][3][4][5][6][7][8][9]. Although most of researches have focused on HPV infection in women because of the association between HPV infection and cervical cancer, very few studies in men have found prevalence as high as those reported in studies conducted in women [16].
The patients in our study were relatively young. It is known that HPV infection is more common in the age group of 20 to 29 years [11]. After 30 years, the prevalence of HPV decreases rapidly. Moststudies [8,11,17,18] demonstrate an inverse association between age and HPV infection, except those with very homogeneous populations in terms of age. The decrease in the prevalence of HPV with age seems independent from sexual activity [11].
Warts were the most common clinical symptoms in our study, followed by condyloma with various locations. Common vulgar warts are located mainly on the back of the hands and fingers; they are more rarely palmar. Their number varies from a few units to several tens and they are sometimes confluent. Periungual and subungual warts may give rise to nail changes. The other locations are less frequent (face, scalp) where they assume the appearance of large warts arranged around the orifices or screening the cervical and bearded region (selfinoculation by shaving) and the flat common warts that sit with predilection on the face, on the back of the hands and on the limbs [19].
Although condylomas are benign, they are often poorly supported psychologically and recurrences after treatment are common, thus leading to high management costs [2,20]. The prevention and management of HPV infections in Africa is gradually expanding beyond national boundaries. However, no country in sub-Saharan Africa has so far been able to cope alone with the high, unavoidable, costs of tackling this   emerging public health challenge at all levels [21].
We found vulvovaginal, oral and perianal mucosal sites that could be related to genito-genital, genito-oral and genitoanal traumatising sexual practices. In fact, the lesions are more frequent in the regions traumatized during the sexual intercourse and can be single or multiple.
In our study, we found that HIV infection, history of sexually transmitted infection (STI), and multiple sexual partnership were significantly associated with mucosal tropism HPV infection while micro trauma and erosions were associated with cutaneous tropism HPV infection. Patients who first had sex between the ages of 11 and 20, those who tested positive for HIV, those who reported a history of STIs, and those who reported more than one sexual partner were more likely to have an infection of HPV. The total number of sexual partners and the number of recent partners appear to beconsistent determinants of HPV infection, especially for oncogenic strains [11]. Co-infection with HIV, which is highly prevalent among sexually active women in sub-Saharan Africa, is a cofactor that facilitates carcinogenesis associated with HPV-HR infections. Indeed, HPV-HR infections are nearly 5-fold more common in HIV-infected women [22], who have a 40-fold higher risk of developing high-grade intraepithelial lesions [22,23], and a 2 to 22-fold higher probability of developing cervical cancer than HIV-negative women [23]. In parallel with the different specific actions carried out within the framework of AIDS programs, the implementation of public health interventions in Africa for the prevention, diagnosis and management of HPV infections and cervical cancer lesions will have to follow a programmatic progression at regional and then national level. In the field of care, the means of diagnosis and curative tools, as well as medical and socio-community agent, follow at national level the organization of the health pyramid [24].
Our study had limitations. Because the study was carried out in a national reference service for dermatological and venereological diseases, its results might not be generalized to the entire Guinean population. In addition, we could not determine the different serotypes of HPV. Nevertheless, it has provided useful information on the epidemiologic and clinical profile of HPV infections in Guinean hospitals.

Conclusion
This study shows that infection with human papilloma virus (HPV) is common in our context with various clinical presentations affecting the skin and mucous membranes. The main associated factors were HIV infection, history of sexually transmitted infection and multi sexual partnership for mucosal infections; microtrauma and erosions for skin tropism infections.
A study including virological aspects would better help understand the involvement of other factors in the occurrence of HPV infection in Guinea.