HPV questions

[ChristianZane]

Hello Doctor and Merry Christmas and Happy Holidays.  I am on an HPV Forum to offer support to people who have been diagnosed with HPV, and I always make it a point to offer as much support as possible and include many of your posts, verbatim, from this website as well as findings from the CDC, etc.  Recently however, someone has joined this group who claims to be a doctor and has been on a mission to systematically dismantle a lot of what you have said about HPV, so I was wondering if it wouldn't be too much trouble to address some of his comments as it caused great distress among our members.

1. You said: "My practical take-home message is that after several months with no wart recurrence normal pap, the person can consider him/herself cured; this is practically true if not always biologically true. Such persons probably transmit HPV to future partners rarely, if ever. Accordingly, I do not consider it ethically mandatory, or even recommended, that every person who ever has had HPV must henceforth and forever tell future partners they once were infected. Although HPV can persist, in most persons the most infections are controlled by the immune system and most experts believe they are truly cured."

His response: "I think its wreckeless, selfish and unethical for people to advocate non-disclosure to future partners, there is an agenda by most federal, state and municipal governments, its called "public health". Just because this is common doesn't make it OK for you to pass on your own disease.  And who exactly are these “experts?”

2.  You said: "And once a person has cleared a particular strain of HPV, the immune system makes it rare to catch that HPV type again. But rare doesn't mean these things never happen; they do, but the large majority of infected persons will never have a recurrence."

His response: It's nice for someone to assure you that you have immunity to this or any strain, but its not a medically sound statement.  Please ANYONE quote reliable primary medical research corroborating this idea that immunologic response is persistent!  Where is the primary research literature (not someone's opinion) corroborating this idea?

3.  He claims the ping-pong theory between two infected monogamous partners is bogus, and that constant reinfection is likely.  Do you have any evidence other than an opinion to support your "you cannot transmit the infection back and forth" statement?

4. One user wasn’t sure whether she had warts on her cervix or not, so this person suggested her boyfriend use a dental dam or "saran wrap" as a way to decrease risk of transmitting warts to someone's oral cavity.  Is this practical?

Thanks Doctor and Happy New Year!

[H. Hunter Handsfield, M.D.]

Nice to hear from you, ST.  Merry Christmas!

It is dangerous to get deeply into "he said, she said" online debates, with comments and quotes often out of context.  It may be that I and the other person would have more agreement than you think, if we could talk it out together.  An important aspect is that much of what patients can and should be advised about HPV is common-sense extrapolation from research that gives clues but is not definitive.  In other words, there is lots of room for legitimate difference of opinion.  That said, I stand by my advice on each of the points you raise, based on reasonable conclusions from uncertain data plus the practical experience that comes from 3 decades dealing with patients with HPV and genital warts.

An underlying principle:  50-80% of all people acquire genital HPV, and some of them have lifelong infection which from time to time may be transmissible.  However, only a few percent of those infections are diagnosed, when they cause warts or are detected by pap smear.  If that small minority informs all future sex partners, on a population level few new HPV infections will be prevented.  When you add the fact that most infections either resolve spontaneously or become non-transmissible after several months, it is obvious the potential for effective prevention is even lower.  

Specific responses:

1) I defer to nobody in my dedication to or understanding of public health principles.  The fact is that HPV DNA drops to undetectable levels after several months in the large majority of persons.  Some of those people probably can transmit HPV to future sex partners, and some may develop later HPV disease (abnormal pap, warts).  But almost certainly the large majority do not do so.

2) The success of the new vaccines is based on type-specific immunity.  Your HPV forum participant apparently is unaware of several studies have showing that once a person acquires a particular HPV type that goes away (according to DNA testing), that person almost never acquires the same HPV type again--even when such people remain sexually active in the same population group where the original HPV type is known to be common.  Specific sources:  Ho et al, N Engl J Med, mid 1990s; Winer et al, recently published (NEJM? or maybe JAMA?); and numerous other references that can be found by looking at the literature citations in the recent research papers reporting success with the new HPV vaccines (e.g., Koutsky et al 2002, Ault et al 2005).  The occurrence of type-specific immunity, either from natural infection or immunization, is not a matter of debate or personal opinion, but hard data.

3) The same studies cited show this as a reasonable conclusion.  If ping-pong infections occur, they are rare, because of the immunity that develops.

4) Plastic wrap or dental dams undoubtedly would be effective, but I know of no STD experts who consider it practical to recommend their widespread use.  Barrier protection for oral sex simply does't pass the "laugh test" among most sexually active people.  Overt oral warts due to genital HPV types are very rare.  However, an interesting research literature is developing, indicating that many (most?) cancers of the larynx, mouth, etc are due to genital HPV strains; and that these diseases may be increasing in frequency.  So it is possible that oral sex and exposure to HPV are riskier in this regard than generally believed.  However, the actual rates of such cancers are very low, as cancers go.  If the association is real, the ultimate resolution probably will lie with the HPV vaccines, not barrier protection for oral sex.

Merry Christmas to all--  HHH, MD

[SunnyTriangle]

Thanks for that, it really does help alleviate so much misinformation and the "social stigmas" of HPV which have sent some of are forum readers into suicidal thinking, and it's most reassuring to share your words with them, it literally has been a life saver for some, and we all thank you for that.

I would like you to address why people are so emotional with finger pointing about this disclosure thing with HPV?  Why don't they care about the 20-40 million people currently walking around with HPV right now in the US who don't know they have it, or might suspect they have it, but don't due to a lack of symptoms or abnormal paps?  Why are some people so pointed about making those with visual symptoms disclose their infection about HPV, is ignorance truly bliss?  Is this based in political, religious, moral, ethical, family upbringing or a personal agenda?  I've never quite understood this preaching about it, which seems to be more prevalent with HPV than anything else.  You must experience this ALL THE TIME among your own peers, how do you explain it away, or not be affected by it?  I'm not sure why people are so adamant about trying to make me feel dirty, that I'm a walking shedding contagious virus who can kill people, I just don't get it.  This will be my last comment, thank you again Doctor.

[H. Hunter Handsfield, M.D.]

I'm not sure I have special insight into why there is so much stigma associated with HPV apnd genital warts.  I do not think it is primarily related to the attitudes of health care providers or the public health establishment, but more to the fact that warts--of any body part--have always been considered "dirty" (e.g., the old wives' tale that they could be caught from toads).  If anything, health care providers trivialize warts and HPV, don't consider infection nearly as important as their patients do.  The fear of unknowingly transmitted a yucky (cancer-causing, wart-causing) infection to partners obviously is a big part of it.  In other words, I believe most of the stigma is generated internally, not the result of "finger pointing" by the health professions, religious leaders, or politicians.

However, the latter probably has contributed to the problem in recent years.  Some people with political agendas--particularly from the religious right and from some persons in the Bush adminstration--have latched onto HPV as a favored STD with which to push fear-based eduction, along with claims that condoms do not protect ahgainst HPV (which is wrong).  But these attitudes are rare, in my experience, in STD and public health experts, who in general strongly condemn such perspectives.

Regards--  HHH, MD

[monkeyflower]

Woohoo. Beautifully said, Dr. Handsfield.

Regarding the stigma associated with STDs, I think that if you feel bad about yourself, you're likely to perceive others as viewing you the same way, AND you're more likely to actually attract others who reinforce your negative self-perception. I have a feeling it becomes kind of a self-fulfilling prophecy.

I think that anyone who is judgmental and critical of someone with a STD isn't someone you'd probably want to be around anyway - not as a friend, not as a doctor, and certainly not as a partner. Years ago, one of my psych professors advised us to pay close attention to how our dates acted around people who weren't "important": the server at a restaurant, the cashier at a store... if s/he was rude to them, beware. I've remembered that all these years, and it's never failed. I think the same applies here.

Happy holidays to everyone :-)

[ChicShane]

Yea I don't understand when those people come onto the hpv forum and support boards and try to tell everyone that they are a public health concern and that they are borderline criminal and should be reported to health authorities, I think it's probably a control issue as they can make you feel a certain way, it's almost like racism, bringing someone down makes them feel better about themselves.  It's quite sad, I'm not sure why someone with the flu (which kills 40,000 people in the US every year) has less of an obligation to tell people about their infection than someone who hasn't had warts or HPV symptoms for 5 years, it's really so dumb.  Ok bye!