Q. What's HPV?

A. Human papillomavirus (HPV) is the most common STD in the world, infecting more than 440 million people.[1] There are over one hundred different types of HPV, and about thirty to forty of them cause genital infections.[2] While most people who contract HPV will not suffer serious consequences from the virus, it does cause 99.7 percent of cervical cancer, and this kills approximately 288,000 women annually.[3]

In the United States the annual death toll from cervical cancer is fewer than four thousand. The reason for the relatively low figure is that HPV is often treated before it leads to cervical cancer. Unfortunately, women in developing nations often lack adequate health care and routine Pap testing. Therefore they are much more likely to suffer the full consequences of the virus.
HPV can also cause genital skin cancer, which has killed more than thirty thousand people in the United States.[4]. Finally, HPV can cause genital warts, but only 1 percent of sexually active people experience this symptom.[5].

Unfortunately, the virus can impact the health of children born to infected mothers. For example, I know of parents who took their infant to the doctor because she had a sore throat. The doctor examined her and told the parents that the child had genital warts growing on her larynx. This condition, recurrent respiratory papillomatosis (RRP), is uncommon but still infects over two thousand children each year.[6] Since there is no cure for HPV, children with RRP often require laser surgeries to remove the warts. Sadly, the average child with RRP needs surgery every three months for several years; such a child will have more than twenty surgeries over the course of his or her lifetime.[7]

Because the virus usually does not show symptoms, most people who have HPV are unaware of their infection. Also, HPV can remain latent in a person’s body for a considerable amount of time. For example, some women have contracted the virus as teens and not suffered health effects from the infection until their thirties or forties. Also, when a woman gets checked for signs of HPV, the doctor’s colposcope may fail to detect genital wart infestations. Doctors may also give a woman a Pap test to see if there is any abnormal cell growth in her cervix caused by HPV. However, this is not technically an “HPV test.” In fact, one study of more than three hundred sexually active teen girls discovered that 62 percent of the girls were infected with HPV, despite the fact that most of them had normal Pap test results![8]

Because the Pap test can sometimes fail to detect HPV, many doctors recommend a yearly test for any woman who has been sexually active, even if she is now abstinent. HPV DNA tests are now available as well. Through an HPV DNA test, a woman who has HPV can know which type (or types) of the virus she is infected with. Doctors can then tell her if she is in a high or low risk category and can follow up with her accordingly.

Recently scientists have developed a vaccine against HPV for women. Although it only prevents a few types of HPV, which infect only 3 percent of women,[9] those few types are responsible for causing most cases of cervical cancer and genital warts.

Men can be infected with HPV as well, but they are less likely to develop cancer from it, so they are often considered “vectors” for the virus. For example, when a husband is infected with HPV, his wife is five times as likely to get cervical cancer.[10] Unfortunately, most men with HPV who get tested for STDs will not learn of their infection unless they have visible genital warts. HPV DNA testing does exist for men, but it is expensive and usually only used for research purposes.

How common is the virus among males? One way to know is to consider how quickly women are infected. According to the British Journal of Obstetrics and Gynecology, 46 percent of teenage girls acquire HPV from their first sexual relationship.[11] Such high rates of infection are widely reported, and scientists estimate that over 50 percent of sexually active men and women have been infected with one or more types of genital HPV.[12] Such high numbers seem almost unbelievable. But one must remember that most people with HPV will not show symptoms or suffer as a result of it.

Although HPV is incurable, this does not mean that it is permanent, like herpes. In fact, HPV will usually go away within a few years.[13] So despite the fact that most women have been infected with HPV,[14] only 27 percent currently test positive for the virus.[15]

Young women are most at risk for HPV infection. For example, 40 percent of sexually active girls between the ages of fourteen and nineteen are currently infected with HPV. The numbers are even higher for women aged twenty to twenty-four (49 percent)![16] Among all women this age bracket has the highest rate of HPV.

The prevalence of HPV also varies according to marital status. For example, only 17 percent of married women are currently infected. However, nearly half of all women who are living with their boyfriends are infected with the virus.[17]

One reason why the virus is so common is that HPV can spread by any genital contact (genital, oral, or by means of the hands).[18] The virus can also be present, without symptoms, on a person’s abdomen or thighs.[19] Therefore condoms are not very effective in preventing its transmission.

This is perhaps one reason why we don’t hear more about HPV. It is the Achilles’ heel of the “safe sex” campaign. For example, researchers followed hundreds of college girls without HPV and discovered that 60 percent of them contracted the virus by the end of the study. According to the researchers, “always using male condoms with a new partner was not protective [of HPV].”[20] One has to wonder if these women would have made different choices if they knew the limitations of the condom.

In order to educate the public about HPV, Congress passed Public Law 106-554. Among other things, this law required government health agencies to make sure that educational materials are “medically accurate regarding the overall effectiveness or lack of effectiveness of condoms in preventing sexually transmitted diseases, including HPV.”[21] Condom labels were to be reexamined for medical accuracy, and the Centers for Disease Control (CDC) were directed to create a report that outlined the best strategies to avoid HPV.

The CDC finally published their report three years later, admitting, “The available scientific evidence is not sufficient to recommend condoms as a primary prevention strategy for the prevention of genital HPV infection.”[22] While condom use may reduce the risk of HPV-related diseases, the CDC explained earlier that “studies which have attempted to assess male condom benefit for women have generally found no evidence of protection against [HPV] infection.”[23]

As soon as the CDC released its report, Congressman Mark Souder wrote a letter to the commissioner of the Food and Drug Administration:

A meta-analysis reviewing “the best available data describing the relationship between condoms and HPV-related conditions” from the past two decades published in the November 29, 2002 edition of the journal Sexually Transmitted Diseases found, “There was no consistent evidence of a protective effect of condom use on HPV DNA detection, and in some studies, condom use was associated with a slightly increased risk for these lesions.” Three years after Public Law 106-554 was signed by President Clinton, condom labels still do not warn consumers about the lack of protection against HPV infection. The Subcommittee urges FDA to act on the release of CDC’s HPV prevention report and immediately relabel condoms to alert consumers that condoms do not provide effective protection against HPV infection.[24]

Because of the inadequacy of the condom in preventing HPV, many people contract the virus while engaging in what they mistakenly believe to be “safe sex.” Senator Tom Coburn, who has been working for years to encourage the FDA to correct condom labels, testified, “It is a cruel distortion of the word ‘prevention’ to tell women and young girls that the tremendous physical, emotional and financial costs of treatment for HPV infection are a cost worth bearing as a consequence of federal health agencies’ intentional distortion and cover-up of scientific data related to HPV.”[25] The financial impact he mentioned is the fact that Americans spend up to six billion dollars each year treating HPV.

While some government officials have urged the FDA to update condom labels, other politicians want it left alone. Congressman Henry Waxman, a long-time opponent of abstinence education, argued, “We want to be sure that we do not end up with an unintended effect of confusing people about the situations where condoms do work. . . . [Condom labels] that include information on HPV can result in so much information on such a small package that it reduces the effectiveness of any information.”[26] Therefore he believes that undermining the public’s confidence in the condom will have “serious public health consequences.” He added, “Are condoms perfect? Of course not. But reality requires us not to make a public health strategy against protection, but rather to ask a key question: compared to what?”[27]

Unfortunately, since Waxman thinks purity is unrealistic, his only option to stop STDs is to exaggerate condom effectiveness in hopes that more people will use them. Some health “experts” concur, saying they we don’t want to “create an epidemic of panic, fear, and anxiety in adolescents and young adults who are embarking on their sexual careers.”[28] One leader in the sex ed movement tried to put an optimistic spin on the issue by saying, “I don’t think we, in any way, want to do anything that will frighten people from using condoms. . . . The bottom-line message always needs to be that most STDs are treatable.”[29]

In the midst of the debate, the FDA has not done a great deal. It said that it is “certainly committed to looking at this and making the requisite changes.”[30] It added that it is “preparing new guidance on condom labeling,” “exploring new opportunities to best inform condom users about important limitations of the device,” and “proposing to amend the classification regulations for condoms.”[31] In other words, not much has changed.

The lack of clarity from government agencies has contributed to confusion within the contraceptive industry. For example, the makers of LifeStyles Condoms issued a press release “encouraging people to have a love affair with condoms.”[32] In it the manufacturers claimed that safe sex reduces the risk of HPV transmission. When asked for the scientific proof to back up their claim, they admitted that their public relations firm “mistakenly included HPV among the diseases for which latex condoms provide protection.”[33]

In 2005 the FDA took a step in the right direction and drafted a document with proposed language for a new condom label. As a result of this document, the commissioner of the FDA said the agency “received roughly 400 comments on the proposed rule. Almost all comments suggested the proposed labeling language was confusing and difficult for consumers to understand. As a result, the Agency intends to undertake additional labeling comprehension studies to help insure that the final labeling recommendations issued by the Agency are understandable to users.”[34]

While the FDA is undertaking its condom “labeling comprehension studies,” millions of people are being infected with HPV while overestimating the effectiveness of so-called “safe sex.”
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[1]. F. Martinon-Torres, et al., “[Human Papillomavirus Vaccines: A New Challenge for Pediatricians],” Anales de Pediatría 65:5 (November 2006): 461–469; Helen Trottier and Eduardo L. Franco, “The Epidemiology of Genital Human Papillomavirus Infection,” Vaccine 24:S1 (30 March 2006): S4; Division of STD Prevention “Prevention of Genital HPV Infection and Sequelae: Report of an External Consultants’ Meeting,” Department of Health and Human Services, Atlanta: Centers for Disease Control and Prevention (CDC) (December 1999): 1; Janet Torpy, “Human Papillomavirus Infection,” The Journal of the American Medical Association 297:8 (28 February 2007): 912.
[2]. M. A. Van Ranst et al., “Taxonomy of the Human Papillomaviruses,” Papillomavirus Report 3 (1993): 61–65. As reported by NIH, “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,” 23.
[3]. World Health Organization, “Cervical Cancer,” International Agency for Research on Cancer, 2005 (www.iarc.fr).
[4]. “Genital Skin Cancer More Deadly for Women,” HealthDay News (5 February 2007).
[5]. L. Koutsky, “Epidemiology of Genital Human Papillomavirus Infection,” The
American Journal of Medicine 102:5A (5 May 1997): 3–8.
[6]. Eloise M Harman, “Recurrent Respiratory Papillomatosis,” www.emedicine.com (2 June 2006).
[7]. Harman.
[8]. Tarkowski, et al., 46–50.
[9]. Eileen F. Dunne, et al., “Prevalence of HPV Infection Among Females in the United States,” The Journal of the American Medical Association 297:8 (28 February 2007): 813–819.
[10]. F. Xavier Bosch, et al., “Male Sexual Behavior and Human Papillomavirus DNA: Key Risk Factors for Cervical Cancer in Spain,” Journal of the National Cancer Institute 88:15 (August 1996): 1060–1067.
[11]. S. Collins, et al., “High Incidence of Cervical Human Papillomavirus Infection in Women During Their First Sexual Relationship,” BJOG : An International Journal of Obstetrics and Gynaecology 109:1 (January 2002): 96–98.
[12]. L.E. Manhart and L.A. Koutsky, “Do Condoms Prevent Genital HPV Infection, External Genital Warts, or Cervical Neoplasia?: A Meta-Analysis,” Sexually Transmitted Diseases 29:11 (November 2002): 725–735; Division of STD Prevention “Prevention of Genital HPV Infection and Sequelae: Report of an External Consultants’ Meeting,” DHHS, (CDC), 7.
[13]. A.B. Moscicki, et al., “The Natural History of Human Papillomavirus Infection as Measured by Repeated DNA Testing in Adolescent and Young Women,” The Journal of Pediatrics 132:2 (February 1998): 277–284; E.L. Franco, et al., “Epidemiology of Acquisition and Clearance of Cervical Human Papillomavirus Infection in Women from a High-Risk Area for Cervical Cancer,” The Journal of Infectious Diseases 180:5 (November 1999): 1415–1423.
[14]. L. Koutsky, “Epidemiology of Genital Human Papillomavirus Infection,” The American Journal of Medicine 102:5A (5 May 1997): 3–8, as cited in Centers for Disease Control, “Tracking the Hidden Epidemics, Trends in STDs in the United States 2000,” (6 April 2001), 18.
[15]. Dunne, et al., 815.
[16]. Dunne, et al., 816.
[17]. Dunne, et al., 813–819.
[18]. Medical Institute for Sexual Health, Sex, Condoms, and STDs, 28; C. Sonnex, et al., 317–319; Winer, et al., 218–226; Hammarstedt, et al., 2620–2623.
[19]. NIH, “Scientific Evidence on Condom Effectiveness for Sexually Transmitted Disease (STD) Prevention,” 26; House of Representatives, “Breast and Cervical Cancer Prevention and Treatment Act of 1999” (22 November 1999), 10.
[20]. Winer, et al., Genital Human Papillomavirus Infection: Incidence and Risk Factors in a Cohort of Female University Students,” American Journal of Epidemiology 157:3 (1 February 2003): 218.
[21]. Public Law 106-554, 106th Congress, 114 Stat. 2763 (21 December 2000).
[22]. Julie Louise Gerberding, “Report to Congress: Prevention of Genital Human Papillomavirus Infection,” Centers for Disease Control and Prevention, Department of Health and Human Services (June 2004), 4–5.
[23]. Division of STD Prevention “Prevention of Genital HPV Infection and Sequelae: Report of an External Consultants’ Meeting,” DHHS, (CDC), 14.
[24]. “Rep. Souder Asks FDA for Action on Condom & HPV Information Law,” abstinence.net (12 February 2004), emphasis mine; Manhart and Koutsky, 725–735.
[25]. Tom Coburn, “Cervical Cancer and Human Papillomavirus,” Hearing before the Subcommittee on Criminal Justice, Drug Policy and Human Resources, U.S. House of Representatives(11 March 2004), 4.
[26]. Ilka Couto and Cynthia Dailard, “Wanted: A Balanced Policy and Program Response to HPV and Cervical Cancer,” The Guttmacher Report on Public Policy 2:6 (December 1999).
[27]. Lara Jakes Jordan, “Condom Warning Labels Mulled,” cbsnews.com The Associated Press, Washington (12 March 2004).
[28]. Audio Transcript, “Scientific Evidence on Condom Effectiveness and STD Prevention,” National Institute of Allergy and Infectious Diseases (12–13 June 2000).
[29]. Tamara Kerinin, as quoted by Cheryl Wetzstein, “Agencies Rapped for Shirking HPV Law,” The Washington Times (23 December 2003).
[30]. Sylvia Smith “Condom Labels Called Inadequate,” The Journal Gazette (12 March 2004) 5-A.
[31]. Statement of Daniel G. Schultz, M.D. Before the Subcommittee on Criminal Justice, Drug Policy, and Human Resources Committee on Government Reform United States House of Representatives March 11, 2004.
[32]. LifeStyles Condoms, Press Release, Ansell Healthcare, Inc. (31 July 2000).
[33]. Letter from Kerry A. Hoffman, Regional Director, Ansell Healthcare, Inc. (8 September 2000).
[34]. “Latest News: Andrew C. Von Eschenbach, M.D. Confirmation, Questions for the Record,” Abstinence Clearinghouse E-mail Update (9 September 2006), Reply to Question 14.