HPV in England

Hi doc. First of all let me say that you have saved me from some of the worse stress in my life - lack of sleep, unable to eat, etc. I have an experience that might help fellow readers, followed by a recurrence theory I would like you to respond to.

I had growths on my penis, went to my local GUM (Genito-Urinary Medicine) clinic in England. The first thing I noticed was the posters and leaflets for genital warts

[H. Hunter Handsfield, M.D.]

It sounds like you found a knowledgeable provider, as I would expect in most UK GUM clinics, and have pretty good information about genital warts and HPV infection.  Although I am not a virologist, nor do I keep up on research developments in the pathogenesis and immune response to HPV, your comments and theories about persistent and recurrent infection seem valid.

I would just add that the very definition of HPV

[Englishman]

Thanks Doc,

It seems to me that most American forums/sites I have investigated seem to promote irrational fear over this. I suspect that perhaps strong (Christian?) morality is influencing opinion rather than a rational scientific approach.

From the news I read, many in the US seem both pro-life (anti-abortion), pro-death (support the death penalty, and indeed the War in Iraq, I am I the only one who spots the irony here?), pro-marriage, and pro-abstience until married. This forum represents a place where people can have rational intelligent discussion removed from religious morality and fear-mongering and I thank you for this.

[Englishman]

One more thing. I accept the argument over "cured" and can see it from both perspectives. I have read your responses before about this. Arguments over definition are nearly always the dividing line between any two opposing views. I have been to university and now teach and have many a debate on a range of issues that almost always come down to a definition. Makes life both interesting and frustrating.

[ChicShane]

Abstinence propogandists like to latch onto HPV as vehicle to promote their religious idealogy.

[Englishman]

Agreed. Either way, it won't work! Not from my experience as a teacher of 12-18 yr olds. Generally the more religous the message, the less likely they are to listen!

[H. Hunter Handsfield, M.D.]

You surely are right about the political slant about HPV in the US.  Happily, some of the outlandish voices have been somewhat stilled recently by the march of science.  The still-to-be published research showing a high degree of efficacy of condoms in preventing HPV has taken wind from their sails.*  And some of the more vocal rightist/populist organizations also have had to stand in support of the coming HPV vaccine, because they can't stand against cancer prevention.  They made a few comments some months ago about the vaccine's supposed potential to promote promiscuity, got overwhelming negative feedback from their own constituents, and changed their tune.  Sometimes common sense prevails, even in this bizarre, simplistic land.

* From a scientific perspective, that research is the most sophisticated and probably most reliable study ever done on condom efficacy for any STD, and it shows that 100% condom use was assoicated with 90% efficacy in preventing new HPV infections.  It has already influenced the US Food and Drug Administration, which was close to requiring a non-effectiveness warning statement on condom packages but now apparently will not do so.

HHH, MD

[H. Hunter Handsfield, M.D.]

You surely are right about the political slant about HPV in the US.  Happily, some of the outlandish voices have been somewhat stilled recently by the march of science.  The still-to-be published research showing a high degree of efficacy of condoms in preventing HPV has taken wind from their sails.*  And some of the more vocal rightist/populist organizations also have had to stand in support of the coming HPV vaccine, because they can't stand against cancer prevention.  They made a few comments some months ago about the vaccine's supposed potential to promote promiscuity, got overwhelming negative feedback from their own constituents, and changed their tune.  Sometimes common sense prevails, even in this bizarre, simplistic land.

* From a scientific perspective, that research is the most sophisticated and probably most reliable study ever done on condom efficacy for any STD, and it shows that 100% condom use was assoicated with 90% efficacy in preventing new HPV infections.  It has already influenced the US Food and Drug Administration, which was close to requiring a non-effectiveness warning statement on condom packages but now apparently will not do so.

HHH, MD

[Englishman]

Hi Doc / Any other readers,

I would still like to know how this study was conducted. Did it assume that ALL HPV infected skin was covered by the condom. What about if HPV infected pubic areas were rubbing together during sex? Does this account for the 10% of transmissions that condoms did not protect? I would assume that on a microscopic scale, scientists would be able to see whether HPV could penetrate through the membrane of a condom. Or more simply if you "pushed" HPV into the membrane of a condom, does it pass through? What maximum force is required to push it through? Does the magnitude of this force translate to possible forces during sex?

I assume the study was probably an epidomological one, but the above questions still need resolving to explain the observed results.

[H. Hunter Handsfield, M.D.]

The study is based on real-time diaries of sexually active persons (as opposed to retrospective recall of condom use in the past, the basis of most condom studies). But you (and everyone else) will have to await its publication for the details.

The study was not designed to explain the exceptions, ie why 10% of 100% condom users still got HPV.  Skin contact above the condom makes sense.  Neither HPV, HIV, nor any other STD pathogen can be "pushed through" intact latex or polyurethane, certainly not at the pressures expected during sex.

HHH, MD

[Englishman]

This explains why CORRECT condom use is so effective against STDs. I saw a documentary on TV about a sex worker in a brothel in Nevada who was very confident about how to use condoms effectively and has never caught an STD despite having sex with hundreds of men over the years. Readers please note that I do not condone, nor condem this behaviour it is between her and her clients and has NOTHING to do with me - I am just interested in this from an educational point of view. In my past I have certainly not used condoms effectively - not enough lube so that they rip, not taking enough time learning how to put one on properly etc. This now translates to my teaching so that people can learn more about the practical ways of using condoms effectively.

[Englishman]

Having said that, I'm sure she probably had asymptomatic HPV at some point in her "career".