The overall prevalence of HPV infection among the women in our study is lower than that observed worldwide. To the best of our knowledge, this is the first population-based study in the south part of Iran to investigate the prevalence rate of HPV infection in this region.
The prevalence rate of HPV infection differs notably according to geographical region . The worldwide prevalence of HPV infection in women with normal cervical cytology was estimated to be 11.7% . Based on molecular epidemiologic evidence among asymptomatic women in the general population, the prevalence of HPV infection was estimated to be in the range of 2-44% . In a comprehensive review, Seoud et al. reported that HPV was found in 1.5-13% of the general population of the Middle East and the Persian Gulf countries . Our study shows that the prevalence of HPV infection in southern Iranian women is among the lowest in the world and Middle Eastern countries. This prevalence rate is much lower than that reported for the Persian Gulf region (4-11%) .
Comparisons of HPV prevalence by geographical area or country are generally hampered by the heterogeneity in laboratory assays employed for HPV infection detection, the population included (women with normal cytology, population-based surveys, or women in routine screening programs), and the variation in HPV types detected .
Although a few population-based studies on the prevalence of HPV infection in the Persian Gulf and the Middle Eastern countries could be found in the medical literature, the low prevalence of oncogenic HPV infection in Iran (the current study) and Kuwait (1.39%)  compared with the rest of the world, may reflect differences in sexual behavior across the Persian Gulf region. In both countries, the majority of women have their first experience of sexual intercourse during married life and have one husband in a lifetime . However, questions related to sexual and reproductive behavior are considered taboo in Muslim countries.
The present community study did not confirm our previous study on reporting HPV prevalence among women in southern Iran  despite of using the same protocols and techniques. However, there is a difference between their target population (population-based study versus gynecology clinic-based study).
In the previous study, we determined the prevalence of various HPV genotypes among women who had routine Pap smear tests in a university gynecology clinic (Table 1). In that study, the prevalence of various HPV genotypes was 11 (5.5%) in 200 samples . This prevalence rate was similar to those reported from various studies in Iran. All previous studies in Iran regarding the prevalence of HPV infection were performed on women attending gynaecological clinics for routine screening programs and examinations [11–13]. HPV DNA was identified in 5.7% women who were admitted to different hospitals and gynecological clinics in Tehran . Safaei et al.  reported positive HPV findings in 5.5% of women who were examined at two gynecological clinics in Shiraz, a city in the southwest of Iran with a population very similar to the population in the current study. Therefore, it seems that the prevalence of HPV infection was very similar in different gynecological clinics in Iran and was comparable to other geographical areas in Muslim and Middle Eastern countries.
Although, in a recent population based study on genital HPV by Khodakarami and her colleagues  among 2342 women in one of the densely populated suburb of Theran the prevalence of HPV infection was 7.8% which is different from our present finding. The number of participant as well as the differences between their communities might be the reason of obsereved difference. Indeed, they have used different techniques compared to ours with different sensitivity such as DNA extraction using magnetic beads and liquid based cytology and even different type of sampling and it could be also considered as the other factor that would explain the difference between our data and their findings.
Similarly, the observed prevalence of HPV high and low risk types in cervical samples taken in a population-based study in Italy was lower than those in studies that were performed on women undergoing voluntary cervical cancer screening in gynaecological clinics [24, 25]. Notably, sampling in gynaecological clinics or voluntary screening programs may select women who are more sexually active than the general population or those with abnormal cytological results. These women usually seek more cervical examinations than women with normal cytology . In contrast, the design of a population-based study mandates a better coverage of the general population .
Based on the present study nine samples were detected HPV positive by Pap smear test meanwhile two of them were approved by HPV DNA PCR test. Moreover, there are other three HPV DNA positive samples among the Pap smear test negatives. This observation could be because of the lack of specificity of Pap smear test for HPV detection.
Previous studies have indicated a significant geographic variation in the pattern of oncogenic HPV types. HPV 16 was the most commonly identified type in most countries of the world . In the current study and our previous clinic-based study, HPV 16 was the most prevalent type, and HPV 18 was the second most prevalent oncogenic HPV type. These findings are consistent with studies on the Extended Middle East and North Africa (EMENA) . It has been estimated that 32% of about 291 million women worldwide who are carriers of HPV are infected with HPV 16 or HPV 18, or both . HPV types 58 and 52 play a more prominent role in cervical cancer in all regions of Asia—except India and Iran—than in other parts of the world [8, 28–30]. We also did not find these oncogenic HPV types in our both studies.
A comparison of our results with some similar studies in Muslim and Middle Eastern countries [31, 32] showed a similar prevalence of epithelial abnormalities in Pap smears. In the current study, the Pap tests of 40 (5.0%) women showed epithelial cell abnormalities. Overall, the majority of women had negative results of both HPV DNA and Pap tests. Also, weakness of cytopathological detection of genital HPV was noted by Khodakarami et al. . Therfore, re-screening of those women can be done at three years . The extended period of re-screening for women with negative results for both tests is considered an advantage for HPV DNA testing . Indeed, the type of used device for cytopathology specimen collection (wooden Ayre spatula) might be a reason for poor quality of detection compared to the plastic cytobrush that used for PCR test.
Our study has several limitations. The small sample size of this study in a population-based setting may have underestimated the prevalence of HPV infection in the general population. Indeed, this limitation may decrease the chance of detection of different genotypes with lower prevalence such as HPV-42 and HPV-6 compared to the prevalent genotypes. In addition, the participation rate in the current study was 87.60%. The non-responders may produce a selection bias. It is probable that the non-responders may be at higher risk of HPV acquisition. However, the major reasons for non-participation were having to work, anxiety and doing Pap smear examination before the invitation time. The cross-sectional design of the study did not provide the opportunity to examine trends over time. We also did not evaluate risk factors for the acquisition and persistence of oncogenic HPV types. We also did not have information on the husband’s sexual behavior and therefore potential confounding effects cannot be evaluated in our study. Because of the low prevalence of HPV infection in the current study, we cannot evaluate the prevalence of oncogenic HPV types among women with epithelial abnormalities in cervical cytological examinations. Moreover, The small number of HPV positive cases in our study precludes any age-specific incidence rate.
Thus, larger population-based studies in different regions are needed to eliminate the drawbacks of our study and to determine the accurate prevalence of HPV infection among women in Iran. Based on the very low prevalence of HPV infection in this study, there are currently no indicative data to support use of HPV vaccine in southern Iranian women. Since cervical cancer ranks as 12th most frequent cancer among women in Iran , screening with HPV plus Pap tests every 2 or 3 years may save additional years of life at reasonable costs.