Lost in the HPV Vaccine Controversy

Marilyn Keefe

Marilyn Keefe is Vice President for Public Policy at the National Family Planning and Reproductive Health Association (NFPRHA).

The promise of dramatically lessening—and someday, eliminating cervical cancer completely is a goal we can all get behind. Right? Well, maybe in the long run but not too quickly—and not this week. What should be a slam dunk on the public health front has, at least temporarily, gotten sidetracked because of an overly aggressive marketing campaign by Merck which has fueled charges by right wing groups like the Family Research Council that parental rights are being violated and that giving adolescent girls the HPV vaccine will somehow lead them away from abstinence and down the path of sexual depravity. Assuming, of course, that we accept the dubious proposition that HPV—that little known virus—plays a significant role in a teenager's decision to engage in or abstain from sexual activity. Research shows it does not.

Marilyn Keefe is Vice President for Public Policy at the National Family Planning and Reproductive Health Association (NFPRHA).

The promise of dramatically lessening—and someday, eliminating cervical cancer completely is a goal we can all get behind. Right? Well, maybe in the long run but not too quickly—and not this week. What should be a slam dunk on the public health front has, at least temporarily, gotten sidetracked because of an overly aggressive marketing campaign by Merck which has fueled charges by right wing groups like the Family Research Council that parental rights are being violated and that giving adolescent girls the HPV vaccine will somehow lead them away from abstinence and down the path of sexual depravity. Assuming, of course, that we accept the dubious proposition that HPV—that little known virus—plays a significant role in a teenager's decision to engage in or abstain from sexual activity. Research shows it does not.

From a practical standpoint, some of the biggest issues surrounding the HPV vaccine are getting lost in controversy, including an inadequate vaccine delivery infrastructure, the high cost, and a continued lack of understanding among much of the public about the connection between HPV and cervical cancer.

The cost issues are paramount. Merck did reach an agreement with the Centers for Disease Control (CDC) to provide the vaccine to the woefully underfunded Vaccines for Children program (VFC),a federal program that covers the cost of vaccines for uninsured and Medicaid-eligible children under the age of 19, at a reduced price. But that cost—$288 through the VFC—threatens to break the bank of many health care systems and providers. The company also has established a patient assistance program to cover vaccine for some lower income women in the 19-26 year old group. But the costs and administrative hoops for providers make it a cumbersome and still expensive option at best. Providers attempting to access the patient assistance program are required to pay the up front cost for the first dose of the vaccine ($120)—a significant barrier—although replacement doses are free. Furthermore, the program is unavailable to many government-funded providers—even if they don't get government funds for the purpose of providing the vaccine. This means that many of the already sexually active women who see the ubiquitous "One Less" commercials and arrive at publicly funded family planning clinics hoping to avail themselves of this breakthrough vaccine won't have access.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

The situation in the private sector is still problematic as well. While many insurance companies are paying for the vaccine, coverage is far from complete. Doctors are expected to pay the high up front cost on the hope of later reimbursement, which may or may not cover the cost of the vaccine, the storage, and its administration, making many unwilling to even stock the product. This problem was driven home by the experience of an employee of NFPRHA who began her odyssey by calling the insurance company to confirm that the vaccine was covered. The "yes" from our insurer was just the beginning of her saga. She next called her doctor's office for the appointment and was told her doctor didn't stock the vaccine. Strike one. She then called a second gynecologist and was told that this doctor, too, didn't stock the vaccine, but that the doctor could give her a prescription for the vaccine that could then be administered by the doctor. However, this created a Catch-22, for beyond the obvious issues with trying to get a vaccine from a pharmacy, she had a bigger problem—even if she could get it from the pharmacy, her insurance would not cover the pharmacy-to-patient-to-doctor-back-to-patient route; it had to go directly from doctor to patient, with no middle man in between. Strike 2. Tired of blindly calling doctor's offices to see whether they had the vaccine, our intrepid staffer then contacted the local health department. Surely they could tell her where she could go to get the vaccine? Strike 3. They had no idea. Finally, after another round of phone calls and searching on the internet, she was able to get the first dose of the vaccine—at the local Planned Parenthood, which her insurance company said it would cover. She got her first dose of the vaccine… followed by a statement from the insurance company saying they would not reimburse most of the cost because the vaccine was not administered by a doctor. And the battle continues…

Many women will not be as "lucky" or as persistent as our staffer was. There are nearly 17 million uninsured women in the United States, a number that grows daily. Many women—especially in the 19-26 year old aged group, don't have any type of insurance—public or private. At $360 for the vaccine, it is certain to be out of reach, even if they can even find a health care provider who offers it. Title X, the nation's family planning program, provides high-quality reproductive health care to nearly 5 million women each year, the majority of whom are low-income and disproportionately women of color, populations that are most at risk of developing cervical cancer. Title X-funded family planning clinics, which provide 2.6 million Pap tests each year and often provide low-income and uninsured women with their only source of health care, represent the best hope for girls and women ages 13-26 to receive the vaccine. Yet most of these clinics, which have been starved of federal funds for years, don't have the resources to offer the vaccine to their patients.

An estimated 80 percent of women will have contracted HPV by age 50. It is therefore critical that all eligible women have access to the vaccine. If some of the money spent to lobby legislatures to endorse mandatory vaccination for adolescents was spent on services to the women most in need, and to better educate the public about the benefits of the vaccine and its relationship to cervical cancer, we would all be better off.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

News Abortion

Study: United States a ‘Stark Outlier’ in Countries With Legal Abortion, Thanks to Hyde Amendment

Nicole Knight Shine

The study's lead author said the United States' public-funding restriction makes it a "stark outlier among countries where abortion is legal—especially among high-income nations."

The vast majority of countries pay for abortion care, making the United States a global outlier and putting it on par with the former Soviet republic of Kyrgyzstan and a handful of Balkan States, a new study in the journal Contraception finds.

A team of researchers conducted two rounds of surveys between 2011 and 2014 in 80 countries where abortion care is legal. They found that 59 countries, or 74 percent of those surveyed, either fully or partially cover terminations using public funding. The United States was one of only ten countries that limits federal funding for abortion care to exceptional cases, such as rape, incest, or life endangerment.

Among the 40 “high-income” countries included in the survey, 31 provided full or partial funding for abortion care—something the United States does not do.

Dr. Daniel Grossman, lead author and director of Advancing New Standards in Reproductive Health (ANSIRH) at the University of California (UC) San Francisco, said in a statement announcing the findings that this country’s public-funding restriction makes it a “stark outlier among countries where abortion is legal—especially among high-income nations.”

Like This Story?

Your $10 tax-deductible contribution helps support our research, reporting, and analysis.

Donate Now

The researchers call on policymakers to make affordable health care a priority.

The federal Hyde Amendment (first passed in 1976 and reauthorized every year thereafter) bans the use of federal dollars for abortion care, except for cases of rape, incest, or life endangerment. Seventeen states, as the researchers note, bridge this gap by spending state money on terminations for low-income residents. Of the 14.1 million women enrolled in Medicaid, fewer than half, or 6.7 million, live in states that cover abortion services with state funds.

This funding gap delays abortion care for some people with limited means, who need time to raise money for the procedure, researchers note.

As Jamila Taylor and Yamani Hernandez wrote last year for Rewire, “We have heard first-person accounts of low-income women selling their belongings, going hungry for weeks as they save up their grocery money, or risking eviction by using their rent money to pay for an abortion, because of the Hyde Amendment.”

Public insurance coverage of abortion remains controversial in the United States despite “evidence that cost may create a barrier to access,” the authors observe.

“Women in the US, including those with low incomes, should have access to the highest quality of care, including the full range of reproductive health services,” Grossman said in the statement. “This research indicates there is a global consensus that abortion care should be covered like other health care.”

Earlier research indicated that U.S. women attempting to self-induce abortion cited high cost as a reason.

The team of ANSIRH researchers and Ibis Reproductive Health uncovered a bit of good news, finding that some countries are loosening abortion laws and paying for the procedures.

“Uruguay, as well as Mexico City,” as co-author Kate Grindlay from Ibis Reproductive Health noted in a press release, “legalized abortion in the first trimester in the past decade, and in both cases the service is available free of charge in public hospitals or covered by national insurance.”