Supplementary Information. Figure 1. Systematic Review Flowchart

Supplementary information. Figure 1. Systematic review flowchart.

1391 publications (728, 360 and 242 identified through PubMedTM, ScopusTM, and EMBASETM searches, respectively, and 61 identified from the bibliographic references of the eligible studies and related reviews)

PubMedTM search expression: (SCCC OR OSSN OR ((scc OR cancer OR neoplasia OR carcinoma OR CIN OR dysplasia) AND (conjunctiva OR conjunctival OR eye OR ocular))) AND (HIV Infections [MeSH] OR HIV [MeSH] OR hiv [tw] OR hiv-1* [tw] OR hiv-2* [tw] OR hiv1 [tw] OR hiv2 [tw] OR hiv infect* [tw] OR human immunodeficiency virus [tw] OR human immunedeficiency virus [tw] OR human immuno-deficiency virus [tw] OR human immune-deficiency virus [tw] OR ((human immun*) AND (deficiency virus[tw])) OR acquired immunodeficiency syndrome [tw] OR acquired immunedeficiency syndrome [tw] OR acquired immuno-deficiency syndrome [tw] OR acquired immune-deficiency syndrome [tw] OR ((acquired immun*) AND (deficiency syndrome [tw])) OR “sexually transmitted diseases, viral” [MeSH:NoExp] OR AIDS OR (papillomaviridae [MeSH] OR Papillomavirus Infections [MeSH Terms] OR HPV [tw] OR papillomavirus [tw] OR papillomaviridae [tw])) NOT (animals[mh] NOT humans[mh])

ScopusTM search expression: TITLE-ABS-KEY(((sccc OR ossn OR ((scc OR cancer OR neoplasia OR carcinoma OR cin OR dysplasia) AND (conjunctiva OR conjunctival OR eye OR ocular)))) AND (((papillomaviridae OR hpv OR papillomavirus)) OR (("HIV Infections" OR hiv OR hiv OR hiv-1 OR hiv-2 OR hiv1 OR hiv2 OR "human immunodeficiency virus" OR "human immunedeficiency virus" OR "human immuno-deficiency virus" OR "human immune-deficiency virus" OR "deficiency virus" OR "acquired immunodeficiency syndrome" OR "acquired immunedeficiency syndrome" OR "acquired immuno-deficiency syndrome" OR "acquired immune-deficiency syndrome" OR "deficiency syndrome" OR aids))))

EMBASETM (OVID) search expression: (SCCC OR OSSN OR ((scc OR cancer OR neoplasia OR carcinoma OR CIN OR dysplasia) AND (conjunctiva OR conjunctival OR eye OR ocular))) AND (HIV Infections OR HIV OR hiv OR hiv-1* OR hiv-2* OR hiv1 OR hiv2 OR hiv infect* OR human immunodeficiency virus OR human immunedeficiency virus OR human immuno-deficiency virus OR human immune-deficiency virus OR ((human immun*) AND (deficiency virus)) OR acquired immunodeficiency syndrome OR acquired immunedeficiency syndrome OR acquired immuno-deficiency syndrome OR acquired immune-deficiency syndrome OR ((acquired immun*) AND (deficiency syndrome)) OR AIDS OR (papillomaviridae OR papillomavirus OR HPV))

1117 articles excluded based on title and abstract assessment: 103 not involving humans 349 reviews on unrelated topics, guidelines or comments without original data 275 case reports or case series 390 studies evaluating the association between HIV and/or HPV infection and outcomes other than OSSN

274 publications

193 articles excluded based on full text assessment: 45 reviews, guidelines or comments 70 case reports or case series 52 not providing a relative risk estimate for the association between HIV and/or HPV infection and OSSN, or the necessary information to compute it 26 data already described in other included study

81 publications

52 articles excluded during data extraction: 37 reviews on related topics 6 data already described in other included study 1 study with increased probability of HIV finding 5 data in a non eligible format for data extraction 1 study whose outcome was ocular cancers other than retinoblastoma and melanoma 1 study in which the excess of risk was computed dividing the observed number of ocular cancers (all were SCCC) by the expected number of all ocular cancers 1 control group only includes patients with AIDS-defining malignancies

29 studies eligible for systematic review

4 not considered for meta-analysis, as they did not detected HPV neither among cases nor among controls

25 studies eligible for meta-analyses

12 studies with data on the 5 studies with data on the 16 studies with data on the association between HIV infection association between cutaneous association between mucosal and OSSN subtypes of HPV and OSSN subtypes of HPV and OSSN

3 studies with data on the 3 studies with data on the association between HPV association between HPV infection and OSSN by HIV status infection and OSSN by HIV status

1 2 Table 1. Main characteristics of the studies included in the systematic review that assessed the association between human immunodeficiency virus (HIV) and/or human papillomavirus (HPV) and ocular surface squamous neoplasia (OSSN). 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Carrilho et al, Mozambique Cases: OSSN Broad spectrum of mucosal and NA Mucosal HPV+ vs No 2013 , Maputo “ low-grade intraepithelial neoplasia (n=4), high- cutaneous HPV subtypes were tested Mucosal HPV- grade intraepithelial neoplasia (n=16), invasive OR=1.40 (0.09-22.16) squamous cell carcinomas (n=13)” HPV were detected in 11 cases (9 for * cutaneous subtypes, 1 for HPV 18 and Controls: 2 for HPV 16) Cutaneous HPV+ vs “ clinically and histologically benign conjunctival cutaneous HPV- conditions in patients with no other cancer Method: PCR OR=3.80 (0.27-52.90) diagnosis (n=5, namely three pingueculae, one * melanosis, and one conjunctivitis).”

Chauhan, 2012 India, Cases: SCCC and Broad spectrum of mucosal HPV NA Mucosal HPV+ vs. No New Delhi “Sixty-four patients with OSSN (44 SCC, 20 CIN)” CIN subtypes were tested mucosal HPV-

Controls: Positive samples were genotyped, and OR=3.69 “15 controls (conjunctival epithelialectomy tissues only HPV subtype 16 was detected in from limbal stem cell deficiency patients)” the seven HPV-positive OSSN (0.22-61.36) * ‖¶ Method: PCR

Asadi-Amoli, Iran, Tehran Cases: SCCC Broad spectrum of mucosal HPV NA Mucosal HPV+ vs. No 2011 “50 SCC cases” subtypes were tested mucosal HPV-

Controls: HPV detected of subtypes not OR=107.59 “ 50 age frequency-matched control patients with specified, though HPV 16, 18, 31 and lesion-free, normal conjunctival biopsies” 33 were ruled out (6.80-1702.19)* ‖ ¶ ‡ Method: nested PCR

1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding

3 publication Exposure assessed Exposure assessed Method Method

Ateenyi-Agaba, Uganda, Cases: SCCC/ Broad spectrum of mucosal HPV NA Mucosal HPV+ vs. Adjusted for 2010 Kampala “ patients admitted to the Departments of Dysplasia subtypes tested, and positive samples mucosal HPV- age, sex and HIV Ophthalmology (…) for eye lesions suspected to were tested for 25 mucosal HPV types status be SCCC (…) A consensus was achieved on the (high-risk: HPV 16, 18, 31, 33, 35, 39, OR=1.0 (0.4-2.7) presence of SCCC in 100 patients” 45, 51, 52, 56, 58, 59, 66, 68, and 70; low-risk: HPV 6, 11, 34, 40, 42, 43, 44, Controls: 53, 54, and 74), plus 17 additional “ Eligible controls were patients who had been HPV subtypes (HPV 26, 30, 55, 61, admitted to the same hospitals as cases for eye 62, 64, 67, 69, 71, 82, 83, 84, 85, 87, conditions other than SCCC or dysplasia, and 89, 90, and 91) required surgical intervention. (…) The most frequent diagnosis were cataract (37%), chalazia HPV of subtypes 16, 45, 52, 53, 83, (12%), corneal tears (10%), and eye trauma (9%). plus 14 cases unclassified were Patients presenting with pterygium or pingueculum detected were not included (…)” Method: PCR 25 cutaneous HPV subtypes (HPV 5, NA Cutaneous HPV+ vs. Adjusted for 8, 9, 12, 14, 15, 17, 19–25, 36–38, 47, cutaneous HPV- age, sex and HIV 49, 75, 76, 80, 92, 93, and 96) were status tested Single infection: OR=2.3 (1.2-4.4) HPV of subtypes 5, 8, 9, 12, 14, 15, 17, 19, 20, 21, 22, 23, 24, 25, 36, 37, Multiple infection: 38, 49, 75, 76, 80, 92, 93, 86, plus 5 OR=18.3 (6.2-54.4) cases unclassified, were detected

Method: PCR reverse hybridization NA HIV of subtype not HIV+ vs. HIV- Adjusted for specified age, sex OR=7.3 (4.2-12.4) Method: ELISA and Western blot

NA Exposure: AIDS AIDS+ vs. AIDS- Adjusted for age, sex AIDS’s assessment: “The OR=5.6 (1.5-20.3) diagnosis of AIDS was based on the presence of cytomegalovirus retinitis, cryptococcal meningitis, or skin rash with weight loss.”

4 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Ateenyi-Agaba, Uganda, Cases: SCCC/ 25 cutaneous HPV subtypes (HPV 5, HIV of subtype not HIV+ and cutaneous Adjusted for 2010 Kampala “ patients admitted to the Departments of Dysplasia 8, 9, 12, 14, 15, 17, 19–25, 36–38, 47, specified HPV+ (single age, sex Ophthalmology (…) for eye lesions suspected to 49, 75, 76, 80, 92, 93, and 96) were infection) vs. HIV+ be SCCC (…) A consensus was achieved on the tested Method: ELISA and and cutaneous HPV-: presence of SCCC in 100 patients” Western blot OR=2.7 (1.3-5.6) HPV of subtypes 5, 8, 9, 12, 14, 15, Controls: 17, 19, 20, 21, 22, 23, 24, 25, 36, 37, HIV+ and cutaneous “ Eligible controls were patients who had been 38, 49, 75, 76, 80, 92, 93, 86, plus 5 HPV+ (multiple admitted to the same hospitals as cases for eye cases unclassified, were detected infection) vs. HIV+ conditions other than SCCC or dysplasia, and and cutaneous HPV-: required surgical intervention. (…) The most Method: PCR OR=15.4 (5.2-45.5) frequent diagnosis were cataract (37%), chalazia (12%), corneal tears (10%), and eye trauma (9%). Patients presenting with pterygium or pingueculum were not included (…)” Simbiri et al , Botswana, Cases: OSSN Broad spectrum of mucosal subtypes HIV -1 positive patients Mucosal HPV+ vs No 2010 Gaborone “ HIV-1 infected patients with conjunctival lesions and HPV type specific 16 and 18 mucosal HPV- (…) 28 whose clinical diagnosis was OSSN” tested Method: ELISA Considering the Controls: HPV 1, 3, 7, 11, 13, 16, 18, 39, 40, 43, samples that were “8 pterygia” 45, 59, 61, 68, 70, 77, 85, 89, 91, 97 positive by at least found one of the three methods applied: Method: PCR; ISH; IHC OR=1.02 (0.45-2.31) *

Considering only the samples that were positive using PCR: OR=2.5 (0.50-12.51) * Guthoff, 2009 Germany, Cases: OSSN Broad spectrum of mucosal subtypes NA HPV infection was not NA Wuerzburg “ Seven cases were considered CIN I and II; 17 tested; genotyping of 15 different HPV detected among cases cases were considered CIN III (…) Seven subtypes (6, 11, 16, 18, 31, 33, 35, 39, or controls with both additional cases were conjunctival invasive 45, 51, 52, 56, 58, 59, and 68) was methods, and squamous cell carcinomas (…)” attempted therefore a relative risk estimate was not Controls: Method: multiplex fluorescent PCR computed “ Five conjunctival specimens of 3 female and 2 Mucosal HPV subtypes 16, 18, 33, 35, NA male patients for primary retinal detachment 39, 45, 56, 58 were tested surgery and with a mean age of 70 (range 65-76) years without any clinically identifiable conjunctival Method: immunohistochemistry disease served as controls.”

5 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Auw-Haedrich, Germany, Cases: CIN Broad spectrum of mucosal subtypes NA Mucosal HPV+ vs. No 2008 ND “ 12 conjunctival specimens (…) excised from the tested mucosal HPV- bulbar conjunctiva with the suspicion of conjunctival intra-epithelial neoplasia (CIN) (…) Detected HPV of subtype 16 OR=2.06 The (…) patients slides were diagnosed (…) as follows: 2 CIN grade I (…), 3 CIN grade II (…), 5 Method: nested PCR CIN grade III (…), and 2 CIN with beginning (1.04-4.11) * ‖ ¶ invasion”

Controls: “ 14 macroscopically normal postmortem conjunctival specimens and 1 conjunctival specimen with slight inflammatory changes” de Koning, 2008 Uganda, Cases: CIN NA HIV of subtype not HIV+ vs. HIV- No country-wide "anyone with a suspect corneo-conjunctival lesion specified was offered removal and histology, and enrolment OR=4.49 in a follow-up study with home visits." Method: two enzyme (1.80-11.20) * immunoassay tests in Controls: parallel, with Western blot "Those who subsequently turned out to have if required lesions other than ocular surface squamous neoplasia were used as a control group in the analyses of HPV." Broad spectrum of mucosal HPV NA Mucosal HPV+ vs. No subtypes tested, and positive samples mucosal HPV- were genotyped for HPV subtypes (high risk: 16, 18, 31, 33, 35, 39, 45, OR=1.0 (0.4-2.7) 51, 52, 56, 58, 59, 66, 68, 70, and low- Not infected with HIV HIV- and mucosal No risk 6, 11, 34, 40, 42, 43, 44, 53, 54, HPV+ vs HIV- and 74) Method: two enzyme mucosal HPV- immunoassay tests in HPV of subtypes 6, 11, 16, 18, 31, 33, parallel, with Western blot OR=1.2 (0.3-5.5) 35, 44, 51, 52, 66, plus 2 cases if required unclassified were detected HIV of subtype not HIV+ and mucosal No specified HPV+ vs. HIV+ and Method: PCR mucosal HPV- Method: two enzyme immunoassay tests in OR=0.9 (0.2-4.3) parallel, with Western blot if required

6 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method de Koning, 2008 Uganda, Cases: CIN NA Cutaneous HPV+ vs. No No country-wide "anyone with a suspect corneo-conjunctival lesion Not infected with HIV cutaneous HPV- was offered removal and histology, and enrolment in a follow-up study with home visits." Method: two enzyme immunoassay OR=8.0 (1.0-169) tests in parallel, with Western blot if HIV- and cutaneous HPV+ No No Controls: required vs. HIV- and cutaneous "Those who subsequently turned out to have HIV of subtype not specified HPV- lesions other than ocular surface squamous neoplasia were used as a control group in the Method: two enzyme immunoassay OR=11.30 analyses of HPV." tests in parallel, with Western blot if required (0.68-188.39)* ‖ ¶ ‡

HIV+ and cutaneous No No HPV+ vs. HIV+ and cutaneous HPV-

OR=0.8 (0.2-3.8) Guech-Ongey, USA, 9 Description of the cohort: SCCC NA Exposure: AIDS AIDS+ vs. AIDS- Adjusted for: 2008 states and 5 “We investigated eye cancers among adults (aged age, race, sex, metropolitan >15 or older) in the U.S. HACM Study diagnosed AIDS’s assessment: SIR=12.2 (6.8-20.2) calendar year and areas with AIDS from 1980 to 2004. The U.S. HACM previous diagnosis registry Study links population-based HIV/AIDS registry and cancer registry databases in 9 U.S. states (…) The expected number of cancers was calculated using general population age-, race-, sex-, calendar year- and registry-specific incidence rates applied to the person time distribution of PWA [persons with AIDS]” Sen, 2007 India, ND Cases: OSSN Mucosal HPV subtypes 6, 18, 31, 33, NA HPV infection was not NA “ Biopsies obtained from (…) 30 cases of ocular 42, 51, 52, 56, 58 were tested detected among cases surface squamous neoplasia (OSSN)” or controls, and Methods: immunohistochemistry (in therefore a relative risk Controls: situ HPV antigen detection) estimate was not “ 30 age and sex-matched controls of normal computed conjunctivas were also obtained from the eye bank”

7 Chinogurei et al , Zimbabwe, Cases: OSSN NA HIV of subtype not HIV+ vs. HIV- No 2006 Harare “ [16] invasive squamous cell carcinoma of specified conjunctiva (…) [10] all forms of dysplasias and OR=22.00 (4.21- carcinoma in situ” Method: ELISA, and 115.01) Western blot confirmation Controls: of doubtful cases “[15] Pterygium” 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Tornesello, 2006 Uganda, Cases: Conjunctival NA HIV of subtype not HIV+ vs. HIV- No south “125 consecutive patients clinically diagnosed with neoplasia specified conjunctival neoplasia” OR=2.99 Method: ELISA, followed (1.36-6.53) * Controls: by Western blot “The 125 cancer-free controls, frequency matched confirmation to the cases by sex and age (…) were Broad spectrum of mucosal HPV NA Mucosal HPV+ vs. No consecutively randomly enrolled from a pool of subtypes tested, in addition to mucosal HPV- patients treated for benign eye lesions (i.e. targeting HPV subtype 16 OR=2.24 pterygium) or eye injuries (…) The control group included two pinguecula, one pterygium and one Only mucosal HPV of subtypes 6 and papilloma of the conjunctiva” 18 were detected (0.11-45.6) * ‖ ¶ ‡ *** Method: PCR HIV of subtype not defined HIV+ and mucosal No HPV+ vs. HIV+ and Method: ELISA, followed mucosal HPV- by Western blot confirmation OR=0.86 (0.04-20.04) * † ¶ ‡ Not infected with HIV HIV- and mucosal No HPV+ vs. HIV- and Method: ELISA, followed mucosal HPV- by Western blot confirmation OR=2.34 (0.10-55.11) * ‡ Broad spectrum of cutaneous HPV NA Cutaneous HPV+ vs. No subtypes tested, in addition to cutaneous HPV- targeting HPV subtype 38 OR=4.93

8 HPV of subtypes 14, 20, 38 were detected (0.28-87.00) * ‖ ¶ ‡ Method: PCR

HIV of subtype not HIV+ and cutaneous No specified HPV+ vs. HIV+ and cutaneous HPV- Method: ELISA, and followed by Western blot OR=2.57 confirmation (0.15-45.28) * † ¶ ‡ Not infected with HIV HIV- and cutaneous No HPV+ vs. HIV- and Method: ELISA, followed cutaneous HPV- by Western blot confirmation OR=2.34 (0.10-55.11) * ‡ 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Ateenyi-Agaba Uganda, Cases: SCC of the Broad spectrum of mucosal and NA Cutaneous HPV+ vs Adjusted for age et al , 2004 Kampala “21 SCC cases” conjunctiva cutaneous subtypes, including EV cutaneous HPV- and gender HPV types were tested. Type specific Controls: HPV probes for HPV 16, 18, 45 and OR=12.0 (1.7-84.9) “ 22 age frequency-matched control patients with EV HPV 38 were also tested. Cutaneous HPV+ vs Adjusted for sun benign conjunctival lesions (…) In total, 10 controls cutaneous HPV- exposure had pterygium, seven pingueculum, four solar EV HPV types 8, 12, 14, 24, 36, 37, 38 keratosis and 1 pigmented naevus” and RTRX7 detected OR=22.7 (1.7-312)

Method: PCR and southern blotting Timm, 2004 Democratic Cases: OSSN NA ELISA, with confirmation HIV+ vs. HIV- No Republic of “ CIN I and II, CIN III and squamous cell by a second ELISA test Congo carcinoma” OR=0.6 (0.11-3.04) * Controls: “ benign lesions [6 pingueculae, 1 papilloma, 1 sebaceous carcinoma]”

9 Porges, 2003 Zimbabwe, Cases: SCCC and NA HIV of subtype not HIV+ vs. HIV- No Mashonalad "a group of 23 African black patients underwent carcinoma specified excisional biopsy for conjunctival lesions." in situ OR=30.0 Method: ELISA, followed (2.19-411.0) * Controls: by confirmation with "The control group with benign conjunctival lesions immunofluorescence or (benign/HIV control group) consisted of seven Western blot patients (…) This group was part of a larger group of patients with conjunctival lesions who had been operated in our unit during the study period"

Tulvatana, 2003 Thailand, Cases: Conjunctival Mucosal HPV subtypes were tested NA HPV infection was not NA ND “ thirty cases were retrieved from the most recent squamous detected among cases pathological tissue diagnosed to be conjunctival cell Method: PCR and dot hybridization or controls, and squamous cell neoplasia.” neoplasia therefore a relative risk estimate was not Controls: computed “Controls were disease-free conjunctiva from age and sex matched patients who underwent planned extracapsular cataract extraction.” 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Scott, 2002 USA, Miami Cases: CIN Mucosal HPV subtypes 16, 18 were NA HPV 16 and/or 18+ vs. No “ 10 consecutive patients who underwent CIN tested HPV 16 and/or 18- excision by one surgeon” Method: in situ hybridization and OR=11.46 Controls: reverse transcriptase in situ PCR “conjunctival specimens from five control patients (age-matched to five of the cases) who had no (0.80-163.26) * ‖ ¶ ‡ clinically identifiable conjunctival disease and who underwent retinal detachment repair”

Newton, 2002 Uganda, Cases: SCCC NA HIV subtype HIV-1 HIV+ vs. HIV- Adjusted for Kampala "60 cases of conjunctival cancer (…) Thirty-two age group, sex, people with eye cancers that were not specifically Method: ELISA OR=10.1 (5.2-19.4) current region of diagnosed clinically as being squamous cell residence and carcinomas, or had a pathological diagnosis of personal income malignancy of uncertain morphology were

10 excluded." Mucosal HPV subtypes 16, 18, 45 NA HPV 16, 18, 45+ vs. Adjusted for tested, and all subtypes were detected HPV 16, 18, 45- age, sex, address, Controls: personal income "The control group included (…) cancers of the Method: serological analysis OR=1.3 (0.5-3.2) and HIV-1 sero- oral cavity (57), oesophagus (150), stomach (74), status liver (103), breast (178), ovary (67), prostate (56), and other cancer sites or types (405). In addition, 124 patients with a provisional diagnosis of cancer, but who subsequently turned out to have benign tumours, were also included in the control group."

Palazzi, 2000 Brazil, São Cases: Carcinoma Mucosal HPV subtypes 11 and 16 NA HPV 11, 16+ vs. HPV No Paulo “ in a sample of patients referred to the in situ, tested; both subtypes were detected 11, 16- Ophthalmology Service of the Cancer Hospital – invasive Antonio Prudente Foundation” SCCC, Method: PCR and dot blot OR=5.90 severe hybridization (0.51-68.61) * ‡ Controls: dysplasia “Swabs of the conjunctiva (…) as well as in sixty and mild matched controls.” dysplasia (OSSN) § 1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Dushku et al , Cases: OSSN Broad spectrum of mucosal HPV NA “ We were unable to NA 1999 “ limbal tumors (n=10: 2 with actinic keratosis subtypes tested detect the 450-bp or dysplasia, 1 with conjunctival intraepithelial the nested 139-bp L1 neoplasia, 3 with carcinoma in situ, and 4 with Method: region HPV DNA squamous cell carcinoma)” PCR fragments in all specimen tested Controls: “specimens of pinguecula (n=1), pterygia (n=13: 7 with primary, 1 with recurrent, 1 with dysplasia, and 4 primary (…)”

Karcioglu, 1997 Saudi Arabia Cases: Invasive Mucosal HPV subtypes 16, 18 tested; NA HPV 16, 18+ vs. HPV No "Specimens from 115 patients, 69 males (60%) SCCC and both subtypes were detected 16, 18- and 46 females (40%) were included in this study." in situ SCCC Method: nested PCR OR=2.7 Controls: (0.87-8.40) *

11 "19 specimens of normal appearing conjunctiva were included"

Tabrizi et al , Australia, Cases: Corneal or Broad spectrum of mucosal HPV NA Mucosal HPV+ vs No 1997) ND “ all cases reported as corneal or conjunctival conjunctival subtypes tested Mucosal HPV- carcinoma or severe dysplasia” (88 cases) carcinoma HPV 6, 11, 16 and 18 found OR=7.68 (2.80-21.04) Controls: * “ control specimens (n=66) were selected from Method: conjunctival and corneal specimens with no or PCR minimal dysplasia and were matched by year of biopsy, gender and age (…) Pterygia was present (…) in 48 (74%) controls”

1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Waddell, 1996 Uganda, Cases: CIN and NA HIV of subtype not HIV+ vs. HIV- No Kampala “all patients in seven countywide eye clinics who SCCC specified had suspicious conjunctival lesions had excision OR=13.1 (4.7-37.6) biopsy of the lesion (…). In September to October Method: serology and 1994 at New Malugo Hospital, Kampala, the same Western blot procedure was followed." (In total, 12 CIN and 20 Mucosal HPV of subtype 16 was NA HPV 16+ vs. HPV 16- No SCCC from Malawi; 11 CIN and 27 SCCC from tested Uganda) OR=1.08 Method: PCR (0.16-7.42) * Controls: "The controls came from the same unit or lived in the same district. Sixteen controls were patients in the eye clinic without neoplasia or clinical features of HIV disease; the remaining 54 were general (non-eye clinic) anonymous outpatients ate the same health units"

Adachi, 1995 Japan, not Cases: SCCC Mucosal HPV subtypes 16 and 18 NA HPV 16 and/or 18+ vs. No further “We tried to identify human papilloma virus (HPV) were tested HPV 16 and/or 18- specified in ocular surface diseases characterized by

12 abnormal epithelial proliferation” Only HPV subtype 16 was detected OR=10.00 (0.53-187.10) * ¶ Controls: Method: PCR “9 normal eyes”

Ateenyi-Agaba, Uganda, Cases: SCCC NA HIV of subtype not HIV+ vs. HIV- No 1995 Kampala "all patients with conjunctival growths who specified presented to the ophthalmology clinic had an OR=13.0 (4.5-39.4) excision biopsy" Method: ELISA, followed by Western blot Controls: confirmation "Age-matched and sex-matched controls were chosen from patients attending the same clinic with other eye diseases."

Goedert, 1995 USA, not Description of the cohort: SCCC NA HIV of subtype not HIV+ vs. HIV- ND further “We investigated the relation of this disease and of specified specified malignant melanoma of the conjunctiva to AIDS SIR=13 (4-34) (…) In 50050 people with AIDS” HIV assessment: previous diagnosis

1st author, Country, Description of the participants Outcome HPV infection HIV infection/AIDS Relative risk Control of year of region estimate (95%CI) confounding publication Exposure assessed Exposure assessed Method Method Saegusa, 1995 Japan, Cases: Dysplasia HPV mucosal subtypes 6, 11, 16, 18, NA HPV 16+ vs. HPV 5, No Kanagawa “four [cases] of dysplasia, and four of squamous and SCCC 31, 33, 42, 52, 58 were tested 11, 16, 18, 31, 33, 42, cell carcinomas surgically removed from the eyelid 52, 58- area (…)” Only HPV subtype 16 was detected Method: PCR and in situ hybridization OR=10.11 Controls: (0.59-172.83) * “12 [cases] of basal cell epithelioma” Kestelyn, 1990 Rwanda, Cases: OSSN NA HIV of subtype not HIV+ vs HIV- No Kigali "all patients with clinical evidence of conjunctival (dysplasia, specified dysplasia or malignancy" (5 CIN and 6 SCCC) in situ OR=13 (2.2-76.9) epitelioma Method: ELISA, followed Controls: and SCCC) by immunofluorescence "To select controls from the same outpatient and Western blot department we took blood from all patients on two confirmation consecutive days at the end of the study period. (…) Patients referred from elsewhere and patients with ocular malignancies were excluded from the control group. We randomly selected two controls, matched on sex and age within five years, for each case and tested their blood for HIV antibody."

13 McDonnell et al , United Cases: OSSN HPV subtypes 16 and 18 were NA Mucosal HPV+ vs No 1989 States of “six patients with dysplastic or malignant lesions of searched mucosal HPV- America, the conjunctiva” Los Angeles Method: OR=13.00 Controls: PCR (0.89-189.39) * “ one specimen each of conjunctival nevus, melanoma, pterygium and cutaneous seborrheic keratosis.”

95%CI – 95% confidence interval;

NA – not applicable;

ND – not defined;

PCR – polymerase chain reaction;

IHC – immunohistochemistry

ISH – in situ hydridization

SCC – squamous cell carcinoma;

SCCC – squamous cell carcinoma of the conjunctiva;

AIDS – acquired immune deficiency syndrome;

CIN- conjunctival intraepithelial neoplasia;

EV - epidermodysplasia verruciformis

* OR estimates and corresponding 95% confidence intervals computed by the authors of the present review using Epi Info 7® with the

information presented in the original study;

14 ‖ None of the controls were infected with HPV;

† None of the HIV infected subjects were HPV infected;

¶ Odds ratio and respective confidence intervals were estimated using the metan command of the STATA®, which adds by default 0.5 to all cells of the 2x2 table of the study;

*** We computed odds ratios after excluding the papilloma included in the control group;

**** Putative new HPV type identified;

‡ OR estimates computed by the authors of the present study, though sample recruitment procedures involved matched controls.

§ When the proportion of exposed subjects was provided separately for two or more of the conditions jointly referred as OSSN (mild-dysplasia, severe dysplasia, carcinoma in situ, invasive squamous cell carcinoma (SCC), we computed an overall RR estimate considering OSSN as the outcome.

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