The Human Papilloma Virus and Cervical Cancer in Ghana

CONTENTS

INTRODUCTION

HUMAN PAPILLOMA VIRUS

• Causes
• Risk factors
• Prevention
• Vaccination & Screening

CERVICAL CANCER

• Signs and symptoms

INTRODUCTION

Sexually Transmitted Infections (STIs) are infections that one can acquire from having sexual contact with an infected person. There are over 20 STIs which have been identified including HIV/AIDS, chlamydia, pelvic inflammatory disease, trichomoniasis, syphilis, gonorrhoea, HPV and genital herpes¹. According to WHO, more than a million people acquire a sexually transmitted infection a day². STIs require treatment but there are some such as HIV/AIDS which are incurable and deadly but can be managed to prolong life. Majority of STIs are asymptomatic² but the infection can still be passed on to partners³. If there are symptoms, they include bumps, sores or warts near the mouth, penis, vagina, or anus, swelling near the penis, skin rash, painful urinations, weight loss, night sweats, aches, pains, fever, chills, jaundice, vaginal or penal discharge and severe itching near genitals⁴. Infections are spread predominantly, as suggested by its name, through sexual contact, including vaginal, oral, anal sex or even genital touching³. Some ways of protecting one’s self against STIs are;

• Abstinence from sexual activities
• Condom usage during sex
• Limiting the number of sexual partners one has. The more the number of partners one has, the higher the chances of catching an STI.
• Practicing monogamy. This means a couple should have sex with only each other
• Careful choice of sex partners. Don’t have sex with someone whom you suspect may have an STI.
• Getting checked for STIs so that the infection is not passed on to others
• Knowing the signs and symptoms of STIs and looking for them in one’s self and their sex partners.
• Learning more about STIs to better protect one’s self.⁴

STIs are classified under bacterial, viral, and parasitic/fungal infections. For the purpose of this paper, the viral group shall be taken into consideration. In general, viral infections involve many different parts of the body at the same time⁵. Viral infections include;

1. Human Papilloma Virus (HPV): The human papilloma virus (HPV) is the most common viral infection. There are about 40 types of HPV that are transmitted sexually through oral, anal or vaginal sex.
2. Genital Herpes: Genital Herpes is caused by the Herpes Simplex Virus. It is in the same family of viruses that cause cold sores around the mouth.
3. Hepatitis B Virus: Hepatitis B or Hep B, affects the liver. It is not to be mistaken with Hepatitis A or C, which are other forms of liver disease. Hepatitis B is easily transmitted not only through sexual activities, but by sharing items like razors, needles and toothbrushes.
4. Human Immunodeficiency Virus (HIV): Human Immunodeficiency virus or HIV/AIDS attacks the body’s immune system, leaving infected individuals unable to fight off other illness. It is transmitted through sexual activities, but also spread by sharing items like razors, needles and toothbrushes.

Cervical cancer occurs when there is an abnormal proliferation of cervical cells. These cells gradually develop pre-cancerous changes before turning into cancers. It is one of the most common cancers in women across the world. When pre-cancerous cell changes are detected early, using a method called the pap test, they can be successfully treated to prevent cancers from developing⁶. Cervical cancers are classified into squamous cell carcinoma and adenocarcinoma.

The focus of this paper is to describe the relationship between one of the viral STIs, the Human Papilloma Virus, and cervical cancer in Ghana.

HUMAN PAPILLOMA VIRUS

Human papilloma viruses, commonly referred to as HPVs, are aetiological agents of cervical intraepithelial neoplasia and cervical cancer⁷. In humans, HPV is the most common sexually transmitted virus. It affects about 50% of sexually active people at some point in their lives⁸. Often, being infected is asymptomatic and the infection may go away without medical treatment.

HPV is spread through contact with infected genital skin, mucous membranes and body fluids, and can be transmitted through vaginal, anal and oral intercourse. HPV lives in the epithelial cells of the body hence it usually affects the surface of the skin, vagina, vulva, anus, cervix, penis head, mouth and throat.

Over 100 HPV types have been identified and each is referred to by a number⁹. HPV can be classified into a high-risk or low-risk strains. Not all of the sexually transmitted types cause serious health problems. High-risk HPV strains are known to cause about 70% of cervical cancers⁸. These are majorly types 16 and 18, but they also include types 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82. Low-risk HPV strains rarely cause cancers but instead cause warts on skin surfaces. Of the total number of virus types found, about 60 cause warts on hands and feet (A papilloma is a benign tumour derived from epithelium­). There are about 40 types of HPV that are transmitted through sex.

CAUSES

HPV infection is caused when the virus enters your body through a cut or abrasion in the epidermis of the skin. The virus is transferred primarily by skin-to-skin contact.

Genital HPV infections are contracted through sexual intercourse, anal sex and other skin-to-skin contact in the genital region. Some HPV infections that result in oral or upper respiratory lesions are contracted through oral sex.

It is possible for a mother with an HPV infection to pass on the virus to her infant during delivery. This exposure may cause HPV infection in the baby’s genitals or upper respiratory system³.

RISK FACTORS

The following are some risk factors inherent in HPV:

• Prevalence of genital HPV is directly related to the number of lifetime sexual partners, recent changes in sexual partners, marital status, age at which one first had sex, illiteracy, oral contraceptive use, alcoholism, hormonal and dietary factors and immune suppression,(domfeh et al)
• Age at first sexual intercourse: the age of a person at the time which they first had sex could be an indicator for the number of sexual partners they have in their lifetime.
• Number of sexual partners. The greater the number of sexual partners one has, the more likely they are to contract a genital HPV infection. Having sex with a partner who has had multiple sex partners also increases the risk.
• Weakened immune systems. People who have weakened immune systems are at greater risk of HPV infections. Immune systems can be weakened by HIV/AIDS or by immune system-suppressing drugs used after organ transplants.

PREVENTION

The best way to prevent getting an HPV infection is to avoid direct contact with the virus, which is transmitted by skin-to-skin contact. It is difficult to avoid skin-to-contact with our loved ones in our relationships. Also, in most cases of HPV infection, there are no visible signs for us to know in order to avoid direct skin contact with infected individuals.

Correct and consistent condom use is associated with reduced HPV transmission between sexual partners but areas not covered by condoms can still pass on the virus when they come into contact partner’s skin.

Regular pap tests, which can detect precancerous changes in the cervix that may lead to cancer are recommended.

SCREENING AND VACCINATION

CERVICAL CANCER

Most cases of cervical cancer are caused by two specific varieties of genital HPV: Types 16 and 18. Once HPV enters an epithelial cell, the virus begins to make the proteins it encodes. Two of the proteins made by high-risk HPVs (E6 and E7) interfere with cell functions that normally prevent excessive growth, helping the cell to grow in an uncontrolled manner and to avoid cell death.

Often, infected cells are recognized by the immune system and eliminated. Sometimes, however, the infected cells are not destroyed, and a persistent infection results. As the persistently infected cells continue to grow, they may develop mutations in cellular genes that promote even more abnormal cell growth, leading to the formation of an area of precancerous cells and, eventually, a cancerous tumour.

Other factors may increase the risk that an infection with a high-risk HPV type will persist and possibly progress into cancer. These include:

• Smoking or chewing tobacco (for increased risk of oropharyngeal cancer)
• Having a weakened immune system
• Increased parity (for increased risk of cervical cancer)
• Long-term oral contraceptive use (for increased risk of cervical cancer)
• Poor oral hygiene (for increased risk of oropharyngeal cancer)
• Chronic inflammation¹⁰

It can take 15 to 20 years for cervical cancer to develop in women with normal immune systems. It takes only about 5 to 10 years in women with weakened immune systems, such as those with untreated HIV infection ⁹

IN GHANA

In Ghana, cervical cancer constitutes about 57.8% of all gynaecological cancers. It is the second most common cancer in women with an estimated incidence of 26.4 per 100,000. It is also the second most common cancer in women aged 15 to 44 years in Ghana. Every year, 3,038 women are diagnosed with cervical cancer and 2,006 die from it in Ghana (Edwin, 2010; Nkyekyer, 2000; WHO, 2010)

The Pap smear and VIA have been observed to have challenges with regards to sensitivity and specificity even though the Pap smear is the gold standard for screening in Ghana.

A study conducted at the Ridge Hospital in 2013, 201 women were sampled to be used to determine the prevalence of HPV and the associated risk factors.

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