Handsfield 6 month disclosure guidelines

First, let me thank you Dr. Handsfield and Dr. Hook for providing this service.  I have read through all of the posts regarding HPV and genital warts.

I know this is an issue that has been raised many times, so I apologize for bringing it up again, but I am in need of some direct advice.

I have read through all the posts regarding HPV disclosure, and the 6 month "rule" so-to-speak.  I have also read Dr. Hook's advice about how one can consider themselves most likely not contagious after being wart free for 3 months.  Despite using a condom, during last December (or January 2008) I acquired low risk HPV.  I had an outbreak of external genital warts the first week of March 2008.  I never had internal warts.  I used Aldara and was cleared of warts by early June 2008.  I have yet to have a recurrence.

I am in the process of rekindling an old relationship from years ago, with a virgin partner I know is uninfected.  When I asked my own gynecologist what I should do about sex and disclosure, he said he didn't see any reason for me to bring up that I had suffered from warts as long as I was using condoms, and that he believed the virus was most likely cleared from me.  When I brought up Dr. Handsfield's six month guidelines, he said "Well, that's one theory.  But I don't think anyone knows for sure about asymptomatic HPV transmission."  Though I trust and respect my gynecologist immensely, this left me even more confused.  The partner I am pursuing a relationship with is extremely judgmental about STD's and would not be accepting of this condition if I disclosed it.  If there is a high likelihood I will transmit this virus to him even using condoms, I will not pursue the relationship sexually.  

Would it be reasonable to trust my doctor's advice and engage in protected sexual activity now?  Or, would it be alright to wait 3 months instead of 6 to begin having protected intercourse again?   Thank you so much.

(Background info: I am female, heterosexual, 21)

[H. Hunter Handsfield, M.D.]

Unfortunately, your confusion is pretty typical.  And really this sort of uncertainty is still going to be with us for years or decades to come.  There are too many uncertainties and lack of knowledge about HPV transmission and risks, it is bound to foster different opinions from equally qualifed experts.

But let's start with this:  there is no "6 month rule", nor have I promoted 6 months as a standard "guideline" about duration of HPV infectiousness.  In fact, I agree exactly with your gynecologist; his words could have been mine.

Most genital HPV infections go away, with or without treatment.  Once visible warts have been removed or resolve on their own (or with treatment), and once an abnormal pap has become normal, it become increasingly unlikely that the virus can be detected by DNA testing, and infectiousness -- the ability to transmit HPV to a partner -- declines.  The time course of these changes, however, is highly variable -- and in fact not well known.  The risk of recurrent disease or transmission may never reach zero.  At any interval you can name, we are dealing with probabilities, not certainties.   Some experts tell their patients that as soon as the wart or abnormal pap is gone, the patient is cured and there is no longer a need to use condoms or warn partners.  Others say 3 months, others 6 months, and others might think a year is the correct interval, and still others routinely warn patients there are no guarantees the infection won't return one day or be transmitted to a partner.  I have generally been in the 6 month camp, and Dr. Hook 3 months -- but nobody really knows, and all such advice is somewhat arbitrary.

The important thing is that none of this matters very much!  Getting HPV is inevitable; it happens to just about all sexually active people.  (The research says at least 70-80%, but most experts believe 100% is closer to the truth for most sexually active persons.)  For every person who tells a partner about his or her current or past HPV infection, it's a fair bet that the partner has had sex with other people who were infected but didn't say anything.  And since the large majority of HPV infections are asymptomatic and go away without ever causing anything abnormal at all, most infections simply have no important health implications.

In other words, nobody can tell you the odds of transmission at this point.  Certainly the risk is lower with consistent condom use.  In any case, nobody should ever fail to pursue a promising sexual relationship for fear of HPV.  The virus isn't that important, and people should not let a normal consequence of human sexuality interfere with sexual or romantic fulfillment.  

So, should tell your prospective partner?  Only you can decide.  But the decision really isn't medical, but in the relationship realm.  Many couples would decide it is a mark of respect and commitment to be honest about such things.  Others would let it lie.  It depends a lot on the nature of the relationship, the personalities of the involved parties, and the like.

I know that's not the vague answer you were looking for, but it's the state of the art and science of HPV transmission.  Keep your eyes open for new information; knowledge undoubtedly will improve in the future.

In case your gyn didn't raise it:  You probably should be immunized against HPV.  Even most women who have had cervical HPV disease and/or warts will benefit from prevention of the other HPV types covered by the vaccine.

Final comment:  Consider telling your gyn that we are in more agreement than might have seemed when you first spoke with him.

Best wishes---  HHH, MD

[JulyBlossoms]

Thank you for your kind, prompt, and knowledgeable advice.  I have received two shots of the HPV vaccine since being diagnosed, and go for my final one at the end of the year.  I regret that I hadn't done it sooner, but I wasn't even aware such a thing existed.  I suppose certain doctors are often too busy through no fault of their own, to tell their patients of such new advancements.

Like you've stated in other posts, there are "no hard or fast rules" regarding HPV disclosure, and it is a decision I will have to make for myself.  Thank you for giving me the guidance to make an informed choice.

[tough_scenario]

A related discussion, Tough Ethical Question was started.