Women of African descent commonly present cervical cancer in more advanced forms. This fact is more observed due to their greater exposure to adverse social living conditions, as well as precarious accessibility conditions and low supply to health services13.
The data cited above corroborate our findings, where the quilombola and gypsy women surveyed were mostly characterized as low socioeconomic status, elderly, black, married, with early sexual activity and with sexual exposure to risk by not using the condom, thus being more vulnerable to HPV infection and the development of cervical cancer.
The incidence of cervical cancer has a strong tendency to be concentrated with a burden of 80% in the poorest countries with a low Human Development Index (HDI). In these areas, this burden is four times higher when compared to more developed areas. Another aspect that shows that cervical cancer is a problem in poor countries is related to the time of diagnosis, because in poor women it occurs late, usually between 44 and 68 years of age. As for mortality, 88% of deaths occur in these less developed regions, around 45 to 76 years of age14.
The overall frequency of cytological alterations in quilombola and gypsy women was low (<6.5%). The positivity of cervical cytology samples varies between 3 and 10%, revealing good quality in their analysis. Therefore, the frequency identified in our study was similar to the parameters reported at national and international levels15.
Regarding the frequency of atypia, our survey found significance with the menopausal phenomenon. Therefore, there is no direct relationship between menopause and the occurrence of atypia. This variable is not related specifically in terms of menopause, but because of the age range in which it occurs16. The risks of CIN II and CIN III progression for single and multiple infections are 71.2% and 28.8%, respectively. The mean age for ASC-US and LSIL HPV lesions has been shown to be 34.5 years for women progressing to CIN17.
In a study conducted in tribal women a higher trend of coinfection for HPV-high risk with HPV-low risk was observed. The prevalent HR-HPV subtypes among tribal women in south India were HPV-18 (28.3%), HPV-45 (22.8%) and HPV-16 (10.7%). Infections with single HPV subtypes were observed in 14.4% and multiple HPV subtypes in 24.7%. Viral co-infections with HR-HPV subtypes were predominant in these, with 59.7% of cases18.
In an international study of 165 Gypsy women aged 25 to 64 years, 6% (10) of the cases of atypia occurred, and HPV was present in only 4 cases19. Thus, in comparison with our findings, we observed a similar frequency, (6% versus 4.54%), where in these results all cases of atypia were infected with HPV.
A relevant systematic review with meta-analysis on the prevalence of HPV in Brazil showed that the overall prevalence of cervical HPV was 25.41 and in the northeastern region (32.82%)20. In comparison to these data, in our findings a higher frequency of HPV(41%) was observed in relation to Brazil and the northeastern region, cited above.
In a nationwide study conducted in 26 state capitals and the Federal District with 5,569 women, black women accounted for 16.77% (1,200). For women belonging to the D/E class, the overall prevalence of high-risk HPV was 37.96%. HPV 16 was the most prevalent in this same group. These findings signal the phenomenon of pauperization of HPV21, pattern also observed in quilombola women, where the occurrence of oncogenic HPV was 18 (85.7% - p value 0.406) with a higher frequency for HPV 16, with 39.28% cases12.
We compared our results with studies conducted in quilombola communities in a state of the southeastern region, we found a higher frequency of HPV with 41.37%. The study conducted in two cities in Espírito Santo (São Mateus and Conceição da Barra) with 352 quilombola women points out that the overall frequency of HPV was only 11.1%22.
The study conducted in Maranhão, with 353 women in 04 quilombos in the cities (Alcântara, Bequimão, Central do Maranhão and Mirinzal), contrasted the main findings of this study with the research evidenced here. The prevalence of HPV identified (13.03%) was also lower than our findings 60 (41%). The single infection was more frequent than multiple infections in quilombola women. In this aspect, regarding the number of infections, the opposite occurred in our findings, where multiple infections were more frequent with 93.75%. As for the high-risk HPVs, there was a higher frequency of these, with 10.2%, followed by low-risk HPV with 2.8%. Regarding the oncogenicity of HPV, in our findings there was a higher frequency of low-risk HPV 18(64.28%) cases23.
Regarding the variable high-risk HPV genotypes, another robust study was conducted in 34 quilombos in 06 cities in MA (São José de Ribamar, Presidente Vargas, Viana, São Luís Gonzaga, Central do Maranhão and Alcântara), the most prevalent types were: HPV68 (26%); HPV58 and HPV52 (20%); HPV31 (10%) and HPV62 (8%); types: 16, 18, 33, 39, 45, 51, 53, 54, 55, 56, 59, 61, 66, 70, 71, 72, 73, 84 were identified(11). Unlike our findings, HPV-16 was the most frequent with 11(39.28%). The identified HPVs were common with our study: 16, 18, 39, 45, 53, 54 and 66.
Given this evidence, it is considered that there was a high prevalence of HPV infection in the ethnic groups analyzed, being higher than the frequencies recorded in other studies published in Brazil and the Northeast. All cases of minor cytological alterations(atypia) were HPV infected. Most women infected with HPV had multiple infections with a predominance of high-risk HPV genotypes, the most frequent being HPV-16. Quilombola women had a higher risk of HPV infection and development of cytological atypia than gypsy women.
HPV strains and sublineages, especially HPV-16 and HPV-18, were not investigated in this study due to the limitations of the molecular methods used. This fact presents itself as a future need for investigation, as well as the follow-up of these women regarding new outcomes.
This study shows that the HPV virus is circulating among quilombola and gypsy women in this region. These minority groups are invisibilized and have great difficulty in accessing health services. On the other hand, the results point to a need for greater reflection on the model of care practiced as well as the approach of the family health strategy with integration of teaching and service in the development of actions and interventions to minimize the chain of transmission of HPV, as well as the follow-up of positive cases of high risk demonstrated. The information revealed about the high frequency of HPV can provide data to support decision makers at the local level in the development of planning for the provision of health policies to these neglected groups.