The Human Papillomavirus: What You Need to Know

Sharon Phillips MD

The Human Papillomavirus (HPV) is the most commonly diagnosed sexually transmitted infection (STI) in the United States.  Approximately 75 percent of all sexually active individuals will contract HPV at some time in their lives.  There are many different strains of HPV, some more dangerous than others.  Here is what you need to know.

Rewire is dedicated to publishing evidence-based information on sexual and reproductive health, rights, and justice issues.  This article examines the basics on Human Papillomavirus and its relationship to cervical cancer based on findings applicable to women in the United States.

What is HPV?

The Human Papillomavirus (HPV) is the most commonly diagnosed sexually-transmitted infection (STI) in the United States. At any given time, 26.8 percent of women between ages 14 and 59 have an active HPV infection, and approximately 75 percent of all sexually active individuals will contract HPV at some time in their lives. 

There are at least 120 different strains of HPV virus. Some of these cause cervical, anal, genital and oral pre-cancerous lesions and cancers.  Others cause genital warts.  The strains are divided into low-risk and high-risk types, with the high-risk types associated with cervical lesions and cancers and the low-risk types generally associated with genital warts.  Because there are many different kinds of HPV, it is possible to be infected with more than one type at a time.

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How do you get HPV?

HPV is transmitted through genital contact, especially during vaginal or anal intercourse.  It can also be transmitted by oral sex.  Condoms decrease the risk of getting HPV, but not completely.

How does HPV cause cancer?

Cancer is caused by abnormal cell growth, and viruses like HPV increase the likelihood of this abnormal growth.  High-risk strains of HPV are responsible for all cervical cancers, most anal cancers, and some vaginal, penile, and throat cancers.  Researchers are not entirely sure why HPV causes pre-cancer or cancer in some men and women and disappears spontaneously in the majority.  Despite this, our bodies usually have an immune response that attacks the virus and removes abnormal cells.  Some people with HPV have an immune response that clears it, some progress to slightly abnormal cells then clear it, and some even progress to pre-cancerous lesions which then resolve spontaneously.  The longer your body is exposed to the virus, the more likely abnormal cells will grow.  This is why we say that it is persistent HPV infection that is associated with cancer, rather than the transient infection most people have.  Developing cervical cancer takes years.  The younger you are, the more likely you are to clear the infection and the virus.  Some people with immune problems, like HIV, are less likely to be able to get rid of the abnormal cells on their own and require more frequent pap smears.

How do I know if I have HPV?

Most doctors will do automatic HPV testing on certain women getting pap smears.  While we used to perform HPV testing on all women getting a pap, most doctors now test women under 30 only if they have abnormal pap smears and all women over 30.  The reason we don’t test women under 30 who have normal paps is that many women have transient HPV infections; if the infection hasn’t caused any abnormal cells, it isn’t important to know if it’s there or not.  Women over 30, on the other hand, are likely to continue to have an HPV infection, because they’re the women whose body didn’t get rid of the infection when they were in their 20s. (remember that most women contract HPV when they’re in their teens and twenties, when they first start having sex).  Women over 30 with positive HPV results undergo yearly pap smears, and sometimes other testing, until the HPV becomes negative.  We only test for certain strains of HPV (those most likely to cause cervical cancer).  Since cervical cancer is only caused by high-risk strains of HPV, and because even with the presence of HPV it takes years to develop cancer, women over 30 who have a normal pap and have a negative HPV test can safely change to screening every 3 years.

I have HPV.  What do I do now?

The good news is that most women’s immune systems will eliminate the virus. Among young women, about 90 percent will clear the virus within a year.  That means that the vast majority of women who get HPV will never have any negative effects; that is, they will never develop pre-cancerous lesions, cancer, or genital warts.  If you found out you have HPV during a pap test, consult with your provider to determine what the next course of action is.  You and your partner can discuss using condoms or other barrier methods to prevent transmission of the virus; however, your partner may well already have had the same strain of the virus that you have, or might have another strain.  Remember that the virus is very prevalent and in most cases causes no harm.

What about the HPV vaccine?

There are currently 2 vaccines available against HPV: one covers types 6 and 11 (common causes of genital warts) and types 16 and 18 (the most common causes of cervical cancer), the other covers HPV types 16 and 18 only.  They are currently recommended for women starting at age 11-12 and men age 9 to 18.   (Keep in mind that these are recommendations from the US Centers for Disease Control; vaccination has been shown to be safe starting at age 9 for young women as well, and has been FDA-approved up to age 26).  A course of three shots is necessary for the best response.  Ideally the series of 3 shots should be completed before starting to have any sexual activity, including oral sex or non-penetrative sex, since all kinds of sexual contact can lead to HPV infection. 

Remember that there are dozens of strains of the HPV virus; these vaccines cover the most common strains that are likely to cause abnormal cervical cells that can turn into cancer if not treated.  They also appear to help protect against some of the other strains.  These vaccines have been shown to decrease the rate of abnormal pap smears and genital warts in women, and to decrease the rate of genital warts and some anal cancers in men.

What about men?

The vaccines are effective in men as well, to prevent genital warts and anal cancers, and appear to be cost-effective when given to men before they start having sexual contact.  Not all insurers are paying for the vaccine for young men yet, which could leave you with a substantial out-of-pocket cost.  Right now it’s considered an optional vaccine for young men rather than recommended; this will likely change as more studies are done regarding the long-term effectiveness of the vaccine.  Note that the vaccine that covers just HPV-16 and HPV-18 is not recommended for men at this time (because types 16 and 18 cause cervical cancer in women but don’t appear to cause any problems for men).  The vaccine that also covers HPV-6 and HPV-11 (which cause genital warts) is appropriate for men to prevent genital warts.

What if I’m over 26 and want the vaccine?

There is no reason why you can’t get one of the HPV vaccines even if you’re over 26; however, you will probably have to pay for it yourself, as it’s not a recommended service.  If you haven’t started to have sex yet it may be a worthwhile investment for you.  If you’ve already had several partners, it may not be worthwhile, as you’ve probably already been exposed to several different types of HPV.

Why do I still need pap smears even though I’ve been vaccinated?

There are many forms of HPV that can cause cervical cancer and the vaccine is only effective against the two most common forms.  Because of this you will continue to need pap smears because at this time we don’t have enough long-term information to know if that can change.  For now, young women who have been vaccinated still should get pap smears at the same intervals recommended for those who have not been vaccinated.  It appears that women who have been vaccinated are less likely to have abnormal pap smears and therefore less likely to need further testing such as colposcopy.  In the future we may know more about the effects of the vaccine and be able to change these recommendations.

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.

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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.

Commentary Law and Policy

Here’s What You Need to Know About Your Birth Control Access Post-Supreme Court Ruling

Bridgette Dunlap

Yes, the Zubik v. Burwell case challenged the Affordable Care Act's contraceptive coverage mandate. But that shouldn't stop you from getting your reproductive health needs met—without a co-payment.

In May, the Supreme Court issued a sort of non-decision in Zubik v. Burwell, the consolidated case challenging the Affordable Care Act’s mandate that employers provide contraceptive coverage. The ruling leaves some very important legal questions unanswered, but it is imperative that criticism of the Court for “punting” or leaving women in “limbo” not obscure the practical reality: that the vast majority of people with insurance are currently entitled to contraception without a co-payment—that includes people, for the most part, who work for religiously affiliated organizations.

Two years ago, hyperbole in response to the Court’s decision in Burwell v. Hobby Lobby—that, for example, the Court had ruled your boss can block your birth control—led too many people to believe the contraceptive coverage requirement was struck down. It wasn’t. The Zubik decision provides a good opportunity to make sure that is understood.

If people think they don’t have birth control coverage, they won’t use it. And if they don’t know what coverage is legally required, they won’t know when their plans are not in compliance with the law and overcharging them for contraceptives or other covered services, perhaps unintentionally. The point of the contraceptive coverage rule is to make it as easy as possible to access contraceptives—studies show seemingly small obstacles prevent consistent use of the most effective contraceptives. Eliminating financial barriers isn’t enough if informational ones undermine the goal.

The most important thing to know is that most health plans are currently required to cover reproductive health services without a co-payment, including:

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  • One version of every kind of FDA-approved contraception—that is, only the generic or the brand-name version of the contraceptive could be covered, but at least one must be. So you shouldn’t be paying a co-payment whether you use the pill, the patch, the shot, or want long-acting reversible contraception (LARC) like an IUD, which is more expensive, but most effective.
  • Screening for HIV and high-risk strains of HPV
  • An annual well-woman visit
  • Breastfeeding counseling and supplies like pumps

There are exceptions, but most plans should be covering these services without a co-payment. Don’t assume that because you work for Hobby Lobby or Notre Dame—or any other religiously affiliated employer—that you don’t currently have coverage.

The original contraceptive coverage rule had an “exemption” for church-type groups (on the somewhat dubious theory that such groups primarily employ individuals who would share their employers’ objection to contraception). When other kinds of organizations, which had religious affiliations but didn’t primarily employ individuals of that same religion, objected to providing contraceptive coverage, the Obama administration came up with a plan to accommodate them while still making sure women get contraceptive coverage.

This “accommodation” is a workaround that transfers the responsibility to provide contraceptive coverage from the employer to the insurance company. After the employer fills out a form noting it objects to providing contraception, the insurance company must reach out to the employee and provide separate coverage that the objecting organization doesn’t pay for or arrange.

This accommodation was originally available only to nonprofit organizations. But dozens of for-profits, like Hobby Lobby, sued under the Religious Freedom Restoration Act (RFRA)—arguing that their owners were religious people whose beliefs were also burdened by the company having to provide coverage.

The Hobby Lobby decision did not say your boss’s religious belief trumps your right to a quality health plan. What the Court did was point to the existence of the accommodation for nonprofits as proof that the government could achieve its goals of ensuring coverage of contraception through a workaround already in place to give greater protection to objectors. Basically, the Court told the government to give the for-profits the same treatment as the nonprofits.

The Hobby Lobby decision states explicitly that the effect of this on women should be “precisely zero.” The Obama administration subsequently amended the contraceptive regulations, making coverage available to employees of companies like Hobby Lobby available through the accommodation. Hobby Lobby added some headaches for administrators and patients, but it did not eliminate the contraceptive coverage rule.

Next, however, the nonprofits went on to argue to the Supreme Court and the public that the accommodation the Court had seemed to bless in Hobby Lobby also violated RFRA—because having to fill out a form, which notified the government that they objected to contraceptive coverage and identifying their insurers, would substantially burden their religious beliefs.

Following oral arguments in Zubik, the eight-member Supreme Court issued a highly unusual order: It asked the parties to respond to its proposed modification of the accommodation, in which the government would not require objecting nonprofits to self-certify that they oppose contraception nor to identify their insurers. The government would take an organization’s decision to contract for a health plan that does not cover contraception to be notice of a religious objection and go ahead with requiring the insurer to provide it instead.

The petitioners’ response to the Court’s proposed solution was “Yes, but…” They said the Court’s plan would be fine so long as the employee had to opt into the coverage, use a separate insurance card, and jump through various other hoops—defeating the goal of providing “seamless” contraceptive coverage through the accommodation.

When the Court issued its decision in Zubik, it ignored the “but.” It characterized the parties as being in agreement and sent the cases back to the lower courts to work out the compromise.

The Court told the government it could consider itself on notice of the petitioners’ objections and move forward with getting separate contraceptive coverage to the petitioners’ employees, through the accommodation process, but without the self-certification form. How the government will change the accommodation process, and whether it will satisfy the petitioners, are open questions. The case could end up back at the Supreme Court if the petitioners won’t compromise and one of the lower courts rules for them again. But for prospective patients, the main takeaway is that the Court ruled the government can move forward now with requiring petitioners’ insurers to provide the coverage that the petitioners won’t.

So—if your plan isn’t grandfathered, and you don’t work for a church or an organization that has sued the government, your insurance should be covering birth control without a co-payment. (If your plan is grandfathered and your employer makes a change to that plan, then those formerly grandfathered plans would be subject to the same contraceptive coverage requirements.) If you do work for one of the nonprofit petitioners, the government should be making contraceptive coverage available even before the litigation is resolved. And in some cases, employees of the petitioners already have coverage. Notre Dame, for example, initially accepted the accommodation before being pressured by off-campus contraception opponents to sue, so its insurer is currently providing Notre Dame students and employees coverage.

Don’t despair about the Supreme Court’s gutting access to contraception. Assume that you have coverage. The National Women’s Law Center has great resources here for finding out if your plan is required to cover contraception and how to address it with your insurance plan if it isn’t in compliance, and a hotline to call if you need help. The fact that equitable coverage of women’s health care is the new status quo is a very big deal that can be lost in the news about the unprecedented litigation campaign to block access to birth control and attacks on Obamacare more generally. Seriously, tell your friends.