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BACKGROUND: Understanding the natural history of anal high-risk human papillomavirus (hrHPV) infection is key for designing anal cancer prevention programmes but has not been systematically characterised. METHODS: We reanalysed data from 34 studies with 16 164 individuals in six risk groups defined by HIV status, gender, and male sexuality: men who have sex with men (MSM) living with HIV (LWH) [MSMLWH], HIV-negative MSM, women LWH (WLWH), HIV-negative women, men who have sex with women (MSW) LWH (MSWLWH), and HIV-negative MSW. We used Markov models to estimate incidence and clearance of 13 hrHPV types and their determinants. RESULTS: HPV16 had the highest incidence:clearance ratio of the hrHPV types. MSMLWH had highest hrHPV incidence (e.g. 15.5% newly HPV16-infected within two years), followed by HIV-negative MSM (7.5%), WLWH (6.6%), HIV-negative women (2.9%), MSWLWH (1.7%), and HIV-negative MSW (0.7%). Determinants of HPV16 incidence included HIV status and number of sexual partners for MSM, women, and MSW, and anal sex behaviour for MSM only. HPV16 clearance was lower for people LWH (PLWH), and lower for prevalent than incident infection. Among MSM, increasing age was associated with lower clearance of prevalent, but not incident, HPV16 infection. CONCLUSIONS: This robust and unifying analysis of anal hrHPV natural history is essential to designing and predicting the impact of HPV vaccination and HPV-based screening programmes on anal cancer prevention, particularly in MSM and PLWH. Importantly, it demonstrates the higher carcinogenic potential of longstanding anal prevalent hrHPV infection than more recent incident infection.

Original publication




Journal article


Clin Infect Dis

Publication Date



HIV, HPV, anus, clearance, incidence