The Significant Association Between Human Papillomavirus (HPV) Infection and Female Genital Mutilation (FGM) Among Women in Ekiti State, Nigeria

Introduction

The global impact of cervical cancer is highly unequal; while it ranks as the fourth most frequent cancer for women worldwide, the greatest concentration of cases and mortality is seen in low- and middle-income nations, especially across Sub-Saharan African [1]. The disease is almost entirely attributable to long-infection with high-risk types of the Human Papillomavirus (HPV). HPV 16 and 18 are implicated in about 70% of the disease burden worldwide [2]. Effective primary prevention measures, such as vaccination, coupled with robust screening programs, can halt the incidence of this malignancy.

In Nigeria, as of 2023, the malignancy ranks the second most frequently occurring among women and an estimated 12,075 women are diagnosed annually with cervical carcinoma [3]. The high prevalence is attributed to limited access to effective prevention and screening programs, common occurrence of high-risk Human Papillomavirus genotypes, and specific behavioral and biological risk factors.

Female Genital Mutilation (FGM), a cultural practice prevalent in some regions of Nigeria, involves the partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons. [4] FGM is a recognized cause of various reproductive health complications, including chronic inflammation, scarring, and obstetric complications [5]. Epidemiological studies have suggested that the tissue damage and long-time inflammation resulting from FGM can foster conditions that enable HPV to infect and persist, which in turn could escalate the risk of cervical carcinogenesis [6].

Despite the high prevalence of FGM in Nigeria, there is a significant gap in context-specific data directly linking this practice to HPV infection status using molecular detection methods. This study addresses this gap by investigating the rate of occurrence of HPV among women of reproductive ages (18–50 years) attending the Federal Teaching Hospital, Ido-Ekiti (FETHI), a key service and referral center in Ekiti State and critically examining the relationship between HPV status and FGM exposure. The findings will provide crucial, evidence-based data to key stakeholders to strengthen cervical cancer prevention programs and inform targeted public health policies.

Materials and Methods                                                                                                                      

The methodology employed a cross-sectional approach for this research. It was a diagnostic, and laboratory-based study carried out in Ekiti State, Southwestern Nigeria, at the Federal Teaching Hospital, Ido-Ekiti (FETHI) between February and July 2025. FETHI is a major tertiary healthcare provider serving a large, diverse population from Ekiti and neighboring states. The study population consisted of 110 consenting women aged 18 to 50 years (child bearing age) attending FETHI clinics, including Antenatal Care, Gynecology Outpatient Department, and the Family Planning unit. Fisher’s formula [12] was used to estimate the sample size. The calculation with a 7% expected prevalence and a 10% attrition rate, yielded a final sample size of 110. Exclusion criteria included women with a prior diagnosis of HPV-related conditions.

A semi-structured, close-ended questionnaire was administered to collect information on age, marital status, education, occupation, parity, and FGM status. 5 mL of blood (for serum) and 20 mL of first-void urine were collected from each participant. Serum samples were screened using a Solid Diagnostic Test Kit (Colloidal Gold), an indirect immunoassay to detect anti-HPV IgG antibodies.

 HPV DNA Detection (Active Infection – PCR): Total DNA contents were isolated from urine samples using a QIAGEN QIAamp Fast DNA Mini Kit, following manufacturer’s guidelines. Extracted DNA was then amplified and typed using the Human Papilloma Virus (Viuick, China) on a CFX96 Real-Time System using an Internal Control (IC) to monitor for PCR inhibition. Ethical approvals were obtained from Federal Teaching Hospital, Ido Ekiti Ethics Committee. The data analysis was done with the aid of Statistical Package for the Social Sciences (SPSS), version 27. Prevalence was calculated using descriptive statistics, and the Chi-square (chi^2) test was applied to access relationships between FGM and HPV infection, with results considered significant if the p-value was less than 0.05.

Results

With a total of 110 people enrolled in this study, 33 {30.0%}) tested positive for anti-human HPV IgG antibodies (past exposure). However, Real-Time PCR confirmed the presence of active viral DNA in 12 participants, yielding an active infection prevalence of 10.9% (Figure 1).

Women who had undergone FGM (n=49) had a 51.0% seroprevalence (RDT) and a 22.4% active infection prevalence (PCR). In contrast, women who had not undergone FGM (n=30) had a 20.0% seroprevalence and only a 3.3% active infection prevalence. The Chi-square test confirmed a highly significant association between FGM and HPV infection status for both RDT (p < 0.001) and PCR (p = 0.006).  The statistical analysis for the association between FGM status and HPV infection was conducted on participants with a definitive FGM status (FGM–Yes, (n=49); FGM–No, (n=30); total n=79).

Discussion

The finding of a 30.0% seroprevalence indicates a high lifetime exposure to HPV in the women of childbearing age in Ekiti State, comparable to other reports from Nigeria [7]. The lower prevalence of 10.9% active infection confirmed by PCR is consistent with the natural history of HPV, where the body’s immune system clears the majority of infections within 1–2 years, leaving only a small fraction to persist and potentially lead to cancer [8].

Furthermore, this study found a highly significant and strong association between Female Genital Mutilation (FGM) and a higher prevalence of HPV infection (RDT: 51.0% vs. 20.0%; PCR: 22.4% vs. 3.3%). This result supports the hypothesis that FGM is not merely a benign cultural practice but acts as a significant reproductive health co-factor.

The mechanisms underpinning this association may include the following:

i. Compromised epithelial barrier as FGM, which involves scarring and tissue damage, may create chronic micro-lesions on the genital mucosa. These lesions could offer easier and more sustained entry points for the virus into the basal epithelial cells, facilitating initial infection.

ii. Chronic inflammation and immunosuppression as the persistent scarring and tissue trauma associated with FGM can lead to a state of chronic inflammation in the genital tract. Chronic inflammation is known to impair local immune surveillance, which could compromise the body’s ability to clear the initial HPV infection, leading to a higher rate of persistence (active infection, or PCR positivity) [9].

This finding is a powerful, evidence-based argument for the complete eradication of FGM, establishing it as a factor that may directly impact the risk of a cancer-causing infection. This study is limited by the fact it relied totally on self-reported FGM status

Conclusion

HPV infection is highly prevalent in Ekiti State. Critically, this research established a highly significant association between Female Genital Mutilation (FGM) and increased prevalence of PCR-confirmed HPV infection (p = 0.006), suggesting FGM is a potential independent co-factor for HPV susceptibility and persistence.

Recommendations

Public health and legal efforts must be intensified for the complete elimination of Female Genital Mutilation. This must be framed not only as a human rights issue but as a direct cancer risk factor to reinforce the urgency of its eradication.

 HPV screening programs should particularly target women with established risk factors, including those with a history of FGM, early sexual debut, and higher parity, to ensure early detection and management of precancerous lesions.

References

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