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Breaking It Down: The Human Papillomavirus

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Although the human papillomavirus (HPV) has been recognized as a transmissible pathogen for the past several decades, the controversial use of HPV vaccines has vaulted the pesky bug into eyes of the mainstream media and scientific communities alike. In effort to better understand the fundamentals of this virus amidst this new flux of interest, I thought that in this edition of "Breaking It Down" I would cover HPV by dispelling commonly-held beliefs using current evidence-based medicine. Okay? Okay, let's do it.

HPV is a virus that only affects those who are sexually active.

Although some of the 100+ subtypes of HPV are contracted through sexual activity, the most common clinical manifestations of this virus are actually a result of non-sexual contact with an infected individual. Ever discover a small, painless growth on the bottom of your foot or palm of your hand? More likely than not, these annoying but harmless warts are caused by HPV.

HPV infection is relatively uncommon, and men are spared of its complications.

Contrary to common belief, HPV is the most commonly diagnosed STI in the United States. In fact, the Center for Disease Control estimates that 75 to 80 percent of sexually-active adults will acquire a genital tract HPV infection before the age of 50. [1] Although most of these sexually-transmitted HPV infections are transient and often cleared by our immune systems within a few years, those contagions that do not resolve go on to cause many different types of disease in both females and males. [2] Where cervical cancer is one of the most devastating complications of HPV infection in women, both sexes infected with HPV subtypes (commonly 6 and 11) are at risk of developing benign but unpleasant condyloma acuminatum, or genital warts. Furthermore, those same subtypes of HPV that cause cervical cancer (commonly 16 and 18) are also associated with penile, anal, and oral cancers. [3, 4]

Unlike other STIs, condoms do not protect partners from HPV.

This is false. Although any genital-genital, oral-genital, and even hand-genital contact puts individuals at risk for HPV-related STIs, a number of large studies demonstrate a reduced likelihood of HPV transmission in the setting of condom use. [5, 6]

In other words, better to buckle up before taking the car out for a spin.

It is too early to tell if HPV vaccines are worth the effort.

The topic of routine vaccination is traditionally controversial, and I typically tend to stray from such loaded material when possible. That said, I cannot shy away from my wholehearted support in vaccinating our youth against HPV.

Here's why.

Both the bivalent (Cervarix™) and quadrivalent (Gardasil™) HPV vaccines available in the U.S. have been scrutinized ever so closely by the scientific community since their public debut in 2009 and 2006, respectively. The most esteemed medical journals have since published large studies supporting the vaccines' efficacy against acquiring HPV subtypes that they aim to prevent (bivalent -- types 16 and 18, quadrivalent -- types 6, 11, 16 and 18). [7, 8] Although long-term studies are not yet available, the impressive safety profile of these vaccinations give strength to their public health benefit relative to their potential risks. [9]

It is true that these vaccinations do carry possible side effects, most commonly manifested as self-resolving fevers and gastrointestinal complaints. However, HPV vaccines are derived from inactive virus-like particles (VLPs), which are known to be one of the safest methods of vaccination currently available.

Furthermore, routine HPV vaccinations are recommended by many of the highest-regarded public health organizations, including the The Advisory Committee on Immunization Practices (ACIP), The American College of Obstetricians and Gynecologists (ACOG), American Cancer Society (ACS), and The World Health Organization (WHO).

Take Home Point: Regardless of the many different public opinions regarding the implementation of routine HPV vaccination, one definite positive outcome of these relatively new vaccines is the vast public attention that this virus surely deserves.

References:

1. Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006 Aug 4;55(RR-11):1-94.

2. Plummer M, Schiffman M, Castle PE, Maucort-Boulch D, Wheeler CM; ALTS Group. A 2-year prospective study of human papillomavirus persistence among women with a cytological diagnosis of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesion. J Infect Dis. 2007 Jun 1;195(11):1582-9. Epub 2007 Apr 16.

3. Chin-Hong PV, Vittinghoff E, Cranston RD, Buchbinder S, Cohen D, Colfax G, Da Costa M, Darragh T, Hess E, Judson F, Koblin B, Madison M, Palefsky JM. Age-Specific prevalence of anal human papillomavirus infection in HIV-negative sexually active men who have sex with men: the EXPLORE study. J Infect Dis. 2004 Dec 15;190(12):2070-6. Epub 2004 Nov 10.

4. El-Mofty SK. HPV-related squamous cell carcinoma variants in the head and neck. Head Neck Pathol. 2012 Jul;6 Suppl 1:S55-62. doi: 10.1007/s12105-012-0363-6. Epub 2012 Jul 3.

5. Baldwin SB, Wallace DR, Papenfuss MR, Abrahamsen M, Vaught LC, Giuliano AR. Condom use and other factors affecting penile human papillomavirus detection in men attending a sexually transmitted disease clinic. Sex Transm Dis. 2004 Oct;31(10):601-7.

6. Nyitray AG, da Silva RJ, Baggio ML, Lu B, Smith D, Abrahamsen M, Papenfuss M, Quiterio M, Villa LL, Giuliano AR. The prevalence of genital HPV and factors associated with oncogenic HPV among men having sex with men and men having sex with women and men: the HIM study. Sex Transm Dis. 2011 Oct;38(10):932-40.

7. FUTURE I/II Study Group, Dillner J, Kjaer SK, Wheeler CM, Sigurdsson K, Iversen OE, Hernandez-Avila M, Perez G, Brown DR, Koutsky LA, Tay EH, García P, Ault KA, Garland SM, Leodolter S, Olsson SE, Tang GW, Ferris DG, Paavonen J, Lehtinen M, Steben M, Bosch FX, Joura EA, Majewski S, Muñoz N, Myers ER, Villa LL, Taddeo FJ, Roberts C, Tadesse A, Bryan JT, Maansson R, Lu S, Vuocolo S, Hesley TM, Barr E, Haupt R. Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial. BMJ. 2010 Jul 20;341:c3493. doi: 10.1136/bmj.c3493.

8. Schauner S, Lyon C. Bivalent HPV Recombinant Vaccine (Cervarix) for the Prevention of Cervical Cancer. Am Fam Physician. 2010 Dec 15;82(12):1541-2.

9. Gee J, Naleway A, Shui I, Baggs J, Yin R, Li R, Kulldorff M, Lewis E, Fireman B, Daley MF, Klein NP, Weintraub ES. Monitoring the safety of quadrivalent human papillomavirus vaccine: findings from the Vaccine Safety Datalink. Vaccine. 2011 Oct 26;29(46):8279-84. Epub 2011 Sep 9.

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