Clinicoepidemiological Profile and Sexual Behavior Pattern of Patients with Anogenital Warts

Introduction: Anogenital wart (AGW) is the infection of the anal and genital mucosa and their adjoining areas by the Human Papilloma Virus (HPV) 6, 11. Genital HPV infections are transmitted primarily through sexual contact. Objective: This study was designed to determine clinical characteristics, sexual behavior patterns


Introduction
W art is caused by Human Papilloma Virus (HPV) infection, and can affect both skin and mucous membranes. 1Anogenital wart (AGW) is the infection of the anal and genital mucosa and its adjoining areas.The terms "Condylomata Acuminata" and "anogenital warts" are generally used interchangeably, however, the former is defined by distinctive histology. 2Out of 120 HPV subtypes, 40 can infect the anogenital area.Fifteen of 40 subtypes have a high chance of developing into cancer.Anogenital warts are caused by subtypes 6 and 11, which are low risk subtypes. 3,4 enital HPV infections are transmitted primarily through social isolation, anxiety, depression, guilt, concerns about future fertility and risk of cancer. 6,7 nderstanding the predisposing clinicoepidemiological profile and other risk factors is essential for the prevention and control of AGW.Considering the dearth of knowledge in Nepal regarding AGW, the present study could be an important work in finding the risk behavior patterns of the patients with AGW and ultimately helpful in devising public health programmes.

Materials and Methods
This hospital-based descriptive cross-sectional study was conducted in Bir Hospital between November 2019 and December 2020.A total of 77 patients who presented to the dermatology OPD and only those patients were diagnosed AGW were included in the study after obtaining their written informed consent individually.AGW was diagnosed based on patient history and clinical examinations by a certified dermatologist.The patient history, physical examination findings, and laboratory reports were recorded in the proforma prepared for the study.Clinical details include number of warts, their location, and morphology, while demographic information of the patient includes age, gender, occupation, education level, and sexual history.Syphilis seropositivity was determined by analyzing corresponding Venereal Disease Research Laboratory (VDRL) and Treponema pallidum hemagglutination (TPHA) test results.VDRL, TPHA, and HIV test reports

Socioeconomic profile of AGW patients
Anogenital warts were present in people with various jobs, including students, business people, housewives, drivers, security guards, farmers, cooks, painters, engineers, dancers, and accountants.Of those who worked in various occupations, students comprised the majority of cases with 20 (26%), while migrant workers, dancers, welders, dental assistants, and accountants had the fewest occurrences with 1 (1.3%) in each category.Anogenital warts were more common amongst married individuals comprising 48 (62.3%) of cases, and less common amongst widow/widower and secondmarriage clients 1 (1.3%) case.Anogenital warts were prevalent among School Leaving Certificate (SLC) graduates and university graduates 25 (32.4%) were also used in the interpretation of results.All statistical analyses were performed using SPSS version 16.A descriptive analysis and a Chi-square test were used, and p < 0.05 was considered statistically significant.

Results
Overview of AGW patients amongst males and females A total of 77 patients comprising 75.3% males and 24.7% females, diagnosed with AGW were studied (Table 1).The age group composition of patients was as follows: 16 -25 years (41.4% males, 52.6% females), 26 -35 years (34.5% males, 36.8% females), 36 -45 years (17.2% males, 10.6% females), 46 -55 years (5.2% males) and above 55 years (1.7% males).The most common age of presentation was 16 -25 years in both males and females, with the mean age of occurrence 27.26±7.02and 30.13±9.7 years in females and males, respectively (Table 1).The mean age of first sexual contact was also recorded almost similar in both sexes.Thirty-five (89.7%) of the 39 married men had extramarital contact, and 5 (38.5%) of the 13 married women patients had extramarital contact.Hence, out of 52 married cases, 40 (51.9%)cases had extramarital contact, while 12 (15.6%)cases did not.This finding is statistically significant with the P value of 0.001, which signifies that individuals with extramarital contact are more at risk of acquiring AGW.In most of the cases, 73 (94.8%) there was no associated surface changes, while only 3 (3.9%)showed macerated changes, and 1 (1.3%) showed secondary infection change.Maximum number of cases presented early within < 3 months of the occurrence of the lesion in 43 (74.1%)males and 15 (79 %) females.In the current study, 25 (32.4%) of the patients were educated at the university level, 17 (22%) had graduated from high school, and the rest had lower education degrees.This finding is consistent with the study done by Tamer et al., who found 56% were educated at the university level and 33.5% at the high school level. 10This study reported that the prevalence of GWs increases with increasing education levels, reflecting a greater awareness of the disease leading to a higher level of early detection and seeking medical advice.
In this study, the affected sites of GWs in males in decreasing order of frequency were penis 42 (72.4%),followed by perianal skin 8 (13.8%), multiple sites 7 (12.1%),and perineum 1 (1.7%); while in females the most common site involved was vulva 11 (57.9%),followed by perianal skin 5 (26.3%), multiple sites (vulva, vagina, cervix) 4 (21.1%) and perineum 1(5.3%).This finding is in contrast to the study done by Tas et al., who found the pubis (43.2%), followed by the penis (12%) as the frequent sites in males; and the perianal region (48.9%),followed by the vulva (11.1%) as the frequent sites in females. 11e current study showed that 56 (72.7%) patients had GW of size 1−5 mm while 10 (12.9%) had GW of size 5−10 mm, and 11 (14.3%) had wart size >10 mm.This finding can be explained by early seeking medical treatment after acquisition of genital warts.The most common morphology of GWs was domeshaped 48 (62.4%), followed by plaque 17(22%) and filiform 12 (15.6%).Similar to the study by El-Hamd et al., in Egypt, papular (dome and filiform) was the most frequent morphology present in 85% patients, followed by plaque in 15% patients. 8ost patients in our study were polygamous, 60 (77.9%) who had sex with girl friend/boy friend or friends/colleagues or commercial sex workers in addition to their spouses.This finding is similar to a study done by Barua et al., who found the majority i.e., 70% of patients with AGW, were polygamous, and only 30% had a monogamous sexual relationship. 2n the current study, only 5 (6.5%) had a history of regularly using condoms, while the majority, 48 (62.3%) of patients with GWs had an occasional history of condom use, followed by 24 (31.2%) who never used condoms at all.This finding is consistent with the study done by El-Hamd et al., in Egypt who found only 15.4% of patients had a history of consistent use of condoms and majority 80% gave a history of occasional use of condoms. 8It is believed that HPV is transmitted by skinto-skin contact and that condoms provide a barrier to transmission of HPV from infected areas of skin.This study found that with increasing duration, the number of AGWs increases, as suggested by our findings in which about 60% of individuals with age of more than nine-month duration had > 10 warts, and none of them of the same duration had few warts.However, the finding was not statistically significant (p=0.355).All patients were checked with "VDRL; TPHA", where 7.8% had coexistent syphilis, which is almost 4.6 times higher than the prevalence of syphilis in the general population (1.7%). 12This finding is similar to a study done by Paudel et al., who found 8.9% cases of syphilis amongst all STIs. 13hile analyzing HIV status in patients with AGW, 2 (2.6%) were positive for HIV serology which is 18.6 times higher than the prevalence of HIV in the general population, which is 0.14%. 14Amongst other coexistent STIs, syphilis was the most common in our study, which is similar to Mueller et al., and Barua et al. 15,2 Hence, patients with AGW should be evaluated and, if required, tested for syphilis and HIV.

Limitations of the study
The study included only participants visiting a single dermatology clinic as cases.The subjective complaints and sexual history is based upon the patients' explanation.

Conclusion
AGW is more common in males than females.The lower proportion of females suggests unreported community cases who can act as infection reservoirs.Youths in their early twenties had more AGW.Hence, college-level education requires sex education so that they can practically implement safe sex practices.Also, to prevent malignant transformation, diagnosing any carcinogenic virus strains early on is important.The national immunization program should include immunizations against the human papillomavirus.

Recommendations
Owing to the presumed high prevalence of patients with AGWs in Nepal, population-based multicenter studies with large sample size is required to understand the epidemiological and clinical aspects of AGWs.

Table 2 :
Clinical characteristics of AGW Altogether three different morphologies, such as dome-shaped, filiform and plaque were recorded (Figures1, 2, 3).Of them, dome-shaped morphology was the commonest (58.6% cases in males and 73.7% cases in females), followed by plaque (22.4% cases in males and 21% cases in females), and filiform (19% cases in males and 5.3% cases in females).