study population and sampling - this study was conducted between 
 august - december 2011 and the women were recruited from central laboratory municipal 
 campo grande , state of mato grosso do sul , brazil , when they were forwarded to 
 gynaecological exams in the public health system . women were eligible to participate if 
 they were  18 years of age and had not undergone a hysterectomy . a total of 171 women 
 provided written informed consent and completed the questionnaire at the time of 
 enrollment . participating women underwent two interventions for hpv dna detection : with 
 verbal and diagrammatic instruction , they self - collected a vaginal specimen ; afterward , 
 a health professional used a speculum and collected an endocervical specimen . 
 dna isolation and hpv testing - the endocervical and vaginal dna were 
 extracted using a wizard   genomic dna purification kit ( promega , 
 corporation , madison , wi , usa ) . hpv dna detection was performed by polymerase chain 
 reaction ( pcr ) amplification with the use of the pgmy09/11 primers ( gravitt et al . samples 
 that amplified the pgmy09/11 primers were genotyped by type - specific pcr using primers 
 for high - risk hpv ( hr - hpv ) , hpv16 , 18 , 31 , 33 , 45 ( guo et 
 al . 2007 ) and low - risk hpv ( lr - hpv ) , hpv6 , 11 ( silva et al . 2003 ) . the pcr products were analysed using 1.5% agarose gel 
 electrophoresis with ethidium bromide staining to visualise the dna under ultraviolet 
 light . statistical analysis - agreement between the self and 
 clinician - collected samples was measured using kappa (  ) statistics . the chi - square test 
 was used to analyse frequency data obtained on the questionnaire . of the samples collected from the 170 participants , only one was excluded because 
 -globin could not be amplified . a total of 30% ( 51/170 ) of the 
 samples were hpv dna - positive . the women in this study were 18 - 65 years of age ( median , 
 35 years ) , while the average age at first sexual intercourse was 17 years ( range , 11 - 30 
 years ) . we found a lower frequency of hpv infection in women  30 years ( p = 0.009 ) . hpv tests results showed that there was 84.6% concordance between the self and 
 clinician - collected samples (  = 0.72 ) , which indicates good agreement . six women tested 
 hpv - positive on clinician - collected samples , but hpv - negative on self - collected samples . twelve women tested hpv - positive on self - collected samples ( table i ) . hpv of any type was detected in 22.9% ( 39/170 ) of the 
 clinician - collected samples and 26.5% ( 45/170 ) of the self - collected samples . table i  concordance between human papillomavirus ( hpv ) dna detected by self and 
 clinician - collected 
 clinician - collectedself - collected n ( % ) 
 total 
 n ( % ) kappaconcordance   ( % )  negativepositive  negative119 ( 70)12 ( 7.1)131 ( 77.1)--positive6 ( 3.5)33 ( 19.4)39 ( 22.9)0.720.84 

 total125 ( 73.5)45 ( 26.5)170 ( 100)-- 
 a : concordance between methods . 
 
 a : concordance between methods . hpv16 , the most frequently detected hr - hpv type , was present in six samples obtained by 
 both methods . the specific hpv types identified in the self and clinician - collected 
 samples are shown in table ii . table ii  specific human papillomavirus ( hpv )  types detected by self and 
 clinician - collectedhpv types ( n)clinician - collected n ( % ) self - collected n ( % ) high - risk  453 ( 7.7)3 ( 6.7 )  184 ( 10.2)3 ( 6.7 )  314 ( 10.2)4 ( 8.9 )  335 ( 12.8)3 ( 6.7 )  166 ( 15.4)6 ( 13.3)low - risk  6/118 ( 20.6)12 ( 26.7 )  undetermined9 ( 23.1)14 ( 31 ) 

 total39 ( 100)45 ( 100 ) 
  lr - hpv types were detected at a higher frequency in the self - collected samples than in 
 the clinician - collected samples ( 23.5% and 15.7% , respectively ; p = 0.78 ) . however , 
 hr - hpv types were identified more frequently in the clinician - collected samples than in 
 the self - collected samples ( 33.3% and 27.4% , respectively ; p = 0.55 ) . the concordance of 
 the specific hpv type results between the collection methods demonstrated that 27.4% of 
 the samples had complete agreement for hr - hpv types and 13.7% had complete agreement for 
 lr - hpv types ( table iii ) . table iii  concordance between low - risk ( lr ) human papillomavirus ( hpv ) and high - risk 
 ( hr ) hpv dna detection in self and clinician - collected 
 hpv   ( n)clinician   / self   n ( % ) clinician   / self   n ( % ) clinician   / self   n ( % ) clinician   / self   n ( % )   concordance   ( % )   kappalr517 ( 13.7)1 ( 1.9)5 ( 9.8)38 ( 74.5)88.20.6hr5114 ( 27.4)3 ( 5.9)-34 ( 66.7)94.10.9 
 a : positive ; b : negative ; 
 c : concordance between methods . a : positive ; b : negative ; 
 c : concordance between methods . hpv infection with multiple types was detected in 20.5% ( 8/51 ) of the 
 clinician - collected samples and 15.5% ( 7/51 ) of the self - collected samples . one sample 
 tested positive for hpv16 , 18 , 31 , 6 and 11 using both methods . herein , we evaluated the hpv dna detection agreement between self and 
 clinician - collected samples . studies have found that the use of self - collected samples 
 can enable the identification of the hpv types that infect the cervix ( gravitt et al . our results demonstrated that self - collection sampling 
 generates comparable amounts of material for hpv testing to those of clinician samples 
 ( both amplified 99.4% of the -globin gene ) . moreover , the concordance 
 between the methods was satisfactory ( 84.6% ,  = 0.72 ) . studies reported a concordance 
 of 87% between the two methods ( brink et al . a recent study showed agreement ( 93% ; 0.849 ) between self - sampling and the 
 reference smears in regards to hr - hpv detected by real - time pcr with a modified gp5+/6 + 
 primer mix ( jentschke et al . one explanation for the high concordance is that the self - collected specimens represent 
 an admixture of vaginal and cervical cells and the sampling order ( self - collection 
 first ) may increase the number of positive samples owing to a higher number of 
 exfoliated cells ( gravitt et al . in addition , hpv testing using 
 pgmy09/11 primers has higher hpv dna detection accuracy than other tests ( bhatla & moda 2009 ) . similarly , we found that the frequencies of hpv dna detection in self and 
 clinician - collected samples were similar ( 26.5% vs. 22.9% , respectively ) and that hpv 
 infection could be detected in both the vaginal and endocervical epithelia . hr - hpv types 
 were well detected in both methods and the concordance between the methods was higher 
 for the detection of hr - hpv dna than that for that of lr - hpv . the hypothesis that sample self - collection may be suitable as a novel method of cervical 
 cancer screening by molecular tests was supported by other studies ( jentschke et al . ( 2013 ) recently reported that the positive predictive value of this test 
 decreased when the sample was self - collected , with better predictive outcomes associated 
 with high - grade lesions . ( 2013 ) detected a positive rate of 
 12.3% for hr - hpv using care hpv ( qiagen , usa ) for detection in self and professionally 
 collected samples . these authors also observed a slightly higher frequency of hr - hpv 
 positive results in the self - sampling group than in the professionally sampled group 
 ( 13.5% vs. 11% , respectively ) , although the results obtained by other authors ( castle et al . 2007 , petignat et al . 2007 ) . in the present study , women were recruited from the public health system after they were 
 referred to a gynaecologist and this may explain the high positive rate of hpv dna ( 30% ) 
 in our samples . the type of test used in the analysis of hpv dna is another relevant variable to 
 consider when determining the efficiency of both collection methods . the more sensitive 
 the detection method , smaller the amount of sample required for successful detection ( de 
 sanjos et al . another factor to 
 consider is the type of instrument used to collect the cells ( liquid - based , swab or 
 endocervical cytobrush ) , which may affect the amount of sample collected ( lorenzato et al . compared to other hpv types , hpv16 and hpv18 confer a higher risk of cervical cancer 
 ( koutsky et al . hr - hpv16 was the most frequently detected type in both the self and clinician - collected 
 samples and thus , self - collected samples show promise as an alternative diagnostic tool , 
 as well as for epidemiologic studies and vaccine trials . the type - specific primers used 
 in this study are considered the most prevalent viral types worldwide ( walboomers et al . 1999 ) . regarding hpv types obtained from different samples , the detection of high - risk 
 oncogenic hpv was more common in the clinical collection group . a study comparing the 
 detection of hpv types in samples of cervical and vaginal origin found that low - risk 
 oncogenic hpv was more prevalent in the vaginal epithelium . hence , it is likely that the 
 oncogenic hpv types have different survival mechanisms and viral production compared to 
 lr - hpv types , which rarely produce cytological abnormalities and prefer to infect cells 
 in the vagina , where the tissue is keratinised ( castle et 
 al . this fact may be associated with the restricted choice using only the primers to lr - hpv6 
 and 11 types . in addition to oncogenic hpv , we verified that sample self - collection has the potential 
 to detect multiple hpv infections . it is remarkable that infections with multiple hpv 
 types were frequently found in a study of brazilian women ( tozetti et al . multiple hpv infections increase a woman s 
 risk of developing cervical neoplasia , even if the co - infections is with an lr - hpv , 
 since it could influence the development of low - grade squamous intraepithelial lesions 
 ( trottier et al . another risk factor of hpv infection is age , as one study of sample self - collection by 
 adolescents showed that hpv infection is more common in sexually active younger women 
 ( silva et al . 1998 ) . in our study , we 
 found lower frequency of infection in women  30 years of age . these results were 
 consistent with those of other studies ( lindell et al . 
 2002 ) , that reported that hpv prevalence differs by age and is less common in 
 women over age . it was suggested that screening using hpv - dna tests is more appropriate 
 in women > 30 years of age since hpv infection is less likely to be transient in this 
 age group unlike in younger women ( franco 
 2003 ) . hpv dna testing has the potential to improve the efficacy of cervical cancer screening 
 and is a more cost - effective solution . using this strategy , the screening interval can 
 be extended to every three years compared to the use of annual pap smears ( chow et al . 2010 ) . recognising this , women who are 
 underserved in terms of cervical cancer screening , mainly those in remote areas of large 
 countries such as brazil , can justify the use of this self - collected method to the 
 public health service . in this study , we demonstrated that the results of the self - collected sampling method 
 are in good agreement with those of the clinician - collected sampling method for the 
 detection and typing of hpv dna . use of the self - collected sampling method as a primary 
 prevention strategy in countries with few resources could effectively identify those 
 women with hr - hpv . the self - collection method is better accepted among women ; therefore , 
 it could enhance cervical cancer screening program coverage and contribute significantly 
 to reducing the incidence of cervical cancer .
women infected with human papillomavirus ( hpv ) are at a higher risk of developing 
 cervical lesions . in the current study , 
 self and clinician - collected vaginal and 
 cervical samples from women were processed to detect hpv dna using polymerase chain 
 reaction ( pcr ) with pgmy09/11 primers . 
 hpv genotypes were determined using 
 type - specific pcr . 
 hpv dna detection showed good concordance between self and 
 clinician - collected samples ( 84.6% ; kappa = 0.72 ) . 
 hpv infection was found in 30% 
 women and genotyping was more concordant among high - risk hpv ( hr - hpv ) than low - risk 
 hpv ( hr - hpv ) . 
 hpv16 was the most frequently detected among the hr - hpv types . 
 lr - hpv 
 was detected at a higher frequency in self - collected ; however , hr - hpv types were more 
 frequently identified in clinician - collected samples than in self - collected samples . 
 hpv infections of multiple types were detected in 20.5% of clinician - collected 
 samples and 15.5% of self - collected samples . in this study , we demonstrated that the 
 hpv dna detection rate in self - collected samples has good agreement with that of 
 clinician - collected samples . 
 self - collected sampling , as a primary prevention 
 strategy in countries with few resources , could be effective for identifying cases of 
 hr - hpv , being more acceptable . the use of this method would enhance the coverage of 
 screening programs for cervical cancer .