Commentary Sexual Health

Oh! The Drama! Soap Opera Treats HPV… the Wrong Way

Martha Kempner

All My Children takes on the world of STDs with a storyline about HPV that is, unfortunately, more dramatic than it is accurate. 

About a week ago, driving my husband to a doctor’s appointment, I began dreading my time in the waiting room. This doctor often keeps us waiting and the last time we were there, Fox TV was blaring right-wing propaganda from the flat-screen in the corner.  It was during the Gulf oil spill and the talking heads were somehow managing to twist events to blame those who wanted new more efficient energy sources. When they turned to Michael Brown, the former head of FEMA who botched the Katrina recovery so badly, for his expert opinion, I found myself screaming at the TV.  So, I was relieved when this time the receptionists had chosen to force us to watch All My Children instead.  I haven’t watched a real soap opera in over a decade, but I grew up on General Hospital and As the World Turns and would take their silly melodrama over Fox’s asinine analysis any day.  And yet, 20 minutes later, I found myself yelling at that same flat-screen in the corner.

The storyline I watched unfold in a series of two-minutes scenes seemed to go like this: The girl in the pink shirt had had a one night stand with the smarmy guy with the slicked back hair (who I assumed was named Storm, Chase, or Brick).  A pregnancy scare had turned out to be a false alarm but now she was anxiously awaiting results of STD tests. She confided this to a ridiculously blond friend who reminded her it could just be a simple infection and she shouldn’t do anything until she hears from the doctor. Instead of heeding blond friend’s advice, she confronts smarmy guy and they each accuse the other of being the source of the not-yet-confirmed infection. Then, standing with a young doctor in what appears to be a hospital corridor (good for privacy and confidentiality), pink shirt girl is informed in classic soap opera overacting mode “You have [pause for dramatic effect] human papillomavirus!!”

That’s when I started screaming at the TV for its inaccuracies and overreaction. It’s also when it was our turn to see the doctor so I didn’t get to find out what happened next or whether the writers redeemed themselves in anyway.  Here is how ABC.com explains this ongoing storyline:

In another part of the hospital Amanda tries to process the news that she has HPV. She could have gotten it recently or a long time ago; often the symptoms stay dormant. Cara is gentle but matter of fact as she informs Amanda is at high risk for cervical cancer. Amanda freaks out, but Cara urges her to keep calm until the next test results return. Amanda heads to the Chandler mansion where she confirms to JR that she has HPV. She urges JR to get tested and tell Marissa, but all JR can do is complain that he might lose Marissa. Furious Amanda calls JR  “selfish;” he could at least show some compassion. She could have cancer! JR thinks that Amanda got HPV from a long time ago since he tested clean after Annie left, which means no one has to know about his one-night with Amanda. Frustrated Amanda reminds JR that he has an obligation to tell Marissa and leaves.

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Ah the exclamation points.  While they got a few things right, AMC’s coverage of HPV leaves a lot to be desired.  Here are some things I wished they’d explained better:

HPV doesn’t usually present with symptoms.

As I understood the back story (admittedly not having seen it transpire), Amanda sought STD testing because she had symptoms—she felt something was wrong—and was told that maybe she just had a simple  infection.  Given that set up, I expected her to be diagnosed with Chlamydia or Gonorrhea both of which can cause itching, burning, and discharge in women, though they often have no symptoms. Human papillomavirus (HPV), on the other hand, can cause genital warts or changes to the cells on a woman’s cervix neither of which are things that a woman is likely to actually feel and neither of which would be confused with a simple infection.

It seems like the writers aimed at accuracy with the comment “She could have gotten it recently or a long time ago; often the symptoms stay dormant.” It’s true that HPV can be in the body undetected for a long time. Again, however, “symptoms” is a bit of a misleading concept here as the virus rarely causes anything that individuals can feel.

Testing for HPV is different than for other STDs.

It is unlikely that a woman like Amanda who goes to her health care provider with symptoms would be tested for HPV right away—again, Chlamydia and Gonorrhea are more likely suspects.  Moreover, as the CDC explains, “there is no general test for men or women to check one’s overall ‘HPV status,’ nor is there an HPV test to find HPV on the genitals or in the mouth or throat.”  There are tests that can check for HPV but they are primarily used to help screen women for cervical cancer. It is suggested that women over 30 undergo these tests in conjunction with their Pap tests, a routine gynecological test that can detect cervical cancer and/or precancerous changes to the cells on a woman’s cervix.  For women under 30, it is only recommended that they have HPV tests if their Pap test comes back abnormal or inconclusive.  In general, women learn that they have HPV as part of the results of their Pap tests rather than as part of set of STD tests.

The reality of HPV testing also means that JR’s insistence that it wasn’t him because “he tested clean after Annie left,” is misleading as well.  While he may have been tested for other STDs, there currently is no FDA-approved HPV test for men.  Some men are diagnosed with HPV when their health care provider notices genital warts on their penis or around their anus but there is no other test, and most men never know whether they do or don’t have this virus.

In the United States, cervical cancer is relatively rare.

I didn’t see the scene where Amanda accuses JR of being insensitive because he’s just worried that their one night stand may be revealed while she now has to worry that she may have cancer, but the recap of it contained exclamation points so I am sure that it was very dramatic.  And as such, it was probably pretty misleading.

It is true that several specific strains of HPV are responsible for virtually all cases of cervical cancer, but it is also important to understand that cervical cancer is a rare and preventable outcome of HPV infection. Moreover, where it does occur, HPV infection does not lead to detectable cervical cancer overnight; it takes time to develop and become detectable.  Approximately 6 million people in the United States get HPV each year and only 12,000 women get cervical cancer.  In fact, most HPV infections clear up on their own and cause no long-term health problems. 

Any doctor who lets a patient newly diagnosed with HPV walk out of his/her office in fear of cancer has not done a very good job of explaining the facts.  Instead, health care providers should explain that further tests can determine whether the patient has those strains of HPV that are linked to cervical cancer (to give credit, the writers did point to further testing). And, he/she should emphasize the importance of routine Pap tests as these can detect precancerous changes and allow for treatment before cervical cancer develops.

HPV infections are widespread.

Obviously, we need to take all STDs seriously, they are an epidemic in this country.  But there is a difference between seriousness and melodrama.

I’m sure real women who, like Amanda, are told that they have HPV need time to “process it” but I hope that while they’re doing that, they are reminded that over 20 million Americans are living with HPV, that it is estimated that between 50 and 80 percent of all sexually active individuals will get HPV at some point in their lives, and that most cases of HPV are cleared by the body with no treatment and no lasting impact. 

Amanda should take STDs seriously, she should think about using condoms the next time she has a one night stand, and she should continue to be screened for cervical cancer but she should know she’s not alone in this and should not feel embarrassed or ashamed (she might feel a little bad for cheating on her husband but that’s another article).

Blame is Not Helpful.  

Soap operas have never provided a model of good communication—doing so would reduce the tension, cut the number of scenes the writers could get out of one conversation at least in half, end the possibility of a whole storyline based on a misunderstanding, and ruin any chance of a good Friday afternoon cliffhanger. So it is not surprising that the two scenes in which JR and Amanda discuss her STD provide an example of bad communication between sexual partners. There are a lot of accusations and much finger-pointing. To be fair, these characters have a lot of other things to deal with—they’re both married to other people, his wife is having an affair though it’s unclear if he knows it, and her husband seems to be part of an evil plot to take over the hospital (or maybe that’s someone else).  Still, it would be nice to see them show a little more understanding and civility (if not empathy).

Prevention is Most Important.

Obviously, staying monogamous is one way to prevent the spread of HPV but monogamy is unlikely in Pine Valley, Port Charles, or other soap opera towns because it makes for boring TV.  So, I would hope that Dr. Cara used this opportunity to remind Amanda and JR (and viewers) of the importance of using condoms to prevent STDs.  Condoms have been given a bad rap against HPV because the virus is transmitted from infected skin to non-infected skin and infected skin can include the scrotum or other areas that are not covered by the condoms. While they can’t provide complete protection against HPV, the CDC still recognizes condoms as important in the fight against HPV and cervical cancer.  Recent research suggests that most HPV infections in men are, in fact, located on portions of the penis covered by a condom. Moreover, research has shown that using condoms has been associated with a reduction in HPV-related health outcomes such as cervical cancer and genital warts in women.

HPV is also unique because there are now two FDA-approved vaccines that can prevent it (Hepatitis-B is the only other STD for which there is a vaccine). Both vaccines (Cervarix and Gardasil) have been shown to protect females against the types of HPV that cause most cervical cancers. Gardasil also protects against most genital warts. The CDC now recommends HPV vaccines as a routine part of health care for adolescent girls.  Of course since the vaccines only recently became available most women today did not receive it at that stage, therefore, the CDC recommends that all women ages 13 to 26 be vaccinated.  Gardasil is also available for boys and men ages 9 through 26.

I know that in television accuracy is often sacrificed for drama and I can forgive a lot for the sake of the art form. Hell, I totally believed that Robert Scorpio was part of an international spy agency and that his arch enemy was able to control the weather in Port Charles (General Hospital circa 1984). Still, as with anyone in the media, I think AMC writers have a unique opportunity to reach an audience (at least until the show goes off the air in September) and should use that opportunity to spread as much accurate information as possible even if they do it with audible sighs and pauses for dramatic impact.

Unless otherwise cited, all information about HPV comes from CDC’s Genital HPV Infaction – Fact Sheet

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.

Analysis Abortion

Legislators Have Introduced 445 Provisions to Restrict Abortion So Far This Year

Elizabeth Nash & Rachel Benson Gold

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

So far this year, legislators have introduced 1,256 provisions relating to sexual and reproductive health and rights. Of these, 35 percent (445 provisions) sought to restrict access to abortion services. By midyear, 17 states had passed 46 new abortion restrictions.

Including these new restrictions, states have adopted 334 abortion restrictions since 2010, constituting 30 percent of all abortion restrictions enacted by states since the U.S. Supreme Court decision in Roe v. Wade in 1973. However, states have also enacted 22 measures this year designed to expand access to reproductive health services or protect reproductive rights.

Mid year state restrictions

 

Signs of Progress

The first half of the year ended on a high note, with the U.S. Supreme Court handing down the most significant abortion decision in a generation. The Court’s ruling in Whole Woman’s Health v. Hellerstedt struck down abortion restrictions in Texas requiring abortion facilities in the state to convert to the equivalent of ambulatory surgical centers and mandating that abortion providers have admitting privileges at a local hospital; these two restrictions had greatly diminished access to services throughout the state (see Lessons from Texas: Widespread Consequences of Assaults on Abortion Access). Five other states (Michigan, Missouri, Pennsylvania, Tennessee, and Virginia) have similar facility requirements, and the Texas decision makes it less likely that these laws would be able to withstand judicial scrutiny (see Targeted Regulation of Abortion Providers). Nineteen other states have abortion facility requirements that are less onerous than the ones in Texas; the fate of these laws in the wake of the Court’s decision remains unclear. 

Ten states in addition to Texas had adopted hospital admitting privileges requirements. The day after handing down the Texas decision, the Court declined to review lower court decisions that have kept such requirements in Mississippi and Wisconsin from going into effect, and Alabama Gov. Robert Bentley (R) announced that he would not enforce the state’s law. As a result of separate litigation, enforcement of admitting privileges requirements in Kansas, Louisiana, and Oklahoma is currently blocked. That leaves admitting privileges in effect in Missouri, North Dakota, Tennessee and Utah; as with facility requirements, the Texas decision will clearly make it harder for these laws to survive if challenged.

More broadly, the Court’s decision clarified the legal standard for evaluating abortion restrictions. In its 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey, the Court had said that abortion restrictions could not impose an undue burden on a woman seeking to terminate her pregnancy. In Whole Woman’s Health, the Court stressed the importance of using evidence to evaluate the extent to which an abortion restriction imposes a burden on women, and made clear that a restriction’s burdens cannot outweigh its benefits, an analysis that will give the Texas decision a reach well beyond the specific restrictions at issue in the case.

As important as the Whole Woman’s Health decision is and will be going forward, it is far from the only good news so far this year. Legislators in 19 states introduced a bevy of measures aimed at expanding insurance coverage for contraceptive services. In 13 of these states, the proposed measures seek to bolster the existing federal contraceptive coverage requirement by, for example, requiring coverage of all U.S. Food and Drug Administration approved methods and banning the use of techniques such as medical management and prior authorization, through which insurers may limit coverage. But some proposals go further and plow new ground by mandating coverage of sterilization (generally for both men and women), allowing a woman to obtain an extended supply of her contraceptive method (generally up to 12 months), and/or requiring that insurance cover over-the-counter contraceptive methods. By July 1, both Maryland and Vermont had enacted comprehensive measures, and similar legislation was pending before Illinois Gov. Bruce Rauner (R). And, in early July, Hawaii Gov. David Ige (D) signed a measure into law allowing women to obtain a year’s supply of their contraceptive method.

071midyearstatecoveragetable

But the Assault Continues

Even as these positive developments unfolded, the long-standing assault on sexual and reproductive health and rights continued apace. Much of this attention focused on the release a year ago of a string of deceptively edited videos designed to discredit Planned Parenthood. The campaign these videos spawned initially focused on defunding Planned Parenthood and has grown into an effort to defund family planning providers more broadly, especially those who have any connection to abortion services. Since last July, 24 states have moved to restrict eligibility for funding in several ways:

  • Seventeen states have moved to limit family planning providers’ eligibility for reimbursement under Medicaid, the program that accounts for about three-fourths of all public dollars spent on family planning. In some cases, states have tried to exclude Planned Parenthood entirely from such funding. These attacks have come via both administrative and legislative means. For instance, the Florida legislature included a defunding provision in an omnibus abortion bill passed in March. As the controversy grew, the Centers for Medicare and Medicaid Services, the federal agency that administers Medicaid, sent a letter to state officials reiterating that federal law prohibits them from discriminating against family planning providers because they either offer abortion services or are affiliated with an abortion provider (see CMS Provides New Clarity For Family Planning Under Medicaid). Most of these state attempts have been blocked through legal challenges. However, a funding ban went into effect in Mississippi on July 1, and similar measures are awaiting implementation in three other states.
  • Fourteen states have moved to restrict family planning funds controlled by the state, with laws enacted in four states. The law in Kansas limits funding to publicly run programs, while the law in Louisiana bars funding to providers who are associated with abortion services. A law enacted in Wisconsin directs the state to apply for federal Title X funding and specifies that if this funding is obtained, it may not be distributed to family planning providers affiliated with abortion services. (In 2015, New Hampshire moved to deny Title X funds to Planned Parenthood affiliates; the state reversed the decision in 2016.) Finally, the budget adopted in Michigan reenacts a provision that bars the allocation of family planning funds to organizations associated with abortion. Notably, however, Virginia Gov. Terry McAuliffe (D) vetoed a similar measure.
  • Ten states have attempted to bar family planning providers’ eligibility for related funding, including monies for sexually transmitted infection testing and treatment, prevention of interpersonal violence, and prevention of breast and cervical cancer. In three of these states, the bans are the result of legislative action; in Utah, the ban resulted from action by the governor. Such a ban is in effect in North Carolina; the Louisiana measure is set to go into effect in August. Implementation of bans in Ohio and Utah has been blocked as a result of legal action.

071midyearstateeligibilitytable

The first half of 2016 was also noteworthy for a raft of attempts to ban some or all abortions. These measures fell into four distinct categories:

  • By the end of June, four states enacted legislation to ban the most common method used to perform abortions during the second trimester. The Mississippi and West Virginia laws are in effect; the other two have been challenged in court. (Similar provisions enacted last year in Kansas and Oklahoma are also blocked pending legal action.)
  • South Carolina and North Dakota both enacted measures banning abortion at or beyond 20 weeks post-fertilization, which is equivalent to 22 weeks after the woman’s last menstrual period. This brings to 16 the number of states with these laws in effect (see State Policies on Later Abortions).
  • Indiana and Louisiana adopted provisions banning abortions under specific circumstances. The Louisiana law banned abortions at or after 20 weeks post-fertilization in cases of diagnosed genetic anomaly; the law is slated to go into effect on August 1. Indiana adopted a groundbreaking measure to ban abortion for purposes of race or sex selection, in cases of a genetic anomaly, or because of the fetus’ “color, national origin, or ancestry”; enforcement of the measure is blocked pending the outcome of a legal challenge.
  • Oklahoma Gov. Mary Fallin (R) vetoed a sweeping measure that would have banned all abortions except those necessary to protect the woman’s life.

071midyearstateabortionstable

In addition, 14 states (Alaska, Arizona, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Maryland, South Carolina, South Dakota, Tennessee and Utah) enacted other types of abortion restrictions during the first half of the year, including measures to impose or extend waiting periods, restrict access to medication abortion, and establish regulations on abortion clinics.

Zohra Ansari-Thomas, Olivia Cappello, and Lizamarie Mohammed all contributed to this analysis.