Sociodemographic and clinical factors of women with HPV and their association with HIV 1

OBJECTIVE: to identify the association between HIV-seropositive or HIV-seronegative status and the sociodemographic and clinical variables of women with genital HPV infection. METHOD: cross-sectional, retrospective study in a reference service in Ribeirão Preto. A total of 824 women undergoing HIV testing who had high or low grade cervical intraepithelial lesions or condylomatous genital lesions caused by HPV were studied. The chi-square test and logistic regression analysis with the calculation of the odds ratio and a confidence interval of 95% were conducted to verify the association. RESULTS: a higher probability of seropositivity was identified for non-white women; with low education; widowed; who consumed alcohol, tobacco or illicit drugs; with hepatitis C; who had multiple partners; and that worked as prostitutes. CONCLUSION: the increasing impairment of women due to sexually transmitted infections, considering the influence of the socioeconomic and behavioral context on the course of these infections, highlights the importance of public policies that establish intervention strategies involving the prevention, early diagnosis and timely treatment of these diseases, so that there is the promotion of quality of life in this population.


Introduction
Infection with the human papillomavirus (HPV) is a public health problem, being considered the most common sexually transmitted infection (STI). It is estimated that approximately 600 million people have HPV worldwide and that about 75-80% of the population will acquire the virus at some point in life (1) .
Brazil is a world leader in incidences of HPV, with women between 15 and 25 years of age being the population most affected. Although this infectious disease also extends to males, it is believed that the number of registered cases is smaller due to the low demand of men for urology services, a factor related to prejudice and a lack of information (2) . HPV infection has been associated with the human immunodeficiency virus (HIV), suggesting a greater chance of developing low (LSIL) and high grade (HSIL) cervical intraepithelial lesions in women living with HIV, due to their immunosuppression (3)(4)(5) . It is noteworthy that the prevalence of these lesions in HIV seropositive women with a CD4+ counts below 200 cells per µl and a viral load greater than 10,000 copies per mL is three times higher when compared to seronegative women (6)(7) .
In addition to the greater chance of developing cervical intraepithelial lesions, women living with HIV present significantly longer persistence of HPV infections than those without the virus. Some authors have associated this predisposition with the fact that these women suffer lower levels of CD4+ T lymphocytes and increased viral load levels (8) , in addition to presenting a greater number of cervical samples of HPV viral DNA (9)(10) and having a higher incidence of high oncogenic risk virus types (11)(12)(13) .
Furthermore, HIV infection alters the natural history of HPV infection, with lower rates of regression from LSIL and higher risk of progression to HSIL and invasive lesions resistant to treatment, making more interventions and monitoring necessary (3,5,10) . A study on the association between HPV infection and women living with HIV found that this issue is particularly relevant in relation to the establishment of appropriate prevention strategies and for the treatment of patients, requiring prior knowledge of the epidemiology and pathogenesis of HPV infection in the population of HIV seropositive women (5) .
Therefore, due to the relevance of HPV/HIV coinfection, the Centers for Disease Control and Prevention (CDC) has considered the precursor lesions of cervical cancer in the classification of HIV infection since 1993.
Women with HIV infection who present LSIL or HSIL are classified as symptomatic (category B of the infection).
Those that present cervical cancer are classified as AIDS carriers (category C) (14) .
Considering the above information, the aim of this study was to analyze the association between HIV-seropositive or HIV-seronegative status and the sociodemographic and clinical variables of women with genital HPV infection. The intention was to contribute to the production of theoretical knowledge capable of supporting the design and implementation of public policies that enhance the management of harm resulting from both infections, through prevention and treatment strategies and the organization of the services and health practices.

Methods
This was a cross-sectional, retrospective study, For the data collect, a structured form was developed specifically for this study, with the form and content having been validated by three specialists in HPV infection. The variables included were:   For the application of the statistical model, the ethnicity variable, which was categorized into four groups, was dichotomized as white and non-white, due to the low numbers found in some of the options of the table, so as to make the analysis feasible.
The answers "no information" for each clinical and socio-demographic variable were considered missing and not entered in the analysis. In the serology for hepatitis B, hepatitis C, and syphilis items the answer "not performed" as well as answer "no information" were considered missing. In the total number of sexual partners item only one woman answered "never had sexual relations", therefore, it was excluded from the analysis, yielding an n of 823 women for this item.
The study was reviewed and approved by the    (15) .

The relationship between ethnicity and HIV/AIDS
is contained in the historical, cultural, political and ideological constructs (16). The exposure of black people to the cumulative processes of social disadvantage influences their greater or lesser access to health services, material goods, education, housing, public goods, and information, leading to higher incidence of HIV infection in this population (16)(17) . Education is a determining factor in social vulnerability. Knowledge mediates attitudes that will benefit or not the risk perception regarding the cervical cancer precursor lesions (18) . Access to healthcare services and adherence to the HIV/AIDS treatment are also mediated by education, which impacts on the comprehension of the therapy, due to difficulties in the interpretation of the information provided by the health team and in the recognition of the importance of performing the treatment correctly (19) .
Regarding marital status, although this study Regarding the fact that being widowed was considered predisposing for HIV-seropositivity, a study performed in an outpatient clinic of a reference center in the STI area, located in São Paulo, which evaluated sexuality and reproductive health of women living with HIV/AIDS, claimed that this data was to be expected, since many of these women became widows because their partners had AIDS (20) . HIV and HPV, than the general population, due to factors directly related to the prostitution, such as the greater number of partners and lack of condom use, and due to socioeconomic factors such as low levels of education and low purchasing power. Therefore, it is necessary that the healthcare services start to pay more attention to this population, both in terms of the provision of preventive programs, as well as the development of new investigations to that would provide better knowledge about the specific risk factors of this group for STIs (25) . to the healthcare services, both for prevention and for the timely diagnosis and ongoing therapy.

Conclusion
A higher possibility of seropositivity was identified in this study for the following women with HPV: nonwhite; with low education levels; widowed; who consumed alcohol, tobacco or illicit drugs; with hepatitis C; who had multiple partners; and that had worked as prostitutes.
The social and economic inequalities experienced by these women reveal numerous consequences resulting from the pathology and the gender disparity, related to stigma and prejudice, with impact in their social, family, emotional and sexual relationships.
Considering the increasing involvement of women in the STIs and the strong influence of the socioeconomic context on the route of these infections, the importance of public policies that establish appropriate strategies for prevention, early diagnosis and treatment are highlighted, aiming for the promoting of quality of life in this population.