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Questions for Infectious Disease specialist
1. What is the sensitivity and specificity of the HPV test used during routine PAP screening and is specific type testing available?
2. Is HPV a systemic or localized infection? If the cervical screen is positive for high risk types, are other orifices (anal/rectal/oral) also positive and at risk of oncogenic changes, or is the infection localized to the vagina/cervix.
3. If a man or woman is a long time carrier of the virus, what screening should be done for HPV CAs other than cervical and at what frequency? (anal/rectal/oral)
2. Is HPV a systemic or localized infection? If the cervical screen is positive for high risk types, are other orifices (anal/rectal/oral) also positive and at risk of oncogenic changes, or is the infection localized to the vagina/cervix.
3. If a man or woman is a long time carrier of the virus, what screening should be done for HPV CAs other than cervical and at what frequency? (anal/rectal/oral)
I want to thank you, Holly, for your thorough feedback and information. Even though this was not my question(s) I have HPV type 39 and have been in fear re: getting cervical cancer. Your feedback has given me stats and facts which have educated me more on this Virus.
Thank you so much!
If you could please answer 2 questions for me I would appreciate it:
1) If I am with the same partner from whom I got HPV type 39, and we have a monogamous relationship, is it possible to contract another/additional/more types of HPV from him? Or will I only have type 39 while with him?
2) Because I know my partner definitely has HPV, can I get oral HPV if I perform oral sex on him? Also, can I get Oral HPV at the same time that I have genital/cervical HPV (I currently have type 39). How can one test for oral HPV?
Thanks for your time!
Thank you so much!
If you could please answer 2 questions for me I would appreciate it:
1) If I am with the same partner from whom I got HPV type 39, and we have a monogamous relationship, is it possible to contract another/additional/more types of HPV from him? Or will I only have type 39 while with him?
2) Because I know my partner definitely has HPV, can I get oral HPV if I perform oral sex on him? Also, can I get Oral HPV at the same time that I have genital/cervical HPV (I currently have type 39). How can one test for oral HPV?
Thanks for your time!
Your questions are interesting and not easily answered. The only high risk HPV test on the market in the US that is FDA approved has false positives because it can react with low risk HPV’s or simply be a false positive by lab error. There are studies done but most of them were done by the manufacturer or paid for by the manufacturer so there can be a question of skewed results depending how they report their results. The sensitivity for the high risk test is supposedly in the 80-90%’s but you have to know what you are comparing those results to ASCUS, LSIL, HSIL etc. to understand the specificity. The most accurate test is PCR (polymerase chain reaction) often done at universities and not readily available for consumers in the US.
When Digene asked for FDA approval they requested it in women over 30 years of age combined with a Pap because the results were more accurate on the negative side (neg Pap, neg HPV—virtually no cancer risk), they received approval for over 30 years of age and FOR WOMEN UNDER 30 WITH ASCUS. There is a lot of controversy over this and many Dr.’s don’t understand it. Most women under 30 are low risk and women under 21 should not have an HPV test. It is well known that most HPV infections in women under the age of thirty usually clear and are transient infections.
HPV does not cause cervical cancer, only persistent HPV may and even then not all the time. Persistent HPV is when you test for the same HPV over a long period of time, you are either re-infected or you don’t clear it. That is the reason the present testing in the US leaves a lot to be desired. You need to know the specific HPV you have in order to know if you are at risk. It can clear as early as 4 menstrual cycles, often at 1 year but it can take up to 4 years.
There was a Harvard study in 07 that said 95% of colposcopies in the U.S. were unnecessary. That means that 5 out of every 100 women have an abnormality, but again that does not mean cancer, some only need treatment for CIN 2 or CIN 3. This means NINETY-FIVE percent are NORMAL. The colposocpy market is 10 billion!
There is an organization on the internet SANE Vax that provides accurate genotyping, it compares your results to the gen bank. The same technology that is used to clear criminals based on DNA. I have read the studies where the labs are sent and they are impressive. They send your specimen to a prominent pathologist that has 100% accurate results. At present it appears to be only for pre and post gardasil on their website but it would be worth checking if you want an accurate test. You would need to go to your Dr. and have him/her collect a specimen, fill out a requisition and send to SANE Vax. So this would be a discussion between you and your Dr. and at the same time it opens the discussion to understand HPV and you will find out how much your Dr. knows about HPV.
If you look at the insert for the Digene test there is a very small study; 209 women (usually studies have larger numbers for verification) the results Digene to PCR are positive by both Digene and PCR 148 women, 25 negative by both Digene and PCR, with 5 positive by PCR and negative by Digene, 31 negative by PCR but positive by Digene. My math indicates 36 conflicting results on a sample of 209 women. So in this small study that would be an 83% agreement for both tests for positive and negative and it indicates a 96% agreement for positive (5 women were negative by Digene that should have been positive and 148 positive by PCR out of 153 therefore HPV positive) and only 44.6% for agreeing on negative (which would be 31 women told that they were positive out of 56 that were actually negative (25 actual HPV negative by PCR). In fairness to the insert they say that this test was conducted prior to a procedural modification. However there has been no update in the insert since the early 2000’s when this same data was given to the FDA. There are studies with much larger discrepancies.
Answers to your questions
1. There are many studies and they often don’t agree but this is data from Wiki
Conventional Pap--Sensitivity 72 Specificity 94
Liquid Pap--Sensitivity 61 Specificity 82 (Most Paps now are liquid based because it is easier for the cytopathologist’s and done by computer, if you compare to conventional the results were better before the change)
HPV test--Sensitivity 88-91(for CIN 3 or higher) Specificity 73-79 (for CIN 3 or higher) The HPV test appears slightly more sensitive but you need to understand that when specificity drops that means the tests are false positive. This is compared to CIN 3 and not to ASCUS, it is lower for ASCUS.
Specificity is the number of negatives that are correctly identified; healthy people that are correctly identified as not having the disease.
Specific typing is available at some universities for research, some labs (google it) and SANE Vax.
2. It is localized; you can have cervical and not rectal and vice versa. I would not worry about oral because it is rare but some Dentists have a wash to test for it.
3. There is no way to know if you are a long time carrier unless you have been genotyped, you could have had it and cleared it. You would need to know what HPV you have. For women an annual Pap is all she needs, if she is negative twice then every 2 years. I would only have a colposcopy for HSIL or greater. She could add an HPV test every 3 years after 30 but I would not do it more often and I’m not really in favor of them due to false positives and false negatives; as long as you understand that the results are not 100% accurate and you do not have a colposcopy for a one time HPV positive test. There are too many colpocopies being done for no disease. Unfortunately there are no tests for men, but condoms help and so does limiting partners. A woman could look for accurate genotyping. She needs to discuss this with her Dr. and I also would only ever have a colposcopy by an OB/Gyn and even then you need to ask questions. I would never have one by a family physician or a nurse practitioner. You need to rely also on the visual during the colposcopy that an expert in the field has. And you need to ask them if they see anything. Blindly doing biopsies is unacceptable, especially under 30 and can do more harm for no disease.
What everyone needs to remember is that there are fewer than 4,000 cases of cervical cancer deaths a year in the US and they are mostly in women that do not get gyn care. I will quote from a physician who understands HPV.
—“If a woman is infected with HPV 18 in January, HPV 18 in July and HPV 31 in December, her cancer risk is zero. Even though these are all high risk types, they are considered transient. It takes repeated infection by the same type to perhaps pose a risk of cervical cancer. When a woman has persistent infection by the same type, if her lifestyle is healthy (no smoking, eating well, does not have multiple partners and is exercising) her risk of cervical cancer is still minimal.”—
Regular Pap testing is important and so is a good OB/GYN that understands HPV.
This was a little lengthier than I had anticipated but hopefully it helps some understand this confusing topic that tends to bring hysteria due to a possible cancer diagnosis when it is really over played by physicians and drug companies.
When Digene asked for FDA approval they requested it in women over 30 years of age combined with a Pap because the results were more accurate on the negative side (neg Pap, neg HPV—virtually no cancer risk), they received approval for over 30 years of age and FOR WOMEN UNDER 30 WITH ASCUS. There is a lot of controversy over this and many Dr.’s don’t understand it. Most women under 30 are low risk and women under 21 should not have an HPV test. It is well known that most HPV infections in women under the age of thirty usually clear and are transient infections.
HPV does not cause cervical cancer, only persistent HPV may and even then not all the time. Persistent HPV is when you test for the same HPV over a long period of time, you are either re-infected or you don’t clear it. That is the reason the present testing in the US leaves a lot to be desired. You need to know the specific HPV you have in order to know if you are at risk. It can clear as early as 4 menstrual cycles, often at 1 year but it can take up to 4 years.
There was a Harvard study in 07 that said 95% of colposcopies in the U.S. were unnecessary. That means that 5 out of every 100 women have an abnormality, but again that does not mean cancer, some only need treatment for CIN 2 or CIN 3. This means NINETY-FIVE percent are NORMAL. The colposocpy market is 10 billion!
There is an organization on the internet SANE Vax that provides accurate genotyping, it compares your results to the gen bank. The same technology that is used to clear criminals based on DNA. I have read the studies where the labs are sent and they are impressive. They send your specimen to a prominent pathologist that has 100% accurate results. At present it appears to be only for pre and post gardasil on their website but it would be worth checking if you want an accurate test. You would need to go to your Dr. and have him/her collect a specimen, fill out a requisition and send to SANE Vax. So this would be a discussion between you and your Dr. and at the same time it opens the discussion to understand HPV and you will find out how much your Dr. knows about HPV.
If you look at the insert for the Digene test there is a very small study; 209 women (usually studies have larger numbers for verification) the results Digene to PCR are positive by both Digene and PCR 148 women, 25 negative by both Digene and PCR, with 5 positive by PCR and negative by Digene, 31 negative by PCR but positive by Digene. My math indicates 36 conflicting results on a sample of 209 women. So in this small study that would be an 83% agreement for both tests for positive and negative and it indicates a 96% agreement for positive (5 women were negative by Digene that should have been positive and 148 positive by PCR out of 153 therefore HPV positive) and only 44.6% for agreeing on negative (which would be 31 women told that they were positive out of 56 that were actually negative (25 actual HPV negative by PCR). In fairness to the insert they say that this test was conducted prior to a procedural modification. However there has been no update in the insert since the early 2000’s when this same data was given to the FDA. There are studies with much larger discrepancies.
Answers to your questions
1. There are many studies and they often don’t agree but this is data from Wiki
Conventional Pap--Sensitivity 72 Specificity 94
Liquid Pap--Sensitivity 61 Specificity 82 (Most Paps now are liquid based because it is easier for the cytopathologist’s and done by computer, if you compare to conventional the results were better before the change)
HPV test--Sensitivity 88-91(for CIN 3 or higher) Specificity 73-79 (for CIN 3 or higher) The HPV test appears slightly more sensitive but you need to understand that when specificity drops that means the tests are false positive. This is compared to CIN 3 and not to ASCUS, it is lower for ASCUS.
Specificity is the number of negatives that are correctly identified; healthy people that are correctly identified as not having the disease.
Specific typing is available at some universities for research, some labs (google it) and SANE Vax.
2. It is localized; you can have cervical and not rectal and vice versa. I would not worry about oral because it is rare but some Dentists have a wash to test for it.
3. There is no way to know if you are a long time carrier unless you have been genotyped, you could have had it and cleared it. You would need to know what HPV you have. For women an annual Pap is all she needs, if she is negative twice then every 2 years. I would only have a colposcopy for HSIL or greater. She could add an HPV test every 3 years after 30 but I would not do it more often and I’m not really in favor of them due to false positives and false negatives; as long as you understand that the results are not 100% accurate and you do not have a colposcopy for a one time HPV positive test. There are too many colpocopies being done for no disease. Unfortunately there are no tests for men, but condoms help and so does limiting partners. A woman could look for accurate genotyping. She needs to discuss this with her Dr. and I also would only ever have a colposcopy by an OB/Gyn and even then you need to ask questions. I would never have one by a family physician or a nurse practitioner. You need to rely also on the visual during the colposcopy that an expert in the field has. And you need to ask them if they see anything. Blindly doing biopsies is unacceptable, especially under 30 and can do more harm for no disease.
What everyone needs to remember is that there are fewer than 4,000 cases of cervical cancer deaths a year in the US and they are mostly in women that do not get gyn care. I will quote from a physician who understands HPV.
—“If a woman is infected with HPV 18 in January, HPV 18 in July and HPV 31 in December, her cancer risk is zero. Even though these are all high risk types, they are considered transient. It takes repeated infection by the same type to perhaps pose a risk of cervical cancer. When a woman has persistent infection by the same type, if her lifestyle is healthy (no smoking, eating well, does not have multiple partners and is exercising) her risk of cervical cancer is still minimal.”—
Regular Pap testing is important and so is a good OB/GYN that understands HPV.
This was a little lengthier than I had anticipated but hopefully it helps some understand this confusing topic that tends to bring hysteria due to a possible cancer diagnosis when it is really over played by physicians and drug companies.
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