All ETDs from UAB

Advisory Committee Chair

Sadeep Shrestha

Advisory Committee Members

Inmaculada Aban

Stella Aslibekyan

Greer A Burkholder

Ashraf E Khan

Document Type


Date of Award


Degree Name by School

Doctor of Philosophy (PhD) School of Public Health


This dissertation research focuses on investigating health burdens of HPV- and HSV- associated clinical conditions (CC) in people living with HIV-1 infection (PLWH) in the Southeastern United States. I designed a retrospective study using the UAB 1917 HIV Clinic Cohort. Electronic health records of PLWH attending the clinic for HIV-care between January 2006 and March 2019 were obtained and reviewed. I first examined incidence rates and trends of anogenital HPV- and HSV-associated CC. Then I adopted a new algorithm to group longitudinal CD4 cell counts based on their trajectories. I compared it with nadir and median CD4 cell counts in the associations of incident ulcers, warts, and anal high-grade squamous intraepithelial lesions (HSIL)/cancer. Last, I examined severities of high-grade anal intraepithelial neoplasia (HGAIN) and clinical practices of anal cancer screenings in PLWH in the region. For the first aim, the diseases of interest included: HPV-associated anogenital warts, cervical, anal, penile low- and high- grade squamous intraepithelial lesions (LSIL and HSIL) and cancers, and HSV-associated anogenital herpetic ulcers. I observed 1,038 and 425 with HPV- and HSV-associated CC, respectively, and 163 patients with both conditions. HPV-associated CC were more common in HIV-infected men than women, whereas HSV-associated CC were more prevalent in HIV-infected women. Rates of warts increased steadily over time. In the second aim, I used a group based trajectory modeling to group longitudinal CD4 counts. Trajectory CD4 groups more precisely predicted the risk of incident herpetic ulcers and anal HSIL/cancer. In the last aim, I observed substantially higher risks of HGAIN and anal cancer among HIV-infected men. However, over 44% of anal cancer patients did not receive a single anal/rectal Pap test during the study period. Also, the onset age of anal cancer was much younger for PLWH than the general US population. PLWH bear higher risks of HPV- and HSV-associated CC in the region. However, except for cervical cancer, none of these conditions are AIDS-defining complications. Hence, screening programs for the conditions are lacking. The thesis expects to raise public and clinical awareness of the conditions in hopes of establishing better screening strategies.

Included in

Public Health Commons



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.